Signs and Symptoms of Takotsubo Cardiomyopathy
Takotsubo cardiomyopathy presents with chest pain, dyspnea, and ECG changes that are clinically indistinguishable from acute myocardial infarction, making urgent coronary angiography mandatory to differentiate these conditions. 1, 2
Cardinal Presenting Symptoms
Chest Pain and Dyspnea
- Acute onset of ischemic-like chest pain occurs in the majority of patients, mimicking ST-elevation myocardial infarction 1, 3
- Dyspnea is a common presenting symptom, particularly in African American patients who may present atypically without chest pain 4
- Symptoms are triggered by emotional stress (death of loved one, heated argument) or physical stress (trauma, infection, surgery) in most cases 2, 5, 3
Electrocardiographic Findings
ECG Abnormalities Present in Most Patients
- ST-segment elevation is the most common finding, typically centered on precordial leads V2-V5 and limb leads II and aVR 2
- T-wave inversion develops in many patients 1, 2
- QT interval prolongation is characteristic 5
- ST-segment elevation in lead V1 is less pronounced compared to anterior STEMI, which helps differentiate the two conditions 2
Cardiac Biomarker Elevation
Troponin Elevation Pattern
- Cardiac troponin is elevated but remains modest and disproportionately low relative to the extensive wall motion abnormalities seen on imaging 1, 6
- BNP/NT-proBNP levels are substantially elevated 5
- This discrepancy between biomarker elevation and severity of ventricular dysfunction is a key diagnostic clue 1
Echocardiographic Manifestations
Regional Wall Motion Abnormalities
- Transient left ventricular apical akinesia with basal hyperkinesis creates the characteristic "takotsubo" appearance 1, 6
- Wall motion abnormalities extend beyond a single coronary artery territory, distinguishing it from typical myocardial infarction 1, 5
- Left ventricular ejection fraction is typically reduced, often <45% 2
- Biventricular involvement occurs in 25% of cases and predicts worse outcomes 2
In-Hospital Complications
Acute Cardiovascular Complications
- Acute heart failure develops in 12-62% of patients 2, 7
- Cardiogenic shock complicates 6-27% of cases and represents the leading cause of death 2, 7
- Left ventricular outflow tract obstruction occurs in 10-25% 2
- Mitral regurgitation affects 14-25% 2
- Pulmonary edema develops in 27% 7
Patient Demographics
High-Risk Population
- Approximately 90-96% of cases occur in postmenopausal women, with mean age of 66.8 years 2, 5
- Female sex carries an odds ratio of 29.0-163.7 for developing the condition 2
- Male patients have up to three-fold increased mortality when affected 2
- Pre-existing psychiatric disorders increase susceptibility 5
Critical Diagnostic Pitfall
Mandatory Coronary Angiography
- Despite the characteristic presentation, coronary angiography is mandatory because clinical presentation, ECG changes, and biomarkers cannot reliably differentiate Takotsubo from acute myocardial infarction 1, 2
- The definitive diagnostic finding is absence of obstructive coronary artery disease on angiography, with no significant culprit stenosis or intracoronary thrombi 1, 5
- Complete functional recovery within 1-4 weeks is required to confirm the diagnosis 1, 5, 6