Aspirin Continuation in Stress-Induced Cardiomyopathy with Elevated Troponin
If the patient was already taking aspirin for a compelling cardiovascular indication such as prior myocardial infarction, prior stroke, or coronary artery disease, continue aspirin 75-100 mg daily indefinitely. 1, 2
Clinical Context and Decision Framework
Stress-induced cardiomyopathy (takotsubo) presents with troponin elevation and wall motion abnormalities that mimic acute coronary syndrome, but occurs in the absence of obstructive coronary disease. 3, 4 The key decision point is whether the patient has an underlying cardiovascular indication for aspirin that predates or exists independently of the takotsubo episode.
For Patients WITH Pre-existing Cardiovascular Disease
Continue aspirin indefinitely at 75-100 mg daily if any of the following apply: 1, 2, 5
Prior myocardial infarction: Aspirin reduces serious vascular events by approximately 25% and should never be discontinued without clear contraindication. 5 The mortality benefit substantially outweighs bleeding risks in secondary prevention. 2
History of coronary revascularization (PCI or CABG): Aspirin should be prescribed indefinitely following any coronary intervention. 1, 2
Established coronary artery disease: Even with angiographically normal coronaries during the takotsubo event, if the patient has known atherosclerotic disease elsewhere (luminal irregularities, prior stenoses), continue aspirin for secondary prevention. 1
Prior ischemic stroke or TIA: Aspirin provides proven mortality benefit in cerebrovascular disease. 2
The 2012 ACC/AHA guidelines explicitly state that aspirin should be continued indefinitely in patients with unstable angina/NSTEMI treated medically, and this applies equally to patients with elevated troponin from any acute cardiac event when underlying CAD exists. 1
For Patients WITHOUT Pre-existing Cardiovascular Disease
Discontinue aspirin after the acute phase if takotsubo occurred in a patient with no prior cardiovascular disease and angiography confirms truly normal coronary arteries without atherosclerotic changes. 1
The 2012 ACC/AHA guidelines state that for patients with elevated troponin but no significant obstructive coronary disease found on angiography, antiplatelet therapy should be administered "at the discretion of the clinician." 1
However, if even luminal irregularities or intravascular ultrasound-demonstrated lesions are present (albeit without flow-limiting stenoses), long-term aspirin and secondary prevention measures should be prescribed. 1
Critical Pitfalls to Avoid
Do not reflexively discontinue aspirin based solely on the takotsubo diagnosis. 2 The diagnosis of stress-induced cardiomyopathy does not negate the need for aspirin in patients with established atherosclerotic disease. Studies show that aspirin interruption in patients with coronary disease is associated with a three-fold increased risk of cardiovascular or cerebrovascular events, with 70% occurring within 7-10 days of discontinuation. 2
Do not use higher aspirin doses. After the acute phase, use 75-100 mg daily rather than higher maintenance doses, as this provides equivalent efficacy with lower bleeding risk. 1, 5
Do not confuse troponin elevation with indication for aspirin. Takotsubo typically causes modest troponin elevation (troponin T ≤6 ng/mL, troponin I ≤15 ng/mL), which is lower than typical STEMI. 3, 6 The troponin level itself does not determine aspirin indication—the underlying cardiovascular substrate does.
Gastroprotection Strategy
Add a proton pump inhibitor if the patient has any bleeding risk factors: 2, 5
- History of gastrointestinal bleeding (Class I recommendation)
- Age >60 years
- Concurrent anticoagulation
- Renal failure or liver disease
Avoid omeprazole or esomeprazole if the patient is also on clopidogrel, as these PPIs inhibit CYP2C19 and reduce clopidogrel effectiveness. 2, 7 Use pantoprazole or lansoprazole instead.
Monitoring After Discharge
No routine platelet function testing is needed. The European Society of Cardiology states that no test of platelet function is recommended to assess aspirin's antiplatelet effect in individual patients due to lack of established benefit. 7
Monitor clinically for bleeding: 7
- Obtain periodic complete blood counts to detect occult bleeding manifesting as anemia, particularly in higher-risk patients
- Assess for hematemesis, melena, hematuria, or excessive bruising through history and physical examination
Reassess aspirin indication at follow-up visits to confirm the underlying cardiovascular substrate justifies continued therapy, weighing thrombotic versus bleeding risks. 2