What is Takotsubo (stress) cardiomyopathy?

From the Guidelines

Takotsubo cardiomyopathy should be managed with conventional agents such as ACE inhibitors, beta blockers, aspirin, and diuretics if the patient is hemodynamically stable, as recommended by the 2018 international expert consensus document on takotsubo syndrome 1.

Diagnosis and Treatment

Takotsubo cardiomyopathy, also known as stress cardiomyopathy or broken heart syndrome, is a temporary heart condition that mimics a heart attack. It occurs when part of the heart muscle becomes suddenly weakened, causing the left ventricle to change shape and enlarge. This condition is typically triggered by intense emotional or physical stress, such as the death of a loved one, a serious accident, or severe illness.

• The condition accounts for approximately 2% of all patients admitted with a potential diagnosis of ACS, and patients are typically female (90%) and perimenopausal, but the condition can affect all patient groups 1.
• Treatment focuses on managing symptoms and supporting heart function while the condition resolves naturally, usually within days to weeks.
• Beta-blockers like metoprolol and ACE inhibitors such as lisinopril may be prescribed to reduce heart workload and improve function, as recommended by the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1.
• Aspirin might be recommended to prevent blood clots.
• Patients should rest, avoid stressful situations, and follow up with a cardiologist regularly during recovery.

Management and Outcome

Unlike a heart attack, takotsubo cardiomyopathy doesn't involve blocked coronary arteries but rather a surge of stress hormones that temporarily stun the heart muscle.

• Most patients recover completely with proper care and experience no long-term heart damage, though recurrence is possible in about 10% of cases.
• Severe LV dysfunction with extended apical ballooning entails the risk of an LV thrombus and subsequent systemic embolism, and anticoagulation with intravenous/subcutaneous heparin may be considered in such patients 1.
• A temporary transvenous pacemaker is appropriate for those with haemodynamically significant bradycardia.
• In case of excessive prolongation of the QT interval or life-threatening ventricular arrhythmias, a wearable defibrillator (life vest) could be considered 1.

From the Research

Definition and Classification of Takotsubo Cardiomyopathy

• Takotsubo cardiomyopathy (TTC) is a clinical condition of transient acute heart failure correlated to regional wall motion abnormalities extending beyond the distribution of a single epicardial coronary artery 2.
• It is classified into four major types: apical, basal, mid-ventricular, and focal 2.
• Takotsubo syndrome (TTS), also known as Takotsubo cardiomyopathy, is a transient left ventricular wall dysfunction that is often triggered by physical or emotional stressors 3.

Pathogenesis and Diagnosis

• Sympathetic nerve stimulation and catecholamine storm are the main players in the pathogenesis of TTC 2.
• The diagnosis of TTS can be made using Mayo diagnostic criteria 3.
• Coronary angiography, left ventriculogram, transthoracic echocardiography, and cardiac magnetic resonance imaging (CMR) are the main tools for making a diagnosis of TTC 2.

Management and Treatment

• The initial management of TTS includes dual antiplatelet therapy, anticoagulants, beta-blockers, angiotensin-converting enzyme inhibitors or aldosterone receptor blockers, and statins 3.
• Treatment is usually provided for up to three months and has a good safety profile 3.
• For TTS with complications such as cardiogenic shock, management depends on left ventricular outflow tract obstruction (LVOTO) 3.
• Chronic pharmacological treatment with beta-blockers, ACE-inhibitors, calcium channels blockers, and aspirin does not provide any benefit in patients with Takotsubo cardiomyopathy 4.

Prognosis and Complications

• The clinical course of disease is generally benign but it may end with life-threatening complications 2.
• The prognosis is generally favorable, but several acute complications have been reported such as congestive heart failure, cardiac rupture, hypotension, left ventricular apical thrombosis, or Torsade de Pointes 5.
• There is a high risk of complications at the initial presentation requiring intense support 6.