Takotsubo cardiomyopathy

Background

  • AKA transient apical ballooning syndrome or stress-induced cardiomyopathy
  • Bulging out of LV apex with preserved function of the base looks like an octopus pot or "tako tsubo" in Japanese
    • Recent recognition of additional subtypes: reverse Takotsubo (basal ballooning), mid-ventricular type, localized type
  • 85% of cases caused by stressful event before symptoms (death of loved one, fear, argument, asthma, surgery, stroke, etc.)[1]
    • Proposed mechanisms include vasospasm, microvascular dysfunction, and abnormal myocyte response to catecholamine surge
    • As high as 28% in ICU patients due to severe physical stress[2]

Clinical Features

  • Mimics Acute coronary syndrome
  • Chest pain
  • Dyspnea
  • Cardiogenic shock and sudden CHF
  • Lethal arrhythmia (e.g. VTach/VF, PEA)

Differential Diagnosis

ST Elevation

Cardiomyopathy

Evaluation

  • Troponin may elevated or normal, but not usually as high as with traditional STEMI
  • ECG
    • May mimic STEMI
    • Frequently affects the anterior distribution and to a lesser extent inferior distribution
  • Echocardiography
    • Systolic Dysfunction (with ejection fraction dropping from normal to <25-35%)
    • Reduced contractility not explained by single vessel disease
    • Apical Ballooning on US
  • Ventriculography
    • Shows LV ballooning
  • Angiogram
    • No significant coronary blockage to explain LV dysfunction

Clinical Differences Between AMI and [4]

AMI Takutsubo
ECGSpecific vascular distributionMultiple regions of change
EchoSpecific vascular distributionMultiple regions of wall motion abnormalities
TroponinSignificant elevationMild to no elevation
NT proBNPMild elevationSignificant elevation
RVUncommon in left heart AMI~1/3 have biventricular ballooning
HypotensionCardiogenic shockMulti-factorial: LVOT obstruction, peripheral vasodilation, LV and/or RV decreased inotropy
PCIStenosisNo coronary obstruction

Management

  • Treat as STEMI until ruled out
  • Anticoagulation may be required until wall motion abnormalities resolve
  • Monitor QTc intervals and arrhythmias
    • Stop all QT prolonging drugs
    • Replete magnesium
  • Management of differs from usual cardiogenic shock[5]
    • IVF
    • With LVOT obstruction, avoid volume depletion and vasodilator therapy (similar to hypertrophic cardiomyopathy management)
    • Avoid use of catecholamine based inotropic meds
    • Consider beta blockers and ACE inhibitors, which reduce recurrence
    • Intra-aortic balloon pump or ECMO in refractory cases

Prognosis

  • Ejection Fraction returns to normal (at least >50%) in nearly all cases
  • Some patients experience recurrence

Disposition

  • Admit for post catheterization care

See Also

  • Cardiomyopathy

Cardiomyopathy (Main)

References

  1. Sharkey, S., Lesser, J., & Maron, B. (2011). Takotsubo (stress) cardiomyopathy. American Heart Association.
  2. Park JH, Kang SJ, Song JK, et al. Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU. Chest 2005;128:296-302.
  3. http://www.thepocusatlas.com/left-ventricle-1
  4. TakotsuboMasoud H. Takotsubo Cardiomyopathy in Intensive Care Unit: Prevention, Diagnosis and Management. International Cardiovascular Forum Journal. 2016; 5:33-35.
  5. Masoud H. Takotsubo Cardiomyopathy in Intensive Care Unit: Prevention, Diagnosis and Management. International Cardiovascular Forum Journal. 2016; 5:33-35.
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