Takotsubo cardiomyopathy

Background

A depicts the left ventricular dilation that occurs in Takotsubo cardiomyopathy compared to a normal heart in B.

• 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
• 85% of cases caused by stressful event before symptoms (death of loved one, fear, argument, asthma, surgery, stroke, etc.)
  • Proposed mechanisms include vasospasm and abnormal response to catecholamine surge
  • As high as 28% in ICU patients due to severe physical stress

Clinical Features

• Mimics Acute Coronary Syndrome
• Chest Pain
• Dyspnea
• Cardiogenic Shock and sudden CHF
• Lethal arrhythmia (e.g. VT/VF, PEA)

Differential Diagnosis

ST Elevation

• Cardiac
  • ST-segment elevation myocardial infarction (STEMI)
  • Post-MI (ventricular aneurysm pattern)
  • Previous MI with recurrent ischemia in same area
  • Wellens' syndrome
  • Coronary artery vasospasm (eg, Prinzmetal's angina)
  • Coronary artery dissection
  • Pericarditis
  • Myocarditis
  • Aortic dissection in to coronary
  • Left ventricular aneurysm
  • Left ventricular pseudoaneurysm
  • Early repolarization
  • Left bundle branch block
  • Left ventricular hypertrophy (LVH)
  • Myocardial tumor
  • Myocardial trauma
  • RV pacing (appears as Left bundle branch block)
  • Brugada syndrome
  • Takotsubo cardiomyopathy
  • AVR ST elevation
• Other thoracic
  • Pneumomediastinum
  • Pneumothorax
  • Pulmonary embolism
• Metabolic
  • Drugs of abuse (eg, cocaine, crack, meth)
    • Cocaine chest pain
  • Hyperkalemia (only leads V1 and V2)
  • Hypothermia ("Osborn J waves")
• Medications
  • Tricyclic (TCA) toxicity
  • Digoxin

Cardiomyopathy

• Dilated cardiomyopathy
• Hypertrophic cardiomyopathy
• Restrictive cardiomyopathy
• Peripartum cardiomyopathy
• Takotsubo cardiomyopathy
• Arrhythmogenic right ventricular dysplasia

Evaluation

LV apical ballooning during systole

• Troponin frequently elevated
• ECG
  • May mimic STEMI
  • Frequently affects the anterior distribution and to a lesser extent inferior distribution
• Echocardiogram
  • Systolic Dysfunction (with ejection fraction dropping from normal to <25-35%)
  • Reduced contractility not explained by single vessel disease
• Ventriculography
  • Shows LV ballooning
• Angiogram
  • No significant coronary blockage to explain LV dysfunction

Management

• Mainly supportive as no true lesion and transient
• Treat as STEMI initially
• Anticoagulation may be considered
• Manage Cardiogenic Shock and acute pulmonary edema
  • IVF
  • With LVOT obstruction, avoid volume depletion and vasodilator therapy (like HCM)
  • Beta Blockers and ACE Inhibitors are commonly used for Takotsuba
  • Consider Intra-aortic balloon pump

Prognosis

Ejection Fraction returns to normal (at least >50%) in nearly all cases

Disposition

• Admit for post catheterization care

See Also

• Cardiomyopathy

External Links

Cardiomyopathy (Main)