Takotsubo cardiomyopathy

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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.)[1]
    • Proposed mechanisms include vasospasm and abnormal response to catecholamine surge
    • As high as 28% in ICU patients due to severe physical stress[2]

Clinical Features

Differential Diagnosis

ST Elevation

Cardiomyopathy

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
    • Apical Ballooning on US
  • Ventriculography
    • Shows LV ballooning
  • Angiogram
    • No significant coronary blockage to explain LV dysfunction

Clinical Differences Between AMI and [3]

AMI Takutsubo
ECG Specific vascular distribution Multiple regions of change
Echo Specific vascular distribution Multiple regions of wall motion abnormalities
Troponin Significant elevation Mild to no elevation
NT proBNP Mild elevation Significant elevation
RV Uncommon in left heart AMI ~1/3 have biventricular ballooning
Hypotension Cardiogenic shock Multi-factorial: LVOT obstruction, peripheral vasodilation, LV and/or RV decreased inotropy
PCI Stenosis No 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
    • Replace magnesium levels
  • Management of differs from usual cardiogenic shock[4]
    • 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

Disposition

  • Admit for post catheterization care

See Also

External Links

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. TakotsuboMasoud H. Takotsubo Cardiomyopathy in Intensive Care Unit: Prevention, Diagnosis and Management. International Cardiovascular Forum Journal. 2016; 5:33-35.
  4. Masoud H. Takotsubo Cardiomyopathy in Intensive Care Unit: Prevention, Diagnosis and Management. International Cardiovascular Forum Journal. 2016; 5:33-35.