Takotsubo Cardiomyopathy

Takotsubo Cardiomyopathy Overview

A STEMI mimic producing ischaemic chest pain, ECG changes +/- elevated cardiac enzymes with characteristic regional wall motion abnormalities on echocardiography.

  • Typically occurs in the context of severe emotional distress (“broken heart syndrome“).
  • Patients have normal coronary arteries on angiography.
  • Originally described in Japan within the last 20 years, Tako-tsubo has become increasingly recognised, possibly in no small part due to the increased use of angiography in cardiology.
ECG Tako-Tsubo Cardiomyopathy

Diagnosis

Mayo Clinic criteria for takotsubo cardiomyopathy (widely but not universally accepted)

  • New ECG changes (ST elevation or T wave inversion) or moderate troponin rise.
  • Transient akinesis / dyskinesis of left ventricle (apical and mid-ventricular segments) with regional wall abnormalities extending beyond a single vascular territory.
  • Absence of coronary artery stenosis >50% or culprit lesion.

Why Is It Called Takotsubo Cardiomyopathy?

The left ventricle, with its apical akinesia looks remarkably like a basket used in japan to catch Octopi.

Tako-Tsubo Octopus pot
(A) Ventriculogram (B) An octopus pot (“Tako-Tsubo”)

Tako-Tsubo ventriculogram
Tako-Tsubo ventriculogram

What Causes Tako-Tsubo?

Classically it occurs in a post-menopausal woman experiencing sudden emotional stress associated with a Cathecholamine Surge

  • Microvascular Spasm.
  • Sympathetic nervous system activation.
  • Underlying  LVOTO.

A sudden surge in cathecholamines is agreed to be the cause, but the reason why this surge causes a characteristic wall motion abnormality remains a matter for debate. 

The most widely held view is that the catecholamines cause microvascular spasm, although left ventricular outflow obstruction is likely to play a part. 

The sympathetic nervous system is also implicated – the condition can be prevented in a laboratory by cardiac sympathectomy, the apical distribution explained as it has the highest density of sympathetic nerve fibres. Similar cardiac histopathological features are seen in patients who’ve had a subarachnoid haemorrhage.


So What Do We Do In The ED?

  • Tako-tsubo cardiomyopathy is indistinguishable from a STEMI in the ED.
  • No criteria can be safely used to differentiate between the two conditions – You should activate your local code STEMI protocol.
  • Tako-tsubo has a better prognosis than STEMIs with a similar ECG but it is certainly not benign.
DO NOT TAUNT THE OCTOPUS Tako-Tsubo

Related Topics

References

LITFL Further Reading

Advanced Reading

ECG LIBRARY 700

ECG LIBRARY

Electrocardiogram

Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

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