Tako-Tsubo Cardiomyopathy

Tako-Tsubo 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 Tako-Tsubo 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

  • ClinicalCases Blogspot with Dr Ves: Takotsubo cardiomyopathy broken heart syndrome
  • Akashi YJ, Goldstein DS, Barbaro G, Ueyama T.Takotsubo cardiomyopathy: a new form of acute, reversible heart failure.Circulation. 2008 Dec 16;118(25):2754-62.PMID: 19106400
  • Abdulla I, Ward MR.Tako-tsubo cardiomyopathy: how stress can mimic acute coronary occlusion.Med J Aust. 2007 Sep 17;187(6):357-60. PMID: 17874985
  • Banning et al. Takotsubo cardiomyopathy BMJ 2010;340:c1272.
  • Salim S. Virani, MD, A. Nasser Khan, MD, Cesar E. Mendoza, MD, Alexandre C. Ferreira, MD, and Eduardo de Marchena, MD Takotsubo Cardiomyopathy, or Broken-Heart Syndrome Tex Heart Inst J. 2007; 34(1): 76–79. [PMC1847940]

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Posted by Dr Ed Burns

Dr Ed Burns . Emergency Physician in Pre-hospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education. Ed is the force behind the LITFL ECG library | + Edward Burns | @edjamesburns

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