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.
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.
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.
- 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;118(25):2754-2762
- Abdulla I, Ward MR. Tako-tsubo cardiomyopathy: how stress can mimic acute coronary occlusion. Med J Aust. 2007;187(6):357-360.
- Banning et al. Takotsubo cardiomyopathy BMJ 2010;340:c1272.
- Virani SS, Khan AN, Mendoza CE, Ferreira AC, de Marchena E. Takotsubo cardiomyopathy, or broken-heart syndrome. Tex Heart Inst J. 2007;34(1):76-79.
- Geisen WR, Rosse C, Menon S, Rudick S. Trump Cardiomyopathy: A New Form of Takotsubo Cardiomyopathy J Card Fail. 2020
- Wiesbauer F, Kühn P. ECG Yellow Belt online course: Become an ECG expert. Medmastery
- Wiesbauer F, Kühn P. ECG Blue Belt online course: Learn to diagnose any rhythm problem. Medmastery
- Rawshani A. Clinical ECG Interpretation ECG Waves
- Smith SW. Dr Smith’s ECG blog.
- Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care. 2e, 2019
- Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
- Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
- Hampton J. The ECG Made Practical 7e, 2019
- Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
- Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care Electrocardiography 1e, 2009
- Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
- Mattu A, Brady W. ECG’s for the Emergency Physician Part I 1e, 2003 and Part II
- Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004
LITFL Further Reading
- ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
- ECG A to Z by diagnosis – ECG interpretation in clinical context
- ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
- 100 ECG Quiz – Self-assessment tool for examination practice
- ECG Reference SITES and BOOKS – the best of the rest