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.

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.

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.

Related Topics

• Anterior STEMI
• Top 100 Ultrasound Case 091

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]

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

Advanced Reading

• Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care Electrocardiography
• Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric
• Wagner GS. Marriott’s Practical Electrocardiography 12e
• Chan TC. ECG in Emergency Medicine and Acute Care
• Rawshani A. Clinical ECG Interpretation
• Mattu A. ECG’s for the Emergency Physician
• Hampton JR. The ECG In Practice, 6e