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.
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.
(A) Ventriculogram (B) An octopus pot (“Tako-Tsubo”)
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 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
- 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
- Dubin D. Rapid Interpretation of EKG’s
- Mattu A. ECG’s for the Emergency Physician
- Hampton JR. The ECG In Practice, 6e