Takotsubo Cardiomyopathy

Overview
  • Transient wall motion abnormality of the left ventricular apex associated with severe emotional or physical stress that usually resolves completely
  • Produces ischaemic chest pain, ECG changes +/- elevated cardiac enzymes in patients with normal coronary arteries on angiography
  • The presentation often mimics a STEMI and angiography is required to definitively differentiate the two conditions

Mayo Clinic diagnostic criteria
  • Transient dyskinesis of the LV apical and/or midsegments
  • Regional wall motional abnormalities beyond a single epicardial vascular distribution
  • Absence of coronary artery stenosis > 50% of culprit lesion
  • New ECG changes (ST elevation or T wave inversion) or moderate troponin rise
  • Absence of phaeochromocytoma and myocarditis

Also known as stress cardiomyopathy, apical ballooning syndrome, or broken heart syndrome.

ECG Tako-Tsubo Cardiomyopathy
Takotsubu Cardiomyopathy: ST elevation is difficult to differentiate from STEMI

History of Takotsubo

Originally described in Japan in 1990, the condition is named after the takotsubo pot, a traditional basket used in Japan to catch octopi. In TCM, apical dyskinesia and subsequent ballooning creates an LV appearance remarkably similiar to this octopus pot.

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

Ultrasound Top 100 091 07 Key to image 1
Echocardiography in TCM: PLAX views demonstrating midsegment and apical dyskinesia resembling the takotsubo pot. LITFL Ultrasound case 091

Pathophysiology

Pathophysiology is thought to be related to a combination of sympathetic nervous system activation, microvascular spasm, and underlying LVOT obstruction:

  • An acute stress response leads to a catecholamine surge
  • Ensuing sympathetic nervous system activation causes microvascular spasm. The apical distribution of the left ventricle has the highest density of sympathetic nervous system fibres which may explain the characteristic regional wall dyskinesia.
  • In at least one-third of cases, there is a degree of underlying left ventricular outflow tract (LVOT) obstruction, which increases LV workload, worsening sympathetic nervous system activation and apical dyskinesis. These patients usually have more severe disease and a poorer prognosis
Takotsubo Cardiomyopathy v1
TCM in patients with underlying LVOT obstruction

The condition can be prevented in a laboratory by cardiac sympathectomy, and similar cardiac histopathological features are seen in patients who have suffered a subarachnoid haemorrhage.


Clinical significance
  • 90% of cases worldwide occur in post-menopausal women, usually associated with sudden emotional stress. Cases in men are more likely to be associated with physical stress
  • Takotsubo cardiomyopathy is difficult to distinguish from STEMI in the ED, and no ECG criteria can be safely used to differentiate between the two conditions. If in doubt, you should activate your local code STEMI protocol
  • Takotsubo has a better prognosis than STEMIs with a similar ECG but it is certainly not benign
  • Treatment is largely supportive, and LV function usually spontaneously returns within 21 days of onset
  • Anticoagulation should be initiated in patients with large areas of cardiac hypokinesis, as they are at high risk of cerebrovascular thromboembolic events

DO NOT TAUNT THE OCTOPUS Tako-Tsubo


References

Advanced Reading

Online

Textbooks


LITFL Further Reading

ECG LIBRARY 700

ECG LIBRARY

Electrocardiogram

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner

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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