Takotsubo cardiomyopathy

Background

• AKA transient apical ballooning syndrome or stress-induced cardiomyopathy

A depicts the left ventricular dilation that occurs in Takotsubo cardiomyopathy compared to a normal heart in B.

Clinical Features

• Mimics Acute Coronary Syndrome
• Chest Pain
• Dyspnea
• Cardiogenic Shock
• Lethal arrhythmia (e.g. VT/VF, PEA)

Differential Diagnosis

ST Elevation

• Cardiac
  • ST-segment elevation myocardial infarction (STEMI)
  • Post-MI (ventricular aneurysm pattern)
  • Previous MI with recurrent ischemia in same area
  • Wellens' syndrome
  • Coronary artery vasospasm (eg, Prinzmetal's angina)
  • Coronary artery dissection
  • Pericarditis
  • Myocarditis
  • Aortic dissection in to coronary
  • Left ventricular aneurysm
  • Left ventricular pseudoaneurysm
  • Early repolarization
  • Left bundle branch block
  • Left ventricular hypertrophy (LVH)
  • Myocardial tumor
  • Myocardial trauma
  • RV pacing (appears as Left bundle branch block)
  • Brugada syndrome
  • Takotsubo cardiomyopathy
  • AVR ST elevation
• Other thoracic
  • Pneumomediastinum
  • Pneumothorax
  • Pulmonary embolism
• Metabolic
  • Drugs of abuse (eg, cocaine, crack, meth)
    • Cocaine chest pain
  • Hyperkalemia (only leads V1 and V2)
  • Hypothermia ("Osborn J waves")
• Medications
  • Tricyclic (TCA) toxicity
  • Digoxin

Cardiomyopathy

• Dilated cardiomyopathy
• Hypertrophic cardiomyopathy
• Restrictive cardiomyopathy
• Peripartum cardiomyopathy
• Takotsubo cardiomyopathy
• Arrhythmogenic right ventricular dysplasia

Diagnosis

• Troponin frequently elevated
• ECG
  • May mimic STEMI
  • Frequently affects the anterior distribution and to a lesser extent inferior distribution
• Echocardiogram
  • Systolic Dysfunction (with ejection fraction dropping from normal to <25-35%)
  • Reduced contractility not explained by single vessel disease
• Angiogram or L Heart Cath
  • No occlusive vascular disease identified to explain the event

Management

Supportive care Start by treating as Acute Coronary Syndrome and exclude STEMI Manage arrhythmias as needed Manage Cardiogenic Shock and acute pulmonary edema See Cardiogenic Shock for emergent management Beta Blockers and ACE Inhibitors are commonly used for Takotsuba Anticoagulation may be considered Consider Endotracheal Intubation Consider Intra-aortic balloon pump

Prognosis

Ejection Fraction returns to normal (at least >50%) in nearly all cases (100% in the Sharkey study) Mortality 2% during hospitalization Recurrence in 5-6%

See Also

• Cardiomyopathy