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Takotsubo Cardiomyopathy: The Octopus Trap

2018-01-30T02:09:43+00:00

Cartoon of Takotsubo CMTakotsubo Cardiomyopathy was first described in Japan in 1990 and  in the United States in 1998. It was named after an octopus trap (“tako-tsubo”) due to the shape of the trap being similar to the appearance of the left ventricular (LV) apical ballooning that occurs in this condition.  Why is this condition so important to know? It can mimic acute coronary syndrome and most patients go to the emergency department because they are worried they are having an acute myocardial infarction.

 

What are other names for  Takotsubo Cardiomyopathy?

  • Stress Cardiomyopathy
  • Broken-Heart Syndrome

What are the hallmark findings of Takotsubo Cardiomyopathy?

  1. Presenting symptoms: Acute onset of chest pain or dyspnea
  2. Triggered by emotional or physical stress
  3. Transient apical and mid-ventricular regional wall-motion abnormality
  4. Minor elevation of cardiac biomarkers
  5. Dynamic electrocardiographic change suggestive of an anterior wall MI
  6. The absence of epicardial coronary artery disease

How common is it?

  • Accounts for up to 2% of suspected ACS cases1
  • In 2000, there were only 2 publications2
  • In 2010, there were nearly 300 publications2

Who is most likely to get it?3

  • 80 – 100% of cases are in women
  • The average age is between 61 – 76 years
  • There is no evidence to suggest familial inheritance.

 What causes it?

  • The basic cause is still being debated with much focus on the autonomic nervous system
  • 85% of cases are triggered by an emotional or physical stressful event
  • Specifically, excess adrenaline is thought to cause this condition

How is it diagnosed?

  • On angiography of the coronary arteries and the left ventricle with dye, there is apical LV dilatation with no evidence coronary artery disease which would account for LV dysfunction.

What is the most common ECG change that can occur?

  • ST elevation (anterior precordial leads) 33 – 56% of cases4,5

 OLYMPUS DIGITAL CAMERA

What is the management plan?

  • There are no controlled data to define the optimal medical regimen
  • Because can mimic ACS, acutely should consider oxygen, aspirin, and nitroglycerin if blood pressure allows
  • Depends on the hemodynamic status of the patient
    • Stable: Supportive, conservative therapy
    • Unstable: Intra-aortic balloon pump (IABP) is the preferred therapy when there is marked LV dysfunction6
    • Unstable: Inotropes can worsen catecholamine release

What is the long term prognosis?

  • Nearly all patients have complete recovery back to normal after several days
  • The chance of another episode is very low, even with future stressful events2
  • The in-hospital mortality is 0 – 8%7
  • The largest patient series of 88 patients had an overall in-hospital mortality rate of 1%1

Take home point

Takotsubo cardiomyopathy is a syndrome of transient dysfunction of the apical left ventricle, triggered by emotional or physical stress, which can present similar to acute myocardial infarction but is not clinically distinguishable in the emergency department.

1.
Bybee K, Kara T, Prasad A, et al. Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med. 2004;141(11):858-865. [PubMed]
2.
Sharkey S, Lesser J, Maron B. Cardiology Patient Page. Takotsubo (stress) cardiomyopathy. Circulation. 2011;124(18):e460-2. [PubMed]
3.
Akashi Y, Goldstein D, Barbaro G, Ueyama T. Takotsubo cardiomyopathy: a new form of acute, reversible heart failure. Circulation. 2008;118(25):2754-2762. [PubMed]
4.
Dib C, Asirvatham S, Elesber A, Rihal C, Friedman P, Prasad A. Clinical correlates and prognostic significance of electrocardiographic abnormalities in apical ballooning syndrome (Takotsubo/stress-induced cardiomyopathy). Am Heart J. 2009;157(5):933-938. [PubMed]
5.
Sharkey S, Lesser J, Menon M, Parpart M, Maron M, Maron B. Spectrum and significance of electrocardiographic patterns, troponin levels, and thrombolysis in myocardial infarction frame count in patients with stress (tako-tsubo) cardiomyopathy and comparison to those in patients with ST-elevation anterior wall myocardial infarction. Am J Cardiol. 2008;101(12):1723-1728. [PubMed]
6.
Sharkey S, Lesser J, Zenovich A, et al. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation. 2005;111(4):472-479. [PubMed]
7.
Vivo R, Krim S, Hodgson J. It’s a trap! Clinical similarities and subtle ECG differences between takotsubo cardiomyopathy and myocardial infarction. J Gen Intern Med. 2008;23(11):1909-1913. [PubMed]
Salim Rezaie, MD

Salim Rezaie, MD

ALiEM Associate Editor
Clinical Assistant Professor of EM and IM
University of Texas Health Science Center at San Antonio
Founder, Editor, Author of R.E.B.E.L. EM and REBEL Reviews