Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (stress cardiomyopathy) is an acute, usually reversible left ventricular dysfunction with regional wall motion abnormality extending beyond a single coronary territory, in the absence of culprit obstructive coronary disease.

Accounts for 1 to 3% of suspected acute coronary syndromes; 90% of patients are women, mean age 66 years, mostly postmenopausal.

Triggers: emotional stress (bereavement, fear) or physical stress (surgery, sepsis, stroke, subarachnoid haemorrhage, asthma exacerbation, pheochromocytoma, exogenous catecholamines).

Pathophysiology: catecholamine surge, microvascular dysfunction, direct myocardial toxicity.

Patterns: apical ballooning (80%), midventricular, basal (inverted) and focal.

Complications: acute heart failure, cardiogenic shock, left ventricular outflow obstruction, mitral regurgitation, ventricular arrhythmia, thromboembolism, wall rupture (rare). In hospital mortality 4 to 5%.

• Acute chest pain, dyspnoea, syncope; mimics STEMI.
• Hypotension, pulmonary oedema, arrhythmias.
• Murmur of mitral regurgitation or LVOT obstruction.

• ECG: ST elevation (anterior) in about 40%, later deep T wave inversion and QT prolongation.
• Troponin modestly elevated (disproportionately low versus extent of dysfunction); BNP markedly raised.
• Coronary angiography: no culprit lesion; left ventriculography or echo shows apical ballooning with basal hyperkinesis.
• Echocardiography for ejection fraction (often 20 to 45%), LVOT gradient, thrombus.
• Cardiac MRI: myocardial oedema without significant late gadolinium enhancement; excludes myocarditis and infarction.
• InterTAK score supports diagnosis. Search for triggers, including pheochromocytoma.

• Supportive care in a monitored setting; heart failure therapy (ACE inhibitor or ARB, diuretics, beta blocker once stable) until recovery. Recovery in 1 to 4 weeks.
• Avoid catecholamines. Cardiogenic shock without LVOT obstruction: levosimendan, mechanical circulatory support (IABP, Impella, VA ECMO).
• LVOT obstruction: IV fluids, beta blocker (esmolol 50 to 200 micrograms/kg/min or metoprolol), phenylephrine; avoid inotropes and nitrates.
• Anticoagulation (heparin then warfarin or DOAC for 3 months) for left ventricular thrombus or severe apical akinesis.
• Treat arrhythmias; temporary pacing for bradycardia; wearable defibrillator for markedly prolonged QT.
• Long term: ACE inhibitor or ARB may reduce recurrence; stress management, psychiatric support. Recurrence about 2 to 4% a year.
• Repeat echo at 4 to 6 weeks to confirm recovery; if persistent dysfunction, reconsider diagnosis.