Takotsubo Syndrome

Mar 30, 2020   |  Sherrie R. Webb, PA-C

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Authors: Boyd B, Solh T.

Citation: Takotsubo cardiomyopathy: Review of broken heart syndrome. JAAPA 2020;33:24-9.

The following are key points to remember about this review of Takotsubo cardiomyopathy:

1. Takotsubo Syndrome cardiomyopathy—also called stress cardiomyopathy, apical ballooning syndrome, or broken heart syndrome—is a condition in which left ventricular (LV) dilatation and acute systolic heart failure occur, typically following an emotional or physical stressor. Ballooning of the LV occurs, most commonly in the apex (75-80%) or midventricle (10-20%).
2. Pathophysiology is uncertain; evidence suggests a surge in stress-related hormones contributes to apical ballooning via disruptions in the microvasculature or by myocardial toxicity.
3. Worldwide, 90% of cases occur in post-menopausal women. In Japan, it is more common in men. Men are more likely to develop the syndrome following physical stress.
4. The most common symptoms are chest pain, dyspnea, and dizziness. Weakness and syncope may occur. Physical findings can include lung rales, S3 gallop, jugular venous distention, tachycardia, hypotension, narrow pulse pressure, and systolic ejection murmur. Most patients have electrocardiographic changes such as ST-segment elevation or T-wave inversion. Cardiac biomarkers—troponin, creatine kinase-myocardial band, and B-type natriuretic peptide—are typically elevated.
5. The diagnosis is often made when a patient with suspected acute myocardial infarction is found at cardiac catheterization to have no coronary blockage. Revised Mayo Clinic diagnostic criteria include the following:
   • Transient dyskinesis of the LV midsegments
   • Regional wall motion abnormalities beyond a single epicardial vascular distribution
   • Absence of obstructive coronary artery disease or acute plaque rupture
   • New electrocardiographic abnormalities or modest troponin elevation
   • Absence of pheochromocytoma and myocarditis
6. Treatment requires inpatient care with cardiology services and is largely supportive until LV function spontaneously returns, usually within 21 days of onset.
7. In stable patients, diuretics and vasodilators can be used for pulmonary congestion. Angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and/or beta-blockers are used to reduce workload and control hypertension. Aldosterone receptor antagonists or angiotensin receptor-neprilysin inhibitors may be beneficial.
8. For patients with unstable hemodynamics, obtain an echocardiogram to determine presence of LV outflow tract obstruction (LVOTO).
   • If LVOTO is present, inotropes should not be used because they may worsen obstruction. Beta-blockers and intravenous fluids are appropriate. Vasopressors can be used. Extracorporeal membrane oxygenation can be considered in severe cases.
   • If LVOTO is not present, use inotropes and vasopressors or LV assist device if needed.
9. A major goal is reducing risk of major cerebral or vascular events, currently 7.1% within 30 days of hospitalization. Anticoagulation should be initiated in patients with large areas of cardiac hypokinesis.
10. Atrial fibrillation is an independent risk factor for mortality. Within several weeks, 95% of patients recover full cardiac function.

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Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Heart Failure and Cardiac Biomarkers

Keywords: Takotsubo Cardiomyopathy, Coronary Artery Disease, Dizziness, Atrial Fibrillation, Troponin, Creatine Kinase, MB Form, Natriuretic Peptide, Brain, Mineralocorticoid Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Vasodilator Agents, Diuretics