Takotsubo Cardiomyopathy (broken heart syndrome) Domina Petric, MD

Transient cardiac syndrome that involves left ventricular apical akinesis. Mimics acute coronary syndrome. ?

elevated cardiac enzyme levels chest pain ST-segment elevation elevated cardiac enzyme levels There is no significant coronary artery stenosis, but there is ventricular apical ballooning. 

Modified Mayo Clinic criteria for diagnosis are Transient hypokinesis, dyskinesis or akinesis of the left ventricular middle segments, with or without apical involvement. Absence of obstructive coronary disease, absence of angiographic evidence of acute plaque rupture. New ECG abnormalities: ST-segment elevation or/and T-wave inversion. Moderate elevation in the cardiac troponin level. Absence of pheochromocytoma or myocarditis. 

Patients with Takotsubo cardiomyopathy are found to shift toward the glucose pathway despite relatively normal myocardial perfusion and lack of ischemia in LV segments.

Pathophysiology neurohormonal stimulation stress-induced catecholamine release reversible focal myocytolysis, mononuclear infiltrates, and contraction band necrosis neurohormonal stimulation  cocaine, methamphetamine, and excessive phenylephrine use exercise stress testing

Endogenous catecholamine-induced myocardial stunning and microinfarction! Impaired myocardial fatty acid metabolism! Multivessel coronary artery spasm! Acute coronary syndrome with reperfusion injury! Etiology Impaired cardiac microvascular function!

Risk factors Learning of a death of a loved one! Natural disasters! Bad financial news! Legal problems! Motor vehicle collisions! Surgery! Exacerbation of a chronic medical illness! Intensive care unit stay! Use of or withdrawal from illicit drugs! Risk factors Newly diagnosed, significant medical condition!

Epidemiology Nearly 90% of reported cases involve postmenopausal women. Mean patient age is 67 years. 57.2% Asian, 40% Caucasian 2.8% other races 

Nearly 95% of patients experiencing complete recovery within 4-8 weeks Nearly 95% of patients experiencing complete recovery within 4-8 weeks. Complications occure in 20% of patients. Prognosis

Complications Death! LV mural thrombus formation! Cardiogenic shock! LV free-wall rupture! Complications Left heart failure with or without pulmonary edema! Cardiogenic shock! LV outflow obstruction! Mitral regurgitation! Ventricular arrhythmias! LV mural thrombus formation!

chest pain and dyspnea palpitations nausea vomiting syncope cardiogenic shock Symptoms

Symptoms Preceding emotionally or physically stressful trigger event occurr in two thirds of patients. The peak occurrence for acute coronary syndrome is during the morning hours. Takotsubo cardiomyopathy events are most prevalent in the afternoon when stressful triggers are more likely to take place.

Physical exam anxiety diaphoresis tachydysrhythmias bradydysrhythmias hypotension

Workup Troponin I (TnI) and tropnin T (TnT) ECG Transthoracic echocardiography (TTE)

Medscape.com

Treatment It is usually treated in emergency department as acute coronary syndrome. After the initial treatment, cardiologist should continue to treat these patients: beta blockers, anticoagulation if there is LV thrombus.

Literature: Medscape.com