1. Takotsubo Ryan Sanford 2/15/09

2. The Name A Japanese term, named after the jar used for trapping octopus

3. In Popular Culture A mechanism of being scared to death? o Ananias and Sapphira o Legal  Larry Whitfield – on trial for 1 st degree murder while holding 79F at gunpoint – “fear induced heart attack”  Willie Ingram – convicted of murder for “emotional upset” causing heart attack, a 64M  Mark Fisher – convicted of murder of 89F for “fear induced heart attack”

4. AKA Broken Heart Syndrome Transient Left Ventricular Apical Ballooning Stress Cardiomyopathy

5. Definition An acute completely reversible systolic heart failure Typical: apical akinesia [ballooning] and hypercontractile base Atypical: midventricular akinesia and hypercontractile base No relevant CAD Mimics symptoms of ACS

6. Causes/Epidemiology Triggered by extreme emotional or physical stress o Deaths, accidents, surprise party, procedure, arguments, legal, public speaking, armed robbery Strong predominance in postmenopausal women Under-recognized, ~2% of all ACS

7. Pathophysiology 1.Coronary Spasm Stunned myocardium 1.not favored 2.Wall involvement extends beyond single vascular territory 3.Few patients demonstrate spasm with provocation during catheterization 4.CEs only slightly elevated, not high enough 2.Microvascular Impairment 1.Certainly present 2.Correlative, but causation doubted

8. Pathophysiology 1.Catecholamine Cardiotoxicity 1.Plasma levels of Epi/NE increased, even higher than in pt’s w/ similar HF. 2.Not uniformly present, but close 3.Pheochromocytoma can cause similar cardiac event 4.Histological findings simliar to in other forms of catecholamine cardiotoxicity

9. Pathophysiology

10. Signs / Symptoms Think ACS o CP, dyspnea, syncope Complications o Pulmonary edema and respiratory failure o Cardiogenic shock o Ventricular tachyarrhythmias o Ventricular wall rupture o Mural thrombus

11. Labs CEs: normal or slightly elevated Elevated BNP High serum catecholamines

12. EKG ST Elevation, TWI, Prolonged QT

13. Imaging

14. Copyright ©2007 BMJ Publishing Group Ltd. Nef, H. M et al. Heart 2007;93:1309-1315 Figure 1 Selective coronary angiography. Left (A) and right (B) coronary arteries in a patient presenting with tako-tsubo cardiomyopathy, excluding coronary artery disease. Left ventriculography during diastole (C) and systole (D) demonstrate the typical left ventricular apical ballooning and a hypercontractile base.

15. Typical Atypical

16. Copyright ©2007 BMJ Publishing Group Ltd. Nef, H. M et al. Heart 2007;93:1309-1315 Figure 4 Transthoracic echocardiogram showing four-chamber views during diastole (A) and systole (B) in a patient presenting with tako-tsubo cardiomyopathy. Real time three-dimensional echocardiography shows the typical contractile pattern of tako-tsubo cardiomyopathy with akinesia of apical segments and hypercontractility of the basal segments (diastole, C; systole, D).

17. Treatment Supportive care according to complications Arrhythmias Cardiogenic shock Pulmonary edema Careful use of pressors

18. Prognosis ~1% hospital mortality ~10% recur ?? Return of LVEF within 2-4 weeks

19. References Nef HM et al. Tako-Tsubo Cardiomyopathy (Apical Ballooning). Heart 2007;93:1309-1315 Akashi YJ et al. Takotsubo Cardiomyopathy – A New Form of Acute, Reversible Heart Failure. Circulation 2008;118:2754-2762 Wittstein IS et al. Neurohumora Features of Myocardial Stunning Due to Sudden Emotional Stress. NEJM 2005;352:539-548 Kurowski V et al. Apical and Midventricular Transient Left Ventricular Dysfunction Syndreom (Tako-Tsubo Cardiomyopathy) – Frequency, Mechanisms, Prognosis. Chest 2007; 132:509-816 Hassan T et al. A Case of Tako-tsubo Cardiomyopathy. Heart 2008;94:177 UpToDate. Stress-induced (takotsubo) Cardiomyopathy. 2009.