Takotsubo Cardiomyopathy

Richard Fox

Why Takotsubo?

• Takotsubo cardiomyopathy (TC) is an acute cardiac syndrome, which presents like ACS

• Misdiagnosis poses a bleeding risk to the patient through thrombolysis

• Awareness of TC and the at risk demographic is therefore vital

• Clinicians should include TC in their differential diagnosis in cases of ACS that show no coronary artery stenosis

What is Takotsubo?

• TC is an acute cardiac syndrome, which presents like ACS

• Transient LV apical ballooning in the absence of coronary artery stenosis

• Often precipitated by acute emotional or physical stress

• “Broken heart syndrome”

• Takotsubo; “Octopus pot” was first documented in Japan in 1991

• It is so named due to the appearance of the left ventriculogram is systole

Fig.1 A. Ventriculogram showing left apical ballooning. B.Japanese octopus pot7

Prevalence

• Since 1991 the number of reported cases has risen annually

• In a recent study in the US, TC accounted for ≈2.2% of STEMI cases

• The true prevalence is still uncertain

Women>Men

• Females are affected more than men• 90% of cases involve women• Majority are post-menopausal • Mean age 68yrs

Presentation

Cannot distinguish between Takotsubo and STEMI at presentation!!!

History

• Acute emotional stress (25% of cases)

• Physical stressor (30% of cases)

• Idiopathic (30% of cases)

Unexpected death in the family

Confrontational argument

Severe anxiety

Asthma attack

Exhaustion

Sepsis

Investigation

• ECG• Angiography• Echocardiography• Cardiac enzymes

ECG

• At presentation:

ST-elevation in pre-cordial leads

Repeat ECG

• Later that day

Resolution of ST-elevation Development of T-wave inversion

Angiography• The absence of coronary artery

stenosis1 • Mid-ventricular wall

akinesis/dyskinesis, with hypercontractile basal segments producing the characteristic appearance6

• Abnormalities in the apical wall, sparing the base

Fig. Ventriculogram in diastole (A) and systole (B)6

Echocardiography

• Acutely reduced ejection fraction1

33 %

(Normal = 55-65%)

Cardiac enzymes

• TnI rises in Takotsubo• In Takotsubo the peak TnI rise is

disproportionate to the level of LV dysfunction

Investigation

Takotsubo STEMI

Initial TnI 1.1 1.9Peak TnI 4.9 7.3Ejection fraction

33 25

Pathophysiology• The pathophysiology of Takotsubo is poorly understood.

Several mechanisms for this reversible cardiomyopathy have been proposed1:

Microvascular dysfunction: coronary artery microspasm*

Excess plasma catecholamines* Myocardial stunning: Acute

sympathetic overactivity

Takotsubo

*Estrogen deficiency: Increased sensitivity in post-menopausal women

Pathophysiology cont….• Increased plasma catecholamines - front runner in explaining the mechanism in Takotsubo

- Catecholamine are 2-3 times higher in TC than in STEMI at hospitalisation.

- Excess catecholamines are shown to cause myocardial damage; focal mycytolysis seen in TC

- Epiphenomenon?• Myocardial stunning - Increased sympathetic activity, linked with emotional

stress, may be important in TC1. - Excess cardiac adrenoreceptor stimulation causes

left ventricular hypocontraction in animal models1.

Estrogen

• Hormones are thought to be the key in explaining the high proportion of cases in PMW

• Estrogen may influence coronary artery vasoreactivity and its absence may increase risk of microspasm1

Diagnosing Takotsubo

Mayo clinic criteria4

New ECG abnormalities * Absence of

obstructive coronary artery disease

Transient LV apical akinesis/ dyskinesis

* Without concurrent conditions; head injury/intracranial bleed/ pheochromocytoma/myocarditis/hypertrophic cardiomyopathy

Management

• At present, treatment is entirely empirical. Management should follow that for ACS and emergency angiography is advised1.

• Other possibilities for “broken heart syndrome”?

http://www.youtube.com/watch?v=fbn75LITtlc&feature=related

Prognosis• Very good; in the absence of comorbidity

• Systolic dysfunction resolves within days-weeks4

• At this time, repeat ECG classically shows resolution of all abnormalities, though T-wave inversion may persist for longer.

• In-hospital mortality is low (1-2%), as is the rate of recurrence (10%)1.

• Ventricular thrombosis and heart failure are possible complications

• Long-term prognosis is unknown and future prospective studies are required.

Summary• TC is an acute cardiac syndrome, transiently affecting

LV function and presenting like ACS.

• It is impossible to differentiate the two at presentation.

• TC should be included as a differential diagnosis in

patients who: - meet the Mayo clinic criteria

- have a history of an acute emotional or physical stressor

• Especially in post-menopausal women, who seem to be more at risk.

References

1. Gianni M, Dentali F, Grandi AM, Summer G, Hiralal, Lonn E. Apical ballooning syndrome or Takotsubo cardiomyopathy:systematic review.Eur Heart J.2006;27;1523-1529

2. Doke K, Sato H, Uchida T, Ishihara M.Myocardial stunning due to simultaneous multivessel coronary spasms:a review of 5 cases.J Cardiol 1991;21;203-14

3. Bybee KA, Prasad A, Barsness GW, Lerman A, Jaffe AS, Murphy JG, et al Clinical characteristics and

thrombolysis in myocadial infarction frame counts in women with transient left ventricular apical ballooning syndrome.Am J Cardiol.2004;94;343-346 4. Barker S, Solomon H, Bergin JD,Huff JS, Brady WJ.Electrocardiographic ST-segment elevation:

Takotsubo cardiomyopathy versus ST segment elevation myocardial infarction-A case series.Am J Emerg Med 2009;27;220-226

5. Bybee KA, Prasad A.Stress related cardiomyopathy syndromes.Circulation.2008;118;397-4096. Nielson LH, Munk K, Goetzsche O et al. Takotsubo cardiomopathyAn important differential

diagnosis to acute myocardial infarctio. Danish medical bulletin.2009;56;165-1687. Kurisu S, Sato H, Kawagoe T, Ishihara M, Shimatani Y, Nishioka K, Kono Y, Umemura T, Nakamura

S (2002) Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction Am Heart J 143(3): 448-455