Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is characterized by transient wall motion abnormalities of the left ventricular apex and mid ventricle in the absence of any angiographically significant CAD that leads to transient left ventricular systolic and diastolic dysfunction (i.e. Takotsubo cardiomyopathy is a transient left ventricular systolic and diastolic dysfunction that results in apical akinesis, hypokinesis or dyskinesis with basal segments hypercontractility giving the classic “takotsubo” (octopus trap) appearance on the echocardiography); It is often precipitated by an intense physical or emotional stress and is commonly present in postmenopausal women.

 

Pathophysiology:- Intense physical or emotional stress leads to catecholamine surge that leads to excessive coronary vasoconstriction and transient ischemia which ultimately results in myocardial stunning (i.e. contractile dysfunction).

 

Presents with acute onset substernal chest pain, SOB, syncope, arrhythmias, cardiogenic shock and sudden cardiac death.

 

Mayo Clinic diagnostic criteria for takotsubo includes:- 

1. Absence of coronary artery disease on angiography.

2. Transient akinesis, hypokinesis or dyskinesis of the left apical and mid-ventricular segments extending beyond a single epicardial vascular distribution.

3. New electrocardiographic abnormalities (either ST-segment elevation and/or T wave inversion).

4. Modest elevation of troponin levels.

5. Absence of all of the following (i.e. recent significant head trauma, intracranial bleeding, pheochromocytoma, obstructive epicardial CAD, myocarditis, hypertrophic cardiomyopathy).

 

Diagnosis:- 

1. Laboratory studies show light elevation of cardiac biomarkers (i.e. CK-MB, troponins). 

2. ECG shows ST elevations/T wave inversions. 

3. Echocardiography shows apical ballooning (due to akinesis, hypokinesis or dyskinesis of the  mid to apical segments), basal hypercontractility, decreased LVEF and LVOT obstruction. 

4. Coronary angiography shows no evidence of coronary obstruction.

5. Cardiac MRI.

 

Treatment:- 

1. Hemodynamically stable patients are treated with diuretics, ACE inhibitors, Beta blockers and anticoagulants (if LV thrombus present). 

 

This transient left ventricular apical ballooning syndrome often resolves within a few weeks.