Epidemiology

History

• 1990: entity was first described in Japan
  • Takotsubo: “octopus pot”

International Takotsubo Registry of 1750 Patients [MEDLINE]

• Association with Female Sex: 89.8% of Takotsubo cases were female
• Triggers
  • Physical Triggers: 36.0% of cases had physical triggers
  • No Evident Trigger: 28.5% of cases had no evident trigger
  • Emotional Triggers: 27.7% of cases had emotional triggers
• Presence of Neurologic/Psychiatric Disease
  • Takotsubo Cardiomyopathy: 55.8% of cases had neuropsychiatric disease
  • Acute Coronary Syndrome: 25.7% of cases had neuropsychiatric disease
• Mean Left Ventricular Ejection Fraction: ejection fraction is significantly lower in Takotsubo cardiomyopathy, as compared to patients with acute coronary syndrome
  • Takotsubo Cardiomyopathy: mean left ventricular ejection fraction was 40.7 ± 11.2%
  • Acute Coronary Syndrome: mean left ventricular ejection fraction was 51.5 ± 12.3%
• In-Hospital Rates of Shock/Death: similar in both Takotsubo cardiomyopathy and acute coronary syndrome
• Predictors of In-Hospital Complications
  • High Troponin Level
  • Low Ejection Fraction on Admission
  • Presence of Acute Neuropsychiatric Disease
  • Presence of a Physical Trigger

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Etiology

Neurologic Disease

• Acute Transverse Myelitis (see Transverse Myelitis, [[Transverse Myelitis]])
• Brain Tumor
• Encephalitis (see Encephalitis, [[Encephalitis]])
• Guillain-Barre Syndrome (see Guillain-Barre Syndrome, [[Guillain-Barre Syndrome]])
• Hydrocephalus (see Hydrocephalus, [[Hydrocephalus]])
• Ischemic Cerebrovascular Accident (CVA) (see Ischemic Cerebrovascular Accident, [[Ischemic Cerebrovascular Accident]])
• Neuroleptic Malignant Syndrome (NMS) (see Neuroleptic Malignant Syndrome, [[Neuroleptic Malignant Syndrome]])
• Posterior Reversible Leukoencephalopathy Syndrome (PRES) (see Posterior Reversible Encephalopathy Syndrome, [[Posterior Reversible Encephalopathy Syndrome]])
• Seizures (see Seizures, [[Seizures]])
  • Epidemiology: case reports
• Subarachnoid Hemorrhage (SAH) (see Subarachnoid Hemorrhage, [[Subarachnoid Hemorrhage]])
  • Epidemiology: left ventricular dysfunction occurs in 10-20% of patients with SAH
  • Risk Factors for Takotsubo Cardiomyopathy in Subarachnoid Hemorrhage
    • Elevated Troponin Levels
    • Female Gender
    • Poor-Grade SAH
    • Prior Stimulant Drug Use
• Subdural Hematoma (SDH) (see Subdural Hematoma, [[Subdural Hematoma]])
• Traumatic Brain Injury (TBI) (see Traumatic Brain Injury, [[Traumatic Brain Injury]])

Other

• Anorexia Nervosa (see Anorexia Nervosa, [[Anorexia Nervosa]])
  • Epidemiology: case reports
• Diabetic Ketoacidosis (DKA) (see Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State, [[Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State]])
  • Epidemiology: case reports
• Opiate Withdrawal (see Opiates, [[Opiates]])
• Pheochromocytoma (see Pheochromocytoma, [[Pheochromocytoma]])
  • Epidemiology: case reports
• Post-Liver Transplantation (see Liver Transplant, [[Liver Transplant]])
  • Epidemiology: case reports
• Recent Emotional Stress
  • Epidemiology: case reports
• Sepsis (see Sepsis, [[Sepsis]])
  • Epidemiology: case reports
• Systemic Lupus Erythematosus (SLE) (see Systemic Lupus Erythematosus, [[Systemic Lupus Erythematosus]])
  • Epidemiology: case reports
• Tetanus (see Tetanus, [[Tetanus]])
• Thyrotoxicosis (see Hyperthyroidism, [[Hyperthyroidism]])
  • Epidemiology: case reports

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Physiology

• Abnormal Cerebral Blood Flow to the Hippocampus/Brainstem/Basal Ganglia (Suggesting Activation of These Regions): results in excessive catecholamine release -> sympathetic stimulation of the myocardium
  • Catecholamine-Triggered Myocyte Injury: may play a role
  • Coronary Microvascular Dysfunction: may play a role
  • Multivessel Epicardial Vasospasm: may play a role
  • Catecholamine-Induced Development of Dynamic Intraventricular Pressure Gradient: results in subendocardial stunning of left ventricular apex

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Diagnosis

Electrocardiogram (EKG) (see Electrocardiogram, [[Electrocardiogram]])

• xxxx

Serum Troponin (see Serum Troponin, [[Serum Troponin]])

• Mildly Elevated

Brain Natriuretic Peptide (BNP) (see Brain Natriuretic Peptide, [[Brain Natriuretic Peptide]])

• May Be Elevated: elevation is predictive of wall motion abnormalities in subarachnoid hemorrhage and iatrogenic catecholamine-induced cardiomyopathy

Echocardiogram (see Echocardiogram, [[Echocardiogram]])

• General Comments: dysfunction always involves the left ventricle
• Classically-Described Pattern: apical ballooning or hypokinesis with hypercontractility of basal segments
  • Right Ventricular Involvement: may accompany left apical ballooning in 26-32% of cases
    • These cases are more likely to have lower ejection fractions, pleural effusions, and longer hospital stays
• Other Patterns
  • Transient Systolic/Diastolic Left Ventricular Dysfunction with Various Wall Motion Abnormalities Which May Extend Beyond the Distribution of a Single Epicardial Coronary Artery
  • Inverted Cardiomyopathy Pattern: basal and mid-ventricular hypokinesis with sparing of the apex
    -This pattern may be more common in patients with an underlying neurologic etiology

Cardiac Catheterization (see Cardiac Catheterization, [[Cardiac Catheterization]])

• xxxx

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Clinical Manifestations

Cardiovascular Manifestations

Abnormal Electrocardiogram

• Clinical
  • Prolonged QT (see Torsade, [[Torsade]])
  • ST Segment Depression/Elevation (see xxxx, [[xxxx]])
  • T-Wave Inversion (see xxxx, [[xxxx]])

Arrhythmias

• Clinical
  • Sinus Bradycardia (see Sinus Bradycardia, [[Sinus Bradycardia]])
  • Sinus Tachycardia (see Sinus Tachycardia, [[Sinus Tachycardia]])

Congestive Heart Failure (CHF)

• Epidemiology: acute systolic heart failure in the absence of obstructive coronary artery disease
• Clinical
  • Cardiogenic Shock (see Cardiogenic Shock, [[Cardiogenic Shock]])
  • Congestive Heart Failure with Systolic Dysfunction (see Congestive Heart Failure, [[Congestive Heart Failure]])

Left Ventricular Outflow Tract Obstruction

• Epidemiology: occurs in 20% of cases [MEDLINE]
  • Seen More Commonly in Older Patients
• Physiology: associated with increased degree of septal bulging
• Diagnosis
  • Echocardiogram
    • Systolic Anterior Motion (SAM) of Anterior Mitral Mitral Valve Leaflet
    • Mitral Regurgitation
• Clinical
  • Cardiogenic Shock (see Cardiogenic Shock, [[Cardiogenic Shock]])

Other

• Chest Pain (see Chest Pain, [[Chest Pain]])
• Sudden Cardiac Death
• Syncope (see Syncope, [[Syncope]])

Pulmonary Manifestations

• Dyspnea (see Dyspnea, [[Dyspnea]])

Other Manifestations

• xxx
• xxx

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Treatment

Specific Management of Takotsubo without Left Ventricular Outflow Tract Obstruction

• Inotropes
  • Dobutamine (Dobutrex) (see Dobutamine, [[Dobutamine]])
  • Dopamine (see Dopamine, [[Dopamine]])
  • Norepinephrine (Levophed) (see Norepinephrine, [[Norepinephrine]])

Specific Management of Takotsubo with Left Ventricular Outflow Tract Obstruction

• Intravenous Fluid Resuscitation
  • Pharmacology: increasing intravascular volume improves the left ventricular outflow tract obstruction
• Avoidance of Inotropes
  • Pharmacology: inotropes (dobutamine, dopamine, norepinephrine) worsen the left ventricular outflow tract obstruction
• Avoidance of Vasodilators
  • Pharmacology: vasodilators worsen the left ventricular outflow tract obstruction
• α1-Adrenergic Receptor Agonists
  • Pharmacology: increases afterload -> decreases left ventricular outflow tract obstruction
  • Agents
    • Phenylephrine (Neosynephrine) (see Phenylephrine, [[Phenylephrine]])
• Beta Blockers (β-Adrenergic Receptor Antagonists) (see β-Adrenergic Receptor Antagonists, [[β-Adrenergic Receptor Antagonists]]) [MEDLINE]
  • Pharmacology: beta blockers decrease heart rate and myocardial contractility -> decrease the left ventricular outflow tract obstruction
• Intra-Aortic Balloon Pump (IABP) (see Intra-Aortic Balloon Pump, [[Intra-Aortic Balloon Pump]]): may be considered, but since it will decrease afterload, it may worsen the left ventricular outflow tract obstruction

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Prognosis

• Rate of Major Adverse Cardiac/Cerebrovascular Events [MEDLINE]: 9.9% per patient-year
• Mortality Rate [MEDLINE]: 5.6% per patient-year

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References

• Dynamic left ventricular outflow tract obstruction in acute myocardial infarction with shock: cause, effect, and coincidence.  Circulation.  2007;116:e110–e113 [MEDLINE]

• A case of takotsubo cardiomyopathy associated with epileptic seizure: reversible left ventricular wall motion abnormality and ST-segment elevation. Heart Vessels. 2007 Jan;22(1):59-63. Epub 2007 Jan 26 [MEDLINE]

• Cardiogenic shock: current concepts and improving outcomes. Circulation 2008;117:686–697 [MEDLINE]

• Clinical implications of midventricular obstruction and intravenous propranolol use in transient left ventricular apical ballooning. Am Heart J 2008, 155:1–7 [MEDLINE]

• Stress-induced cardiomyopathy in the critically ill – why inotropes fail to improve outcome. Int J Cardiol 2013, 168:4489–4490 [MEDLINE]

• Takotsubo cardiomyopathy associated with opiate withdrawal. QJM. 2014 Apr;107(4):301-2. doi: 10.1093/qjmed/hct219. Epub 2013 Oct 29 [MEDLINE]

• Stress cardiomyopathy (tako-tsubo) triggered by nervous system diseases: a systematic review of the reported cases. Int J Cardiol. 2013 Sep 10;167(6):2441-8. doi: 10.1016/j.ijcard.2013.01.031. Epub 2013 Feb 13 [MEDLINE]

• Prevalence, associated factors and management implications of left ventricular outflow tract obstruction in takotsubo cardiomyopathy: a two-year, two-center experience.  BMC Cardiovasc Disord. 2014 Oct 22;14:147. doi: 10.1186/1471-2261-14-147 [MEDLINE]

• Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N Engl J Med. 2015 Sep 3;373(10):929-38. doi: 10.1056/NEJMoa1406761 [MEDLINE]