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
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
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
Diagnosis
Electrocardiogram (EKG) (see Electrocardiogram, [[Electrocardiogram]])
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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
- Right Ventricular Involvement: may accompany left apical ballooning in 26-32% of cases
- 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]])
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Clinical Manifestations
Cardiovascular Manifestations
Abnormal Electrocardiogram
- Clinical
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
- Echocardiogram
- 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
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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
Prognosis
- Rate of Major Adverse Cardiac/Cerebrovascular Events [MEDLINE]: 9.9% per patient-year
- Mortality Rate [MEDLINE]: 5.6% per patient-year
References
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Dynamic left ventricular outflow tract obstruction in acute myocardial infarction with shock: cause, effect, and coincidence. Circulation. 2007;116:e110–e113 [MEDLINE]
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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]
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Cardiogenic shock: current concepts and improving outcomes. Circulation 2008;117:686–697 [MEDLINE]
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Clinical implications of midventricular obstruction and intravenous propranolol use in transient left ventricular apical ballooning. Am Heart J 2008, 155:1–7 [MEDLINE]
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Stress-induced cardiomyopathy in the critically ill – why inotropes fail to improve outcome. Int J Cardiol 2013, 168:4489–4490 [MEDLINE]
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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]
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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]
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Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N Engl J Med. 2015 Sep 3;373(10):929-38. doi: 10.1056/NEJMoa1406761 [MEDLINE]