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Key Features

Essentials of Diagnosis

  • Occurs after a major catecholamine discharge

  • Acute chest pain or shortness of breath

  • Predominately affects postmenopausal women

  • Presents like an acute anterior myocardial infarction, but coronaries normal at cardiac catheterization

  • Imaging reveals apical left ventricular (LV) ballooning due to anteroapical stunning of the myocardium

  • Most patients recover completely

General Considerations

  • LV apical ballooning

    • Follows a high catecholamine surge

    • The resulting shape suggests a rounded ampulla form similar to a Japanese octopus pot (tako-tsubo pot)

  • Mid-ventricular ballooning has also been described

  • The myocardial stunning that occurs does not follow the pattern suggestive of coronary ischemia

  • Has been described following some stressful event, such as

    • Hypoglycemia

    • Lightning strikes

    • Earthquakes

    • Postventricular tachycardia

    • Alcohol withdrawal

    • Surgery

    • Hyperthyroidism

    • Stroke

    • Severe emotional stress ("broken-heart syndrome")

  • Virtually any event that triggers excess catecholamines has been implicated

  • Pericarditis and even tamponade has been described in isolated cases

  • Recurrences have been described

Clinical Findings

  • Symptoms are similar to any acute coronary syndrome

    • Typical angina

    • Dyspnea

    • Arrhythmias

    • Syncope (rare)

Diagnosis

Laboratory Tests

  • Initial cardiac enzymes are positive but often taper quickly

Imaging Studies

  • Chest radiograph either normal or shows pulmonary congestion

  • MRI hyperenhancement studies reveal no long-term scarring in almost all cases

Diagnostic Studies

  • ECG reveals

    • ST segment elevations

    • Deep anterior T wave inversion that gradually resolve over time

  • Echocardiogram reveals LV apical dyskinesia usually not consistent with any particular coronary distribution

  • Urgent cardiac catheterization reveals LV apical ballooning in association with normal coronary arteries

Treatment

  • Immediate therapy is similar to any acute myocardial infarction

  • Long-term therapy depends on whether LV dysfunction persists

  • Most patients receive aspirin, β-blockers, and angiotensin-converting enzyme (ACE) inhibitors until the LV fully recovers

  • Use of ACE inhibitors or angiotensin receptor blockers but not β-blockers has been associated with improved long-term survival

Outcome

Complications

  • The rate of severe in-hospital complications, including shock and death, are similar to those with an acute coronary syndrome

  • Physical triggers, acute neurologic or psychiatric disease, high troponin levels and a low EF are independent predictors of in-hospital complications

  • Men appear to be at higher risk for major adverse cardiac and cerebrovascular events during the first 30 days following hospitalization

Prognosis

  • Good unless there is a serious complication (eg, mitral regurgitation, ventricular rupture, ventricular tachycardia)

  • Recovery is expected in most cases after a period of weeks to months

  • At times, LV function recovers in a few days

  • Approximately 10% of patients will have cardiac and neurologic adverse outcomes over the next year

When to Refer

  • All patients with an acute coronary syndrome should be urgently ...

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