Cardiomyopathy, Stress (Tako-Tsubo)

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 have been described in isolated cases

• Recurrences have been described

• Symptoms are similar to any acute coronary syndrome

  • Typical angina

  • Dyspnea

  • Arrhythmias

  • Syncope (rare)

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

• Immediate therapy is similar to any acute myocardial infarction

• Long-term therapy depends on whether LV dysfunction persists

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

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

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

• Mortality reported during the acute phase in hospitalized patients is approximately 4–5%; this figure is comparable to that of ST-segment-elevation myocardial infarction in the era of primary percutaneous coronary interventions

• 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 seen by a cardiologist for further evaluation and monitored until resolution of the ventricular dysfunction