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    Takotsubo Syndrome

    Cardiovascular

    Last Updated Aug 28, 2020
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    Context

    • Takotsubo Syndrome (also known as Takotsubo cardiomyopathy, stress cardiomyopathy, apical ballooning syndrome and broken heart syndrome) is an important clinical entity and mimic of myocardial infarction that has been increasingly recognized over the last 20 years.
    • Takotsubo Syndrome causes a transient regional systolic dysfunction of the left ventricle in the absence of coronary artery disease on angiography. The name “Takotsubo” comes from the Japanese word for an “octopus pot”, which has a shape that resembles the apical ballooning typical of this condition.
    • Patients present in a manner similar to acute coronary syndrome (chest pain or shortness of breath with ECG changes and/or elevated troponin), and in the emergency department, they are typically indistinguishable.
    • Patients often, but not always, present after an acute psychological or physiological stressor, such as the death of a loved one, acute infection, trauma, etc.
    • While the condition is typically mild and transient for most patients, some may develop severe complications such as cardiogenic shock and heart failure or may develop an intra-ventricular thrombus which can cause systemic embolization.

    Diagnostic Process

    • The diagnosis of Takotsubo Syndrome is generally not made in the emergency department. It is typically a retrospective diagnosis made by the cardiologist after extensive investigation, and requires the following:
      • Transient regional wall motion abnormalities on echocardiography (typically apical).
      • Absence of obstructive coronary artery disease on angiography.
      • Presence of new ECG abnormalities or troponin elevation.
      • Note: ECG abnormalities do NOT have to include ST-elevation, though this is a common presentation.
    • All patients with possible Takotsubo Syndrome should have inpatient cardiology consultation in order to exclude coronary artery disease causing acute coronary syndrome.

    Recommended Treatment

    • Specific treatment of Takotsubo Syndrome is typically outside the purview of emergency clinicians, as the diagnosis is made after inpatient investigations.
    • Initial treatment for possible acute coronary syndrome should be given, in consultation with your local cardiologist, until an acute coronary syndrome can be excluded.
    • Management of Takotsubo Syndrome is generally supportive, as this is a transient condition.
    • Medical management is variable but typically consists of typical heart failure therapy, such as beta-blockers, ACE inhibitors, and diuretics as indicated. There is no evidence for improved outcomes with initiation of specific treatment for Takotsubo Syndrome.
    • Management of patients who develop severe complications of Takotsubo Syndrome such as cardiogenic shock is typically an inpatient issue and beyond the scope of this article. However, these patients may require aggressive resuscitation with vasopressor and inotropic support and even mechanical circulatory support such as an intra-aortic balloon pump or extracorporeal life support.
    • Patients who develop intraventricular thrombus will require anticoagulation, and some cardiologists may prescribe prophylactic anticoagulation to prevent thrombus formation.

    Prognosis

    • Patients with Takotsubo Syndrome generally have complete recovery with little residual cardiac dysfunction. However, those who develop severe complications such as heart failure or shock have significantly increased mortality and morbidity.

    Other Resources

    Takotsubo Cardiomyopathy (broken heart syndrome). Echocardiogram of typical apical wall motion abnormality in Takotsubo Syndrome. (Mastering & Guidelines in Ultrasound & Echo YouTube channel).

     

    Quality Of Evidence?

    Justification

    This condition has a low incidence and there is little prospective data to guide management strategies. Evidence is primarily based on case reports/series and retrospective reviews, which are at high risk of bias. Further prospective investigation is needed.

    Low

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