Download - Takotsubo
Stress-Induced Cardiomyopathy
Takotsubo Cardiomyopathy
Overview
• Left ventricular apical akinesis• Octopus trap
• Mimics acute coronary syndrome• ST elevation• Elevated troponin• No Coronary Stenosis
• Unknown Etiology • Triggered by emotional stressor
Overview
• 1.7-2.2% of patients who had suspected ACS• Women 90%• Asian or Caucasian.• 57.2% were Asian, • 40% were Caucasian• 2.8% were other races.
• Postmenopausal 90%.
Etiology
• Unknown.• Proposed mechanisms:• Multi-vessel coronary artery spasm,• Impaired cardiac microvascular function,• Impaired myocardial fatty acid metabolism,• ACS with reperfusion injury• Endogenous catecholamine-induced myocardial stunning
and microinfarction
Presentation• Most common ACS • chest pain • Dyspnea
• Less common • Palpitations, • Nausea/vomiting • Syncope
• Rare • Cardiogenic shock
Reported triggers• Emotional• Death of a loved one (including pets)• Surprise party• Family member being arrested• Fierce argument• Robbery• Public speaking
• Surgery – Hysterectomy, Cholecystectomy• Stress echo with dobutamine• Opiate withdrawal• Thyrotoxicosis • Physical exhaustion ( triathlon, sexual, gym)- males
Differential diagnosis• Acute Coronary Syndromes• Angina Pectoris• Aortic Dissection• Boerhaave Syndrome• Cardiac Tamponade• Cardiogenic Shock• Cardiomyopathy• CocaineDilated Hypertrophic
• Coronary Artery Vasospasm
Workup• EKG• Anterior precordial leads• ST elevation 67-75%• T wave inversion 61%
• Cardiac enzymes• BNP• Circulating catecholamines• Echocardiogram – apical akinesis ( ballooning) • Angiography- normal coronary/abnormal ventriculography• Chest X-ray, normal or pulmonary edema.
Treatment
• Pre-hospital must be treated as ACS• Emergency Department, treated as ACS until proven
otherwise. ASA, clopidogrel, nitrates, -blockers, etc• Cardiology admission- cardiac catheterization facilities. • Medication- No RCT studies• ACE Inhibitors• -blockers
Prognosis• 95% complete recovery within 4-8 weeks.• 3% recurrence • Complications• Death 1%• Left heart failure with and without pulmonary edema• Cardiogenic shock• Left ventricular outflow obstruction• Mitral regurgitation• Ventricular arrhythmias• Left ventricular mural thrombus formation• Left ventricular free-wall rupture