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