Takotsubo Syndrome

Background

• Takotsubo syndrome is characterized by acute heart failure with a distinctive regional left ventricular contraction profile, often accompanied by significantly reduced left ventricular ejection fraction.
• Takotsubo syndrome has a similar presentation to acute coronary syndrome, but is not caused by coronary artery obstruction and is often triggered by an emotionally or physically stressful event.
• Postmenopausal women account for about 90% of cases.
• The exact cause is unknown, but potential contributors include catecholamine excess and sympathetic nervous system hyperactivity.

Evaluation

• Suspect takotsubo syndrome in:
  • postmenopausal woman with clearly identified precipitant physical or emotional stress and echocardiographic left ventricle dysfunction more severe than electrocardiogram (ECG) changes and the degree of cardiac biomarker elevation indicate
  • patients with acute cardiac chest pain with ST-segment elevation
  • patients with symptoms similar to acute coronary syndrome
• No universally accepted criteria for takotsubo syndrome exist, but several diagnostic criteria have been proposed.
• Initial testing to rule out acute coronary syndrome may include:
  • electrocardiogram
  • cardiac biomarkers including B-type natriuretic peptide (BNP) and troponin
  • coronary angiography
  • echocardiography
• Perform urgent coronary angiography to rule out ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI) in patients presenting with cardiac chest pain.
• If no apparent coronary occlusions are detected, perform ventriculography (unless contraindicated) to evaluate the left ventricular function where abnormalities that are consistent with takotsubo syndrome include:
  • apical ballooning of the left ventricle, regional wall motion abnormality, and reduced left ventricular ejection fraction in typical takotsubo syndrome
  • a large area of dysfunctional myocardium beyond single coronary artery myocardial distribution
  • symmetrical regional abnormalities involving mid-ventricular segments of the lateral, anterior, and inferior walls giving a circumferential pattern

Management

• Most patients with takotsubo syndrome have a spontaneous recovery of normal cardiac function.
• Use risk stratification to help guide the treatment decision based on the risk of complications, where patients with left ventricular ejection fraction (LVEF) > 45% and no complications may be considered for early discharge and higher-risk patients should be monitored in a coronary care or high-dependency unit with continuous electrocardiographic monitoring.
• Medications may be used as part of supportive therapy.
  • Avoid the use of inotropes and medications with sympathomimetic properties.
  • Consider heart failure medications (such as beta blockers and angiotensin-converting enzyme [ACE] inhibitors) in lower-risk patients with reduced LVEF and in higher-risk patients.
  • Consider beta blockers for left ventricular outflow obstruction resulting in hypotension (management should be guided by hemodynamics and may also include fluids and phenylephrine).
• Mechanical supportive therapy may be warranted in patients with severe takotsubo syndrome.
• Follow all patients for 3-6 months after discharge regardless of severity. At follow-up:
  • Review medications:
    • Stop drug therapy for acute coronary syndrome.
    • If left ventricular function is restored and there are no other indications, wean patients from beta blockers or ACE inhibitors.
  • Confirm the resolution of regional wall motion abnormality and electrocardiography abnormalities with cardiac imaging.