Takotsubo cardiomyopathy: Difference between revisions

No edit summary
(8 intermediate revisions by 5 users not shown)
Line 3: Line 3:
*AKA transient apical ballooning syndrome or stress-induced cardiomyopathy
*AKA transient apical ballooning syndrome or stress-induced cardiomyopathy
*Bulging out of LV apex with preserved function of the base looks like an octopus pot or "tako tsubo" in Japanese
*Bulging out of LV apex with preserved function of the base looks like an octopus pot or "tako tsubo" in Japanese
**Recent recognition of additional subtypes: reverse Takotsubo (basal ballooning), mid-ventricular type, localized type
*85% of cases caused by stressful event before symptoms (death of loved one, fear, argument, asthma, surgery, stroke, etc.)<ref> Sharkey, S., Lesser, J., & Maron, B. (2011). Takotsubo (stress) cardiomyopathy. American Heart Association.</ref>
*85% of cases caused by stressful event before symptoms (death of loved one, fear, argument, asthma, surgery, stroke, etc.)<ref> Sharkey, S., Lesser, J., & Maron, B. (2011). Takotsubo (stress) cardiomyopathy. American Heart Association.</ref>
**Proposed mechanisms include vasospasm and abnormal response to catecholamine surge
**Proposed mechanisms include vasospasm, microvascular dysfunction, and abnormal myocyte response to catecholamine surge
**As high as 28% in ICU patients due to severe physical stress<ref>Park JH, Kang SJ, Song JK, et al. Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU. Chest 2005;128:296-302.</ref>
**As high as 28% in ICU patients due to severe physical stress<ref>Park JH, Kang SJ, Song JK, et al. Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU. Chest 2005;128:296-302.</ref>


==Clinical Features==
==Clinical Features==
*Mimics [[Acute Coronary Syndrome]]
*Mimics [[Acute coronary syndrome]]
*Chest Pain
*[[Chest pain]]
*Dyspnea
*[[Dyspnea]]
*[[Cardiogenic Shock]] and sudden [[CHF]]
*[[Cardiogenic shock]] and sudden [[CHF]]
*Lethal arrhythmia (e.g. VT/VF, PEA)
*Lethal [[arrhythmia]] (e.g. [[VTach]]/[[VF]], [[PEA]])


==Differential Diagnosis==
==Differential Diagnosis==
Line 21: Line 22:
==Evaluation==
==Evaluation==
[[File:Takotsubo ventriculography.gif|thumbnail|LV apical ballooning during systole]]
[[File:Takotsubo ventriculography.gif|thumbnail|LV apical ballooning during systole]]
*Troponin frequently elevated
*[[Troponin]] may elevated or normal, but not usually as high as with traditional STEMI
*[[ECG]]  
*[[ECG]]  
**May mimic STEMI
**May mimic STEMI
**Frequently affects the anterior distribution and to a lesser extent inferior distribution
**Frequently affects the anterior distribution and to a lesser extent inferior distribution
*Echocardiogram
*[[Echocardiography]]
**Systolic Dysfunction (with ejection fraction dropping from normal to <25-35%)
**Systolic Dysfunction (with ejection fraction dropping from normal to <25-35%)
**Reduced contractility not explained by single vessel disease
**Reduced contractility not explained by single vessel disease
**Apical Ballooning on US
[[File:apicalballooning.gif|thumbnail|Apical Ballooning<ref>http://www.thepocusatlas.com/left-ventricle-1</ref>]]
*Ventriculography
*Ventriculography
**Shows LV ballooning
**Shows LV ballooning
Line 38: Line 42:
| align="center" style="background:#f0f0f0;"|'''Takutsubo'''
| align="center" style="background:#f0f0f0;"|'''Takutsubo'''
|-
|-
| EKG||Specific vascular distribution||Multiple regions of change
| ECG||Specific vascular distribution||Multiple regions of change
|-
|-
| Echo||Specific vascular distribution||Multiple regions of wall motion abnormalities
| Echo||Specific vascular distribution||Multiple regions of wall motion abnormalities
Line 56: Line 60:
==Management==
==Management==
*Treat as STEMI until ruled out
*Treat as STEMI until ruled out
*Anticoagulation may be required until wall motion abnormalities resolve
*[[Anticoagulation]] may be required until wall motion abnormalities resolve
*Monitor QTc intervals and arrhythmias
*Monitor QTc intervals and arrhythmias
**Stop all QT prolonging drugs
**Stop all QT prolonging drugs
**Replace magnesium levels
**Replete [[magnesium sulfate|magnesium]]
*Management of differs from usual [[cardiogenic shock]]<ref>Masoud H. Takotsubo Cardiomyopathy in Intensive Care Unit: Prevention, Diagnosis and Management. International Cardiovascular Forum Journal. 2016; 5:33-35.</ref>
*Management of differs from usual [[cardiogenic shock]]<ref>Masoud H. Takotsubo Cardiomyopathy in Intensive Care Unit: Prevention, Diagnosis and Management. International Cardiovascular Forum Journal. 2016; 5:33-35.</ref>
**IVF
**[[IVF]]
**With LVOT obstruction, avoid volume depletion and vasodilator therapy (similar to [[hypertrophic cardiomyopathy]] management)
**With LVOT obstruction, avoid volume depletion and vasodilator therapy (similar to [[hypertrophic cardiomyopathy]] management)
**Avoid use of catecholamine based inotropic meds
**Avoid use of catecholamine based inotropic meds
**Consider Beta Blockers and ACE Inhibitors, which reduce recurrence
**Consider [[beta blockers]] and [[ACE inhibitors]], which reduce recurrence
**Intra-aortic balloon pump or ECMO in refractory cases
**Intra-aortic balloon pump or [[ECMO]] in refractory cases


==Prognosis==
==Prognosis==
Ejection Fraction returns to normal (at least >50%) in nearly all cases
*Ejection Fraction returns to normal (at least >50%) in nearly all cases
*Some patients experience recurrence


==Disposition==
==Disposition==

Revision as of 17:05, 26 September 2019

Background

A depicts the left ventricular dilation that occurs in Takotsubo cardiomyopathy compared to a normal heart in B.
  • AKA transient apical ballooning syndrome or stress-induced cardiomyopathy
  • Bulging out of LV apex with preserved function of the base looks like an octopus pot or "tako tsubo" in Japanese
    • Recent recognition of additional subtypes: reverse Takotsubo (basal ballooning), mid-ventricular type, localized type
  • 85% of cases caused by stressful event before symptoms (death of loved one, fear, argument, asthma, surgery, stroke, etc.)[1]
    • Proposed mechanisms include vasospasm, microvascular dysfunction, and abnormal myocyte response to catecholamine surge
    • As high as 28% in ICU patients due to severe physical stress[2]

Clinical Features

Differential Diagnosis

ST Elevation

Cardiomyopathy

Evaluation

LV apical ballooning during systole
  • Troponin may elevated or normal, but not usually as high as with traditional STEMI
  • ECG
    • May mimic STEMI
    • Frequently affects the anterior distribution and to a lesser extent inferior distribution
  • Echocardiography
    • Systolic Dysfunction (with ejection fraction dropping from normal to <25-35%)
    • Reduced contractility not explained by single vessel disease
    • Apical Ballooning on US
Apical Ballooning[3]
  • Ventriculography
    • Shows LV ballooning
  • Angiogram
    • No significant coronary blockage to explain LV dysfunction

Clinical Differences Between AMI and [4]

AMI Takutsubo
ECG Specific vascular distribution Multiple regions of change
Echo Specific vascular distribution Multiple regions of wall motion abnormalities
Troponin Significant elevation Mild to no elevation
NT proBNP Mild elevation Significant elevation
RV Uncommon in left heart AMI ~1/3 have biventricular ballooning
Hypotension Cardiogenic shock Multi-factorial: LVOT obstruction, peripheral vasodilation, LV and/or RV decreased inotropy
PCI Stenosis No coronary obstruction

Management

  • Treat as STEMI until ruled out
  • Anticoagulation may be required until wall motion abnormalities resolve
  • Monitor QTc intervals and arrhythmias
    • Stop all QT prolonging drugs
    • Replete magnesium
  • Management of differs from usual cardiogenic shock[5]

Prognosis

  • Ejection Fraction returns to normal (at least >50%) in nearly all cases
  • Some patients experience recurrence

Disposition

  • Admit for post catheterization care

See Also

External Links

Cardiomyopathy (Main)

References

  1. Sharkey, S., Lesser, J., & Maron, B. (2011). Takotsubo (stress) cardiomyopathy. American Heart Association.
  2. Park JH, Kang SJ, Song JK, et al. Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU. Chest 2005;128:296-302.
  3. http://www.thepocusatlas.com/left-ventricle-1
  4. TakotsuboMasoud H. Takotsubo Cardiomyopathy in Intensive Care Unit: Prevention, Diagnosis and Management. International Cardiovascular Forum Journal. 2016; 5:33-35.
  5. Masoud H. Takotsubo Cardiomyopathy in Intensive Care Unit: Prevention, Diagnosis and Management. International Cardiovascular Forum Journal. 2016; 5:33-35.