Takotsubo cardiomyopathy: Difference between revisions
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*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 | *Mimics [[Acute coronary syndrome]] | ||
*Chest | *[[Chest pain]] | ||
*Dyspnea | *[[Dyspnea]] | ||
*[[Cardiogenic | *[[Cardiogenic shock]] and sudden [[CHF]] | ||
*Lethal arrhythmia (e.g. | *Lethal [[arrhythmia]] (e.g. [[VTach]]/[[VF]], [[PEA]]) | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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==Evaluation== | ==Evaluation== | ||
[[File:Takotsubo ventriculography.gif|thumbnail|LV apical ballooning during systole]] | [[File:Takotsubo ventriculography.gif|thumbnail|LV apical ballooning during systole]] | ||
*Troponin | *[[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 | ||
* | *[[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 | ||
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| align="center" style="background:#f0f0f0;"|'''Takutsubo''' | | align="center" style="background:#f0f0f0;"|'''Takutsubo''' | ||
|- | |- | ||
| | | 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 | ||
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==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 | ||
** | **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 | **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
- 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
- Mimics Acute coronary syndrome
- Chest pain
- Dyspnea
- Cardiogenic shock and sudden CHF
- Lethal arrhythmia (e.g. VTach/VF, PEA)
Differential Diagnosis
ST Elevation
- Cardiac
- ST-segment elevation myocardial infarction (STEMI)
- Post-MI (ventricular aneurysm pattern)
- Previous MI with recurrent ischemia in same area
- Wellens' syndrome
- Coronary artery vasospasm (eg, Prinzmetal's angina)
- Coronary artery dissection
- Pericarditis
- Myocarditis
- Aortic dissection in to coronary
- Left ventricular aneurysm
- Left ventricular pseudoaneurysm
- Early repolarization
- Left bundle branch block
- Left ventricular hypertrophy (LVH)
- Myocardial tumor
- Myocardial trauma
- RV pacing (appears as Left bundle branch block)
- Brugada syndrome
- Takotsubo cardiomyopathy
- AVR ST elevation
- Other thoracic
- Metabolic
- Drugs of abuse (eg, cocaine, crack, meth)
- Hyperkalemia (only leads V1 and V2)
- Hypothermia ("Osborn J waves")
- Medications
Cardiomyopathy
- Dilated cardiomyopathy
- Hypertrophic cardiomyopathy
- Restrictive cardiomyopathy
- Peripartum cardiomyopathy
- Takotsubo cardiomyopathy
- Arrhythmogenic right ventricular dysplasia
Evaluation
- 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
- 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]
- IVF
- With LVOT obstruction, avoid volume depletion and vasodilator therapy (similar to hypertrophic cardiomyopathy management)
- Avoid use of catecholamine based inotropic meds
- Consider beta blockers and ACE inhibitors, which reduce recurrence
- Intra-aortic balloon pump or ECMO in refractory cases
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
References
- ↑ Sharkey, S., Lesser, J., & Maron, B. (2011). Takotsubo (stress) cardiomyopathy. American Heart Association.
- ↑ 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.
- ↑ http://www.thepocusatlas.com/left-ventricle-1
- ↑ TakotsuboMasoud H. Takotsubo Cardiomyopathy in Intensive Care Unit: Prevention, Diagnosis and Management. International Cardiovascular Forum Journal. 2016; 5:33-35.
- ↑ Masoud H. Takotsubo Cardiomyopathy in Intensive Care Unit: Prevention, Diagnosis and Management. International Cardiovascular Forum Journal. 2016; 5:33-35.