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Takotsubo Cardiomyopathy
By Dymond Unutoa
OBJECTIVES
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Learn various names of Takotsubo Cardiomyopathy
(TTC)
Understand the Presentation of TTC
Understand the Etiology and Pathophysiology of
TTC
Understand the Diagnostic tools/measures in
diagnosing TTC
Understand the difference between TTC and AMI
Understand some Treatment/Interventions utilized
after TTC diagnosis
Understand the general Prognosis of TTC
Understand the Prevalence of TTC
Other names know by:
Stress cardiomyopathy
 Transient left ventricular apical
ballooning7,8
 “Ampulla” cardiomyopathy4
 “Broken Heart Syndrome”2,3
 Neurogenic Myocardial Stunning6
 Stress-Induced Cardiomyopathy
 Apical ballooning syndrome1
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The Term “Takotsubo”
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Japanese term
meaning “octopus
pot”
First described in
1990 by Japanese
MDs correlating the
heart shape to a
fisherman’s takotsubo
[3]
Presentation
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Acute onset of chest
pain
Dyspnoe in addition
to a transient left
ventricular (LV)
dysfunction
Acute stage: Often
mimics MI (AMI)
Apical Akinesia
Basal Hyperkinesia
[1,2,3,4]
Presentation
Shortened LVEF (Left Ventricle Ejection
Fraction)
 New ECG abnormalities (ST-segment
elevation and/or T-wave inversion)
 Modest elevation in cardiac troponin
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Etiology and
Pathophysiology
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[1-9]
The true cause of TTC is still under study
but some proposed factors include…
Coronary spasm
Emboli with spontaneous fibrinolysis
Myocarditis
Stunning after/during stressful event
Abnormal response (increase) in
catecholamines such as
epinephrine/norepinephrine
Etiology cont’d
Life altering stressors
such as…
-Death of a loved one
-Loss of employment
-Divorce
 Narcotics withdrawal
-Cocaine abuse
-Opiate withdrawal
-Alcohol withdrawal
 Extreme physical
exertion
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Etiology cont’d
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Catastrophic
medical diagnosis
Domestic abuse
Gambling losses
Confrontational
arguments
Natural Disasters
Diagnostic Measures
Echocardiography
 Contrast ventriculography
 CMRI (Cardiac MRI)
 To distinguish the difference between
TTC and AMI, a coronary angiography
(CAG) is usually performed [8]
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Mayo Clinic Criteria for Dx of
TTC [3,5]
1. Transient akinesis or dyskinesis of the
left ventricular apical and mid-ventricular
segments w/ regional wall-motion
abnormalities extending beyond a single
epicardial vascular distribution
 2. Absence of obstructive coronary disease
or angiographic evidence of acute plaque
rupture
 3. New electrocardiographic abnormalities
(either ST-segment elevation or T-wave
inversion)
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Mayo Clinic TTC Dx cont’d
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ABSENCE OF:
 Recent significant head trauma
 Intracranial bleeding
 Pheochromocytoma
 Obstructive epicardial coronary artery
disease
 Myocarditis
 Hypertrophic cardiomyopathy
Exclusions made before TTC
Dx
Coronary Artery disease (especially
proximal L main or L anterior coronary
artery stenosis)
 Acute coronary syndrome
 Acute myocardial infarction
 Myocarditis, Pericarditis, Aortic
dissections
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Takotsubo vs. Acute Anterior
MI
[8]
Can be distinguished by CAG
 12 Lead ECG study performed to see if
other differences can be picked up between
the two. 3 main results found in TTC vs.
AMI were…
-1. greater ST segment elevation in leads V4
6
-2. absence of reciprocal changes in the
inferior leads
-3. absence of abnormal Q waves
Prognosis
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[1,2,310]
The prognosis of patients with TTC is generally favorable;
however, fatal complications have been reported with
TTC such as left ventricular free wall rupture.
Patients generally recover in a couple of days to a few
weeks with excellent outcomes.
Heart failure, with or without pulmonary edema, is the
most common clinical complication. We believe that the
published in-hospital mortality data are underestimated.
It is important to pay attention to the hemodynamics in
the acute phase, which often correspond to New York
Heart Association class III heart failure. Only a handful of
recurrent TTC cases have been reported.
Mechanisms underlying susceptibility to recurrence are
not understood. Articles are being published
Prognosis Cont’d
[4]
In a systematic study of multiple case
reports, 14, a favorable outcome was
likely. In-Hospital mortality was found
in 3 of 286 patient (2 multiple organ
failure, 1 ovarian cancer)
 In addition, only 6 of 169 evaluated
patients had a recurrence (true
recurrence rate limited to the 169 out of
286)
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So What does it look like?
Takotsubo “In Motion”
Prevalence
The prevalence of the disease is still
unknown and under study
 More cases are being found in women,
especially for those 60+ (one study states
75-95% of cases)
 Since TCC is becoming more and more
widely recognized and more specific
diagnostic criteria are being established,
higher prevalence rates are being reported.
In 2006, a study found the U.S. presenting a
2-2.2% of TTC cases for patients admitted
for STEMI or unstable angina
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Treatment and Intervention
Immediate treatment
involves the
catheterization lab to
rule out coronary
obstruction disease
 Mild Heart Failure
-Beta blockers
-ACE Inhibitors
-Diuretics
 Severe Heart Failure
-Positive inotropic
therapy
-Intra-aortic balloon
pump
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Tx and Intervention cont’d
Stress Management
-Psychiatrist, Counseling
 Dietary changes
 Physical Therapy
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 Cardiac Rehab
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Supervised Exercise until cleared by MD
Role of PT in Takotsubo
Patients
Since Takotsubo is a cardiomyopathy,
cardiac rehab should be utilized.
 Easy non-stressful exercises
 Postural exercises to open chest wall
 Breathing exercises to aide in oxygen
uptake
 Relaxation exercises to ease stressors
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Other Related Findings…
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In a study, African American (AA) women
had similar presenting symptoms of TTC to
Non-AA women, but may differ in the
electrocardiographic findings and in-hospital
course of the disease. Fewer developed
hypotension or needed hemodynamic
support.[5]
In a case report a 37 year old woman was
diagnosed with TTC after being struck by
lightning. She developed an acute cardiogenic
shock that put her into respiratory distress
during the initial hospital assessment.
Transthoracic ECG confirmed the diagnosis.[6]
Limitations in Studies
The ONE main factor affecting good
validity of data in all research for TTC
remains with subject numbers.
Although it is growing in diagnostic
criteria, the numbers are still relatively
low and cohort studies are hard to
design due to its rarity. [8,5]
 Timing of follow-up assessments varied
widely, ranging from 8-days to 4
years.[4]
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References
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1. Stensææth K, Fossum E, Hoffmann P, Mangschau A, Skretteberg P,
Kløøw N. Takotsubo cardiomyopathy in acute coronary syndrome;
clinical features and contribution of cardiac magnetic resonance during
the acute and convalescent phase. Scandinavian Cardiovascular Journal
[serial online]. April 2011;45(2):77-85.
2. Biteker M, Duran N, Özkan M, et al. Broken heart syndrome in a 17year-old girl. European Journal Of Pediatrics [serial online]. October
2009;168(10):1273-1275.
3. Koulouris S, Pastromas S, Sakellariou D, Kratimenos T, Piperopoulos
P, Manolis A.S. Takotsubo Cardiomyopathy: The “Broken Heart”
Syndrome. Hellenic Journal of Cardiology [serial online]. 2010;51: 451457
4. Gianni M, Dentali F, Grandi A.M., Sumner G, Hiralal R, Lonn E.
Apical ballooning syndrome or takotsubo cardiomyopathy: a
systematic review. European Heart Journal.
Doi:10.1093/eurheartj/ehl032. May 2006; 27, 1523-1529
5. QaQa A, Daoki J, Jallad N, Aburomeh O, Goldfarb I, Shamoon F.
Takotsubo Syndrome in African American vs. Non-African American
Women. Western Journal of Emergency Medicine [serial online] May
2011;12(2): 218-223
References cont’d
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6. Dundon B, Puri R, Leong D, Worthley M. Takotsubo
cardiomyopathy following lightning strike. BMJ Case Rep.
Doi:10.1136/bcr.03.2009.1646
7. Ibanez B, Navarro F, Farre’ J, Marcos-Alberca et al. Tako-Tsubo
Transient Left Ventricular Apical Ballooning Is Associated With a Left
Anterior Descending Coronary Artery With a Long Course Along the
Apical diaphragmatic Surface of the Left Ventricle. Rev Esp Cardiol
[serial online] 2004;57(3):209-16
8. Ogura R, Hiasa Y, Takahashi T, et al. Specific Finding of the Standard
12-Lead ECG in Patients With ‘Takotsubo’ Cardiomyopathy –
Comparison With the Finding of Acute Anterior Myocardial Infarction.
Circulation Journal [serial online] Aug 2003; 67:687-690
9. ALEXANDRE J, BENOUDA L, CHAMP-RIGOT L, LABOMBARDA
F. Takotsubo cardiomyopathy triggered by alcohol withdrawal. Drug &
Alcohol Review [serial online]. July 2011;30(4):434-437.
10. Akashi Y, Goldstein D, Barbaro G, Ueyama T. Takotsubo
Cardiomyopathy:A New Form of Acute, Reversible Heart Failure.
Circulation. 2008; 118: 2754-2762 doi:
10.1161/CIRCULATIONAHA.108.767012