Tako-Tsubo Cardiomyopathy

Definition

• A STEMI mimic producing ischaemic chest pain, ECG changes +/- elevated cardiac enzymes with characteristic regional wall motion abnormalities on echocardiography.
• Typically occurs in the context of severe emotional distress (“broken heart syndrome”).
• Patients have normal coronary arteries on angiography.

Tako-tsubo cardiomyopathy

Background

Only described in Japan within the last 20 years, Tako-tsubo has become increasingly recognised, possibly in no small part due to the increased use of angiography in cardiology.

Mayo Clinic criteria for tako-tsubo cardiomyopathy (widely but not universally accepted)

1. New ECG changes (ST elevation or T wave inversion) or moderate troponin rise.
2. Transient akinesis / dyskinesis of left ventricle (apical and mid-ventricular segments) with regional wall abnormalities extending beyond a single vascular territory.
3. Absence of coronary artery stenosis >50% or culprit lesion.

Why Is It Called Tako-Tsubo Cardiomyopathy?

The left ventricle, with its apical akinesia looks remarkably like a basket used in japan to catch Octopi.

(A) Ventriculogram (B) An octopus pot ("Tako-Tsubo")

Tako-Tsubo ventriculogram

What Causes Tako-Tsubo?

Classically it occurs in a post-menopausal woman experiencing sudden emotional stress.

Cathecholamine Surge

• Microvascular Spasm.
• Sympathetic nervous system activation.
• Underlying  LVOTO.

A sudden surge in cathecholamines is agreed to be the cause, but the reason why this surge causes a characteristic wall motion abnormality remains a matter for debate.  The most widely held view is that the catecholamines cause microvascular spasm, although left ventricular outflow obstruction is likely to play a part.  The sympathetic nervous system is also implicated – the condition can be prevented in a laboratory by cardiac sympathectomy, the apical distribution explained as it has the highest density of sympathetic nerve fibres. Similar cardiac histopathological features are seen in patients who’ve had a subarachnoid haemorrhage.

So What Do We Do In The ED?

Tako-tsubo cardiomyopathy is indistinguishable from a STEMI in the ED.  No criteria can be safely used to differentiate between the two conditions.  You should activate your local code STEMI protocol.

Tako-tsubo has a better prognosis than STEMIs with a similar ECG but it is certainly not benign.

Related Topics

• Anterior STEMI

Further Reading

• ECG BASICS — Waves, Intervals, Segments and Clinical Interpretation
• ECG CLINICAL CASES — Your favourite ECG’s placed in clinical context with a challenging Q&A approach
• ECG and Cardiology Eponymous Syndromes — Cheats guide to eponymous emancipation
• ECG Exam Template — a framework for the FACEM part 2 exam.
• ECG Reference Sites on the WEB — the best of the rest

Author Credits

References

• ClinicalCases Blogspot with Dr Ves: Takotsubo cardiomyopathy broken heart syndrome
• Akashi YJ, Goldstein DS, Barbaro G, Ueyama T.Takotsubo cardiomyopathy: a new form of acute, reversible heart failure.Circulation. 2008 Dec 16;118(25):2754-62.PMID: 19106400
• Abdulla I, Ward MR.Tako-tsubo cardiomyopathy: how stress can mimic acute coronary occlusion.Med J Aust. 2007 Sep 17;187(6):357-60. PMID: 17874985
• Banning et al. Takotsubo cardiomyopathy BMJ 2010;340:c1272.
• Salim S. Virani, MD, A. Nasser Khan, MD, Cesar E. Mendoza, MD, Alexandre C. Ferreira, MD, and Eduardo de Marchena, MD Takotsubo Cardiomyopathy, or Broken-Heart Syndrome Tex Heart Inst J. 2007; 34(1): 76–79. [Reference]
• Taokutsubo Website