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.

tako-tsubo

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

Tako-Tsubo ventriculogram

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.

CODE BLUE IN THE MORTUARY... Octopus2

Related Topics

Further Reading

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]
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Comments

  1. Terry says

    One of the better explanations of Takotsubo cardiomyopathy I’ve found. I had a takotsubo attack in September of 2011….in the midst of a cardiac conference, no less. If you have to have one, I guess that’s the place to be! I was in the ED in less than 12 minutes, off to the cath lab (nothing like a bunch of your old co-workers doing your prep, but beats the alternative!) and diagnosed quickly. Six weeks later….good as new.

    Unlike most of what I’ve read, I did not have any “immediate” precipitating stress, but had been under considerable chronic stress for several months. But then I’m sure there are always exceptions.

    At any rate, since I work collecting data on open heart surgeries and often find myself describing Takotsubo to others, especially women, I keep an eye out for short pieces that can be fairly easily assimilated by non-clinical individuals. This one’s a keeper and will go in my “favorites” file!

  2. Barbara Shaw says

    I was in a semnar on Monday 9th February 2014 listening to a lecture on changes to the management structures within the NHS and the CCG when I first started suffering from Chest pain. It wasn’t until two days later when having another bout of chest pain that I was taken into hospital and diagnosed with Takotsubo’s cadiomyopathy. I did not experience any immediate stress prior to my attack although I do have a very stressful job. I spent Valentine’s Day in intensive care having my broken heart mended. At the moment I feel awful with tiredness and lack of vitality, but then it is only one week since the angiogram.

    My main frustration is lack of information and what I have recieved is contradictory. Is there anyone out there in the UK who is a real specialist in this area of heart disease?

    Barbara

  3. Caron says

    Hi Barbara, I suffered from a takotsubo cardiomyopathy attack in October of last year. Into my 5th month now I am just starting to get my energy levels back and feel more like my pre-episode self . I believe some people recover completely within 2weeks but others can take a year or more. After not being confident with my local hospital who were quite dismissive , ( despite abnormal ECGs and chest pain/ breathing difficulties) so in november I found an excellent cardiologist who specialises in takotsubo and he has been very thorough in further investigations ( scans have consequently showed there were/are ongoing issues from the Takotsubo attack) which we are now addressing. I will gladly pass on further details if you need them .

    • Pam says

      I suffered Takotsubo cardiomyopathy on February 7th of this year (2014) and am experiencing many of the feelings you described (Caron) and would like information regarding your cardiologist. I have been researching cardiologists to find someone knowledgeable about Takotsubo cardiomyopathy, to no avail. My current cardiologist’s diagnosis seems to be correct, but he’s expecting me to be fully recovered and I’m not. Not only does he have a very poor bedside manner, but he also does not listen to me at all. All he says is, “You’ve got to get your stress under control.” Right now I’m currently not working because my job is my main stressor (chronic stress plus an emotional episode and severe bronchitis when this occurred), however, he thinks I’m physically okay to return to work (told me on my follow-up visit 17 days after the episode). Hello, red flag! I’ve already had one episode where my BP shot up to dangerous levels and I began having the same chest pains. My discomfort with my cardiologist isn’t helping my situation right now. Thank God for my family practitioner! I’d appreciate any information regarding a qualified cardiologist with Takotsubo. Thanks!!

  4. Caron says

    Hi Pam,
    I’m so sorry to hear of your recent Takotsubo episode and that you are finding it difficult to locate a specialist in this field.
    My initial cardiologist said 2 -3 months off work ( I run my own business so was rather taken aback) so 17 days does seem somewhat premature for you! There is literature out there that mentions some patients fully recover in 14 days but my chosen cardiologist who specialises in Takotsubo cardiomyopathy says the lucky ones might, but he has seen with his research and patients that is not the norm as he has patients in the 3-6 month range for recovery and some who are already 1year post attack and still not fully recovered.
    I don’t know what further tests your consultant has done but the Echo cardio gram I had 1month after my attack showed my heart was 60 percent back to normal shape, then my new consultant did an MRI scan ( December) which showed heart back to normal shape but as my ECGs were still abnormal and I was getting chest pain and palpatations he did a series of nuclear scans in January. These showed I still had an “electrical storm ” ( sympathetic nervous system still over firing ) in my heart going on . This would not have been picked up on any echocardiogram , MRI etc so would have affected my treatment ( or lack of it as I initially encountered with my local hospital)
    I wanted to share this, not to get my my story off my chest , but to say please don’t accept the answers ( or lack of them) from your current cardiologist. I think as we are unusual cases ( but now it is recognised becoming more common) he perhaps simply doesn’t know ?
    My cardiologist is based in London but I don’t know where you live ? But if you are distant don’t worry as I will gladly email him. He is passionate about his work, is leading global research into Takotsubo and lectures around the world so I’m confident he will know the right person to send you to. If you are local , brilliant !
    I am hoping to set up a Takotsubo support group so it would be really good to keep in touch too!
    Kindest regards,
    Caron

    • Avril Fraser says

      Hi Caron I too have had a Takisubo last June would be interested in joining a group as I’m still experiencing problems! Avril

  5. Caron Curragh says

    Hi Avril,
    so sorry for late reply , I have been away , tried to respond via my phone but it looks like my reply didn’t come through .
    Also sorry that you are still experiencing problems, it is so interesting how some Takotsubo patients recover very quicky then there are those of us approaching or over the 1yr mark.
    I am in the process of setting up a Takotsubo support group but in the meantime please email me at caron.curragh@me.com as it would be good to chat about our experiences etc
    kindest regards
    Caron

      • Conny Holmann says

        Hello Avril . I had Takotsubo due to a high emotional trauma . That was 2 years ago , and I still have Panic Attacks . But my son is looking for people like us to try and make a Group of people so people can understand this illness so few people know about !
        Are you willing to talk about it ? So the World can learn and support us ? Many people just think we are crazy !

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