Takotsubo Cardiomyopathy (Stress-Induced Cardiomyopathy)

Epidemiology

History

  • 1990: entity was first described in Japan
    • Takotsubo: “octopus pot”

International Takotsubo Registry of 1750 Patients [MEDLINE]

  • Association with Female Sex: 89.8% of Takotsubo cases were female
  • Triggers
    • Physical Triggers: 36.0% of cases had physical triggers
    • No Evident Trigger: 28.5% of cases had no evident trigger
    • Emotional Triggers: 27.7% of cases had emotional triggers
  • Presence of Neurologic/Psychiatric Disease
    • Takotsubo Cardiomyopathy: 55.8% of cases had neuropsychiatric disease
    • Acute Coronary Syndrome: 25.7% of cases had neuropsychiatric disease
  • Mean Left Ventricular Ejection Fraction: ejection fraction is significantly lower in Takotsubo cardiomyopathy, as compared to patients with acute coronary syndrome
    • Takotsubo Cardiomyopathy: mean left ventricular ejection fraction was 40.7 ± 11.2%
    • Acute Coronary Syndrome: mean left ventricular ejection fraction was 51.5 ± 12.3%
  • In-Hospital Rates of Shock/Death: similar in both Takotsubo cardiomyopathy and acute coronary syndrome
  • Predictors of In-Hospital Complications
    • High Troponin Level
    • Low Ejection Fraction on Admission
    • Presence of Acute Neuropsychiatric Disease
    • Presence of a Physical Trigger

Etiology

Neurologic Disease

Other

  • Anorexia Nervosa (see Anorexia Nervosa, [[Anorexia Nervosa]])
    • Epidemiology: case reports
  • Diabetic Ketoacidosis (DKA) (see Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State, [[Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State]])
    • Epidemiology: case reports
  • Opiate Withdrawal (see Opiates, [[Opiates]])
  • Pheochromocytoma (see Pheochromocytoma, [[Pheochromocytoma]])
    • Epidemiology: case reports
  • Post-Liver Transplantation (see Liver Transplant, [[Liver Transplant]])
    • Epidemiology: case reports
  • Recent Emotional Stress
    • Epidemiology: case reports
  • Sepsis (see Sepsis, [[Sepsis]])
    • Epidemiology: case reports
  • Systemic Lupus Erythematosus (SLE) (see Systemic Lupus Erythematosus, [[Systemic Lupus Erythematosus]])
    • Epidemiology: case reports
  • Tetanus (see Tetanus, [[Tetanus]])
  • Thyrotoxicosis (see Hyperthyroidism, [[Hyperthyroidism]])
    • Epidemiology: case reports

Physiology

  • Abnormal Cerebral Blood Flow to the Hippocampus/Brainstem/Basal Ganglia (Suggesting Activation of These Regions): results in excessive catecholamine release -> sympathetic stimulation of the myocardium
    • Catecholamine-Triggered Myocyte Injury: may play a role
    • Coronary Microvascular Dysfunction: may play a role
    • Multivessel Epicardial Vasospasm: may play a role
    • Catecholamine-Induced Development of Dynamic Intraventricular Pressure Gradient: results in subendocardial stunning of left ventricular apex

Diagnosis

Electrocardiogram (EKG) (see Electrocardiogram, [[Electrocardiogram]])

  • xxxx

Serum Troponin (see Serum Troponin, [[Serum Troponin]])

  • Mildly Elevated

Brain Natriuretic Peptide (BNP) (see Brain Natriuretic Peptide, [[Brain Natriuretic Peptide]])

  • May Be Elevated: elevation is predictive of wall motion abnormalities in subarachnoid hemorrhage and iatrogenic catecholamine-induced cardiomyopathy

Echocardiogram (see Echocardiogram, [[Echocardiogram]])

  • General Comments: dysfunction always involves the left ventricle
  • Classically-Described Pattern: apical ballooning or hypokinesis with hypercontractility of basal segments
    • Right Ventricular Involvement: may accompany left apical ballooning in 26-32% of cases
      • These cases are more likely to have lower ejection fractions, pleural effusions, and longer hospital stays
  • Other Patterns
    • Transient Systolic/Diastolic Left Ventricular Dysfunction with Various Wall Motion Abnormalities Which May Extend Beyond the Distribution of a Single Epicardial Coronary Artery
    • Inverted Cardiomyopathy Pattern: basal and mid-ventricular hypokinesis with sparing of the apex
      -This pattern may be more common in patients with an underlying neurologic etiology

Cardiac Catheterization (see Cardiac Catheterization, [[Cardiac Catheterization]])

  • xxxx

Clinical Manifestations

Cardiovascular Manifestations

Abnormal Electrocardiogram

  • Clinical
    • Prolonged QT (see Torsade, [[Torsade]])
    • ST Segment Depression/Elevation (see xxxx, [[xxxx]])
    • T-Wave Inversion (see xxxx, [[xxxx]])

Arrhythmias

Congestive Heart Failure (CHF)

  • Epidemiology: acute systolic heart failure in the absence of obstructive coronary artery disease
  • Clinical

Left Ventricular Outflow Tract Obstruction

  • Epidemiology: occurs in 20% of cases [MEDLINE]
    • Seen More Commonly in Older Patients
  • Physiology: associated with increased degree of septal bulging
  • Diagnosis
    • Echocardiogram
      • Systolic Anterior Motion (SAM) of Anterior Mitral Mitral Valve Leaflet
      • Mitral Regurgitation
  • Clinical

Other

  • Chest Pain (see Chest Pain, [[Chest Pain]])
  • Sudden Cardiac Death
  • Syncope (see Syncope, [[Syncope]])

Pulmonary Manifestations

  • Dyspnea (see Dyspnea, [[Dyspnea]])

Other Manifestations

  • xxx
  • xxx

Treatment

Specific Management of Takotsubo without Left Ventricular Outflow Tract Obstruction

  • Inotropes
    • Dobutamine (Dobutrex) (see Dobutamine, [[Dobutamine]])
    • Dopamine (see Dopamine, [[Dopamine]])
    • Norepinephrine (Levophed) (see Norepinephrine, [[Norepinephrine]])

Specific Management of Takotsubo with Left Ventricular Outflow Tract Obstruction

  • Intravenous Fluid Resuscitation
    • Pharmacology: increasing intravascular volume improves the left ventricular outflow tract obstruction
  • Avoidance of Inotropes
    • Pharmacology: inotropes (dobutamine, dopamine, norepinephrine) worsen the left ventricular outflow tract obstruction
  • Avoidance of Vasodilators
    • Pharmacology: vasodilators worsen the left ventricular outflow tract obstruction
  • α1-Adrenergic Receptor Agonists
    • Pharmacology: increases afterload -> decreases left ventricular outflow tract obstruction
    • Agents
      • Phenylephrine (Neosynephrine) (see Phenylephrine, [[Phenylephrine]])
  • Beta Blockers (β-Adrenergic Receptor Antagonists) (see β-Adrenergic Receptor Antagonists, [[β-Adrenergic Receptor Antagonists]]) [MEDLINE]
    • Pharmacology: beta blockers decrease heart rate and myocardial contractility -> decrease the left ventricular outflow tract obstruction
  • Intra-Aortic Balloon Pump (IABP) (see Intra-Aortic Balloon Pump, [[Intra-Aortic Balloon Pump]]): may be considered, but since it will decrease afterload, it may worsen the left ventricular outflow tract obstruction

Prognosis

  • Rate of Major Adverse Cardiac/Cerebrovascular Events [MEDLINE]: 9.9% per patient-year
  • Mortality Rate [MEDLINE]: 5.6% per patient-year

References

  • Dynamic left ventricular outflow tract obstruction in acute myocardial infarction with shock: cause, effect, and coincidence.  Circulation.  2007;116:e110–e113 [MEDLINE]

  • A case of takotsubo cardiomyopathy associated with epileptic seizure: reversible left ventricular wall motion abnormality and ST-segment elevation. Heart Vessels. 2007 Jan;22(1):59-63. Epub 2007 Jan 26 [MEDLINE]

  • Cardiogenic shock: current concepts and improving outcomes. Circulation 2008;117:686–697 [MEDLINE]

  • Clinical implications of midventricular obstruction and intravenous propranolol use in transient left ventricular apical ballooning. Am Heart J 2008, 155:1–7 [MEDLINE]

  • Stress-induced cardiomyopathy in the critically ill – why inotropes fail to improve outcome. Int J Cardiol 2013, 168:4489–4490 [MEDLINE]

  • Takotsubo cardiomyopathy associated with opiate withdrawal. QJM. 2014 Apr;107(4):301-2. doi: 10.1093/qjmed/hct219. Epub 2013 Oct 29 [MEDLINE]

  • Stress cardiomyopathy (tako-tsubo) triggered by nervous system diseases: a systematic review of the reported cases. Int J Cardiol. 2013 Sep 10;167(6):2441-8. doi: 10.1016/j.ijcard.2013.01.031. Epub 2013 Feb 13 [MEDLINE]
  • Prevalence, associated factors and management implications of left ventricular outflow tract obstruction in takotsubo cardiomyopathy: a two-year, two-center experience.  BMC Cardiovasc Disord. 2014 Oct 22;14:147. doi: 10.1186/1471-2261-14-147 [MEDLINE]

  • Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N Engl J Med. 2015 Sep 3;373(10):929-38. doi: 10.1056/NEJMoa1406761 [MEDLINE]