Takotsubo Cardiomyopathy Clinical Presentation

  • Author: Eric B Tomich, DO; Chief Editor: David FM Brown, MD   more...
 
Updated: Aug 8, 2011
 

History

The clinical presentation of patients ultimately diagnosed with takotsubo cardiomyopathy (TCM) is usually indistinguishable from that of acute coronary syndrome. The most common presenting symptoms are chest pain and dyspnea, although palpitations, nausea, vomiting, syncope, and rarely, cardiogenic shock have been reported.

One of the more unique features of TCM is its association with a preceding emotionally or physically stressful trigger event, occurring in approximately two thirds of patients.

A large systematic review found patients with TCM tend to have a lower incidence of traditional cardiac risk factors, such as hypertension, hyperlipidemia, diabetes, smoking, or positive family history for cardiovascular disease.[17]

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Physical Examination

Physical examination findings are nonspecific and often normal, but the patient may have the clinical appearance of having acute coronary syndrome or acute congestive heart failure. Patients may appear anxious and diaphoretic. Tachydysrhythmias and bradydysrhythmias have been reported, but the average heart rate in one review was 102 bpm.[7]

Hypotension can occur from a reduction in stroke volume because of acute left ventricular systolic dysfunction or outflow tract obstruction. Murmurs and rales may be present on auscultation in the setting of acute pulmonary edema.

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Contributor Information and Disclosures
Author

Eric B Tomich, DO  Staff Physician, Department of Emergency Medicine, Brooke Army Medical Center

Eric B Tomich, DO is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Emily Luerssen, MD  Assistant Program Director, Department of Emergency Medicine, Madigan Army Medical Center

Emily Luerssen, MD is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Christopher S Kang, MD, FACEP, FAWM  Attending Physician, Department of Emergency Medicine, Madigan Army Medical Center; Clinical Assistant Professor, Division of Emergency Medicine, University of Washington School of Medicine; Adjunct Assistant Professor, Uniformed Services University of the Health Sciences; Staff, Providence St Peter's Hospital

Christopher S Kang, MD, FACEP, FAWM is a member of the following medical societies: American College of Emergency Physicians, Society of US Army Flight Surgeons, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Edward Bessman, MD  Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Gary Setnik, MD  Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School

Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other

Chief Editor

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Sato H, Tateishi H, Uchida T, et al. Kodama K, Haze K, Hon M, eds. Clinical Aspect of Myocardial Injury: From Ischaemia to Heart Failure. Tokyo: Kagakuhyouronsya; 1990:56-64.

  2. Terefe YG, Niraj A, Pradhan J, Kondur A, Afonso L. Myocardial infarction with angiographically normal coronary arteries in the contemporary era. Coron Artery Dis. Dec 2007;18(8):621-6. [Medline].

  3. Kawai S, Kitabatake A, Tomoike H. Guidelines for diagnosis of takotsubo (ampulla) cardiomyopathy. Circ J. Jun 2007;71(6):990-2. [Medline].

  4. Lindsay J, Paixao A, Chao T, Pichard AD. Pathogenesis of the Takotsubo syndrome: a unifying hypothesis. Am J Cardiol. Nov 1 2010;106(9):1360-3. [Medline].

  5. Afonso L, Bachour K, Awad K, Sandidge G. Takotsubo cardiomyopathy: pathogenetic insights and myocardial perfusion kinetics using myocardial contrast echocardiography. Eur J Echocardiogr. Nov 2008;9(6):849-54. [Medline].

  6. Khallafi H, Chacko V, Varveralis N, Elmi F. "Broken heart syndrome": catecholamine surge or aborted myocardial infarction?. J Invasive Cardiol. Jan 2008;20(1):E9-13. [Medline].

  7. Dorfman TA, Iskandrian AE. Takotsubo cardiomyopathy: State-of-the-art review. J Nucl Cardiol. Jan-Feb 2009;16(1):122-34. [Medline].

  8. Carrillo A, Fiol M, Garcia-Niebla J, Bayes de Luna A. Electrocardiographic differential diagnosis between Takotsubo syndrome and distal occlusion of LAD is not easy. J Am Coll Cardiol. Nov 2 2010;56(19):1610-1; author reply 1611. [Medline].

  9. Lindsay J, Paixao A, Chao T, Pichard AD. Pathogenesis of the Takotsubo syndrome: a unifying hypothesis. Am J Cardiol. Nov 1 2010;106(9):1360-3. [Medline].

  10. Dhoble A, Abdelmoneim SS, Bernier M, Oh JK, Mulvagh SL. Transient left ventricular apical ballooning and exercise induced hypertension during treadmill exercise testing: is there a common hypersympathetic mechanism?. Cardiovasc Ultrasound. Jul 18 2008;6:37. [Medline].

  11. Buchholz S, Rudan G. Tako-tsubo syndrome on the rise: a review of the current literature. Postgrad Med J. Apr 2007;83(978):261-4. [Medline].

  12. Citro R, Previtali M, Bossone E. Tako-tsubo cardiomyopathy and drowning syndrome: is there a link?. Chest. Aug 2008;134(2):469. [Medline].

  13. Bybee KA, Prasad A, Barsness GW, et al. Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome. Am J Cardiol. Aug 1 2004;94(3):343-6. [Medline].

  14. Ito K, Sugihara H, Katoh S, Azuma A, Nakagawa M. Assessment of Takotsubo (ampulla) cardiomyopathy using 99mTc-tetrofosmin myocardial SPECT--comparison with acute coronary syndrome. Ann Nucl Med. Apr 2003;17(2):115-22. [Medline].

  15. Donohue D, Movahed MR. Clinical characteristics, demographics and prognosis of transient left ventricular apical ballooning syndrome. Heart Fail Rev. Dec 2005;10(4):311-6. [Medline].

  16. Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J. Jul 2006;27(13):1523-9. [Medline].

  17. Pilgrim TM, Wyss TR. Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: A systematic review. Int J Cardiol. Mar 14 2008;124(3):283-92. [Medline].

  18. Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J. Mar 2008;155(3):408-17. [Medline].

  19. Bybee KA, Kara T, Prasad A, et al. Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med. Dec 7 2004;141(11):858-65. [Medline].

  20. Merchant EE, Johnson SW, Nguyen P, Kang C, Mallon WK. Takotsubo cardiomyopathy: a case series and review of the literature. WestJEM. 2008;9:104-11.

  21. Sharkey SW, Lesser JR, Menon M, Parpart M, Maron MS, Maron BJ. Spectrum and significance of electrocardiographic patterns, troponin levels, and thrombolysis in myocardial infarction frame count in patients with stress (tako-tsubo) cardiomyopathy and comparison to those in patients with ST-elevation anterior wall myocardial infarction. Am J Cardiol. Jun 15 2008;101(12):1723-8. [Medline].

  22. Kolkebeck TE, Cotant CL, Krasuski RA. Takotsubo cardiomyopathy: an unusual syndrome mimicking an ST-elevation myocardial infarction. Am J Emerg Med. Jan 2007;25(1):92-5. [Medline].

  23. Kosuge M, Ebina T, Hibi K, Morita S, Okuda J, Iwahashi N. Simple and accurate electrocardiographic criteria to differentiate takotsubo cardiomyopathy from anterior acute myocardial infarction. J Am Coll Cardiol. Jun 1 2010;55(22):2514-6. [Medline].

  24. Eitel I, von Knobelsdorff-Brenkenhoff F, Bernhardt P, Carbone I, Muellerleile K, Aldrovandi A, et al. Clinical characteristics and cardiovascular magnetic resonance findings in stress (takotsubo) cardiomyopathy. JAMA. Jul 20 2011;306(3):277-86. [Medline].

  25. Scheffel H, Stolzmann P, Karlo C, et al. Tako-tsubo phenomenon: dual-source computed tomography and conventional coronary angiography. Cardiovasc Intervent Radiol. Jan-Feb 2008;31(1):226-7. [Medline].

  26. Kurisu S, Inoue I, Kawagoe T, Ishihara M, Shimatani Y, Nakama Y. Incidence and treatment of left ventricular apical thrombosis in Tako-tsubo cardiomyopathy. Int J Cardiol. Feb 2 2009;[Medline].

  27. Sealove BA, Tiyyagura S, Fuster V. Takotsubo cardiomyopathy. J Gen Intern Med. Nov 2008;23(11):1904-8. [Medline].

 
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Electrocardiogram of a patient with takotsubo cardiomyopathy demonstrating ST-segment elevation in anterior and inferior leads.
Electrocardiogram from the same patient examined in the previous ECG, obtained several days after initial presentation. This demonstrates resolution of ST-segment elevation, and now with diffuse T-wave inversion and poor R-wave progression.
Example of takotsubo, or octopus pot.
Coronary angiogram of a patient with takotsubo cardiomyopathy demonstrating normal coronary arteries.
Coronary angiogram of a patient with takotsubo cardiomyopathy demonstrating normal coronary arteries.
Ventriculogram during systole in a patient with takotsubo cardiomyopathy demonstrating apical akinesis.
Ventriculogram during diastole in a patient with takotsubo cardiomyopathy.
Echocardiogram of a patient with takotsubo cardiomyopathy during diastole several days after presenting to the emergency department.
Echocardiogram of a patient with takotsubo cardiomyopathy during systole, which demonstrates apical akinesis. Ejection fraction is 40%.
Echocardiogram of a patient with takotsubo cardiomyopathy during systole, nearly 2 months after presenting to the emergency department. Note the improved contractility of the apex. Ejection fraction increased from 40% to 65%.
Echocardiogram of a patient with takotsubo cardiomyopathy during diastole, approximately 2 months after presenting to the emergency department.
Echocardiogram focused on left ventricle of a patient with takotsubo cardiomyopathy during diastole.
Echocardiogram focusing on left ventricle of a patient with takotsubo cardiomyopathy during systole. Note apical akinesis.
Echocardiogram focusing on left ventricle of a patient with takotsubo cardiomyopathy during systole, approximately 2 months after presenting to the emergency department. Note improved apical contraction.
Echocardiogram focusing on left ventricle of a patient with takotsubo cardiomyopathy during diastole, approximately 2 months after presenting to the emergency department.
 
 
 
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