Takotsubo Cardiomyopathy Treatment & Management

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

Approach Considerations

Prehospital care

Because takotsubo cardiomyopathy (TCM) mimics acute coronary syndrome and no initial ECG finding reliably differentiates TCM from STEMI, prehospital personnel should follow their established protocols for evaluating and transporting patients with chest pain and/or acute coronary syndrome.

Inpatient care

Patients with TCM will require admission to the appropriate cardiology service. Treatment options are largely empirical and supportive; however, when hemodynamics permit, beta blockers seem to be helpful. Serial imaging studies may be necessary. Patients who are found to have left ventricular thrombus, which occurs in 5% of patients with TCM, require anticoagulation.[26]

Outpatient care

Close follow-up care with a cardiologist in the weeks after diagnosis is recommended for patients with TCM to ensure resolution of the cardiomyopathy, usually with serial echocardiograms. Thereafter, annual clinical follow-up is advised, because the long-term effects and natural history of TCM are unknown.[18, 27]

Consultations and transfer

Consultation with a cardiologist is necessary, as coronary angiography is required for the diagnosis of TCM. Patients may need to be transferred to a facility with a cardiologist and a cardiac catheterization laboratory.[21, 22, 20, 27]

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Emergency Department Care

Patients should be treated as having acute coronary syndrome until proven otherwise. Addressing the airway, breathing, and circulation; establishing intravenous access, and providing supplemental oxygen and cardiac monitoring should take precedence. Testing in the emergency department should include electrocardiography, chest radiography, cardiac biomarker levels, brain natriuretic peptide level, and other appropriate laboratory studies.

If the patient continues to manifest a clinical picture consistent with acute coronary syndrome, especially STEMI, then standard therapies, such as the following, may be indicated:

  • Aspirin
  • Beta blockers
  • Nitrates
  • Heparin or enoxaparin
  • Platelet glycogen (GP) IIb/IIIa inhibitors
  • Morphine
  • Clopidogrel

Patients in acute congestive heart failure may require diuresis, and patients with cardiogenic shock may require resuscitation with intravenous fluids and inotropic agents. If available, bedside echocardiography could show the characteristic wall-motion abnormality.

The insertion of an intra-aortic balloon pump has also been reported as being a successful resuscitative intervention, due to left ventricular outflow obstruction that can result from a hyperkinetic basal segment and dyskinetic apex. Fluids and beta blockers, or calcium channel blockers, are beneficial in this situation, whereas inotropes may exacerbate the problem and should be used with caution.

Dysrhythmias and cardiopulmonary arrest should be treated using current advanced cardiac life support (ACLS) protocols. Although thrombolytics will not benefit patients with takotsubo cardiomyopathy (TCM), their use should not be withheld when percutaneous coronary intervention (PCI) is not available and patients otherwise meet criteria.[20, 27]

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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

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  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].

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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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