History

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

One of the more unique features of takotsubo cardiomyopathy is its association with a preceding emotionally or physically stressful trigger event, occurring in approximately two thirds of patients. Unlike ACS, for which the peak occurrence is during the morning hours, takotsubo cardiomyopathy events are most prevalent in the afternoon, when stressful triggers are more likely to take place.^[31]

A large systematic review found that patients with takotsubo cardiomyopathy tend to have a lower incidence of traditional cardiac risk factors, such as hypertension, hyperlipidemia, diabetes, smoking, or positive family history for cardiovascular disease.^[26]

Physical Examination

Physical examination findings in patients with takotsubo (stress) cardiomyopathy (broken heart syndrome) are nonspecific and often normal, but the patient may exhibit the clinical appearance of 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.

Differential Diagnoses

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Dorfman TA, Iskandrian AE. Takotsubo cardiomyopathy: State-of-the-art review. J Nucl Cardiol. 2009 Jan-Feb. 16(1):122-34. [QxMD MEDLINE Link].
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Lindsay J, Paixao A, Chao T, Pichard AD. Pathogenesis of the Takotsubo syndrome: a unifying hypothesis. Am J Cardiol. 2010 Nov 1. 106(9):1360-3. [QxMD MEDLINE Link].
Afonso L, Bachour K, Awad K, Sandidge G. Takotsubo cardiomyopathy: pathogenetic insights and myocardial perfusion kinetics using myocardial contrast echocardiography. Eur J Echocardiogr. 2008 Nov. 9(6):849-54. [QxMD MEDLINE Link].
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. 2008 Jul 18. 6:37. [QxMD MEDLINE Link].
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Donohue D, Movahed MR. Clinical characteristics, demographics and prognosis of transient left ventricular apical ballooning syndrome. Heart Fail Rev. 2005 Dec. 10(4):311-6. [QxMD MEDLINE Link].
Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J. 2006 Jul. 27(13):1523-9. [QxMD MEDLINE Link].
Pilgrim TM, Wyss TR. Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: A systematic review. Int J Cardiol. 2008 Mar 14. 124(3):283-92. [QxMD MEDLINE Link].
Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J. 2008 Mar. 155(3):408-17. [QxMD MEDLINE Link].
Singh K, Carson K, Usmani Z, et al. Systematic review and meta-analysis of incidence and correlates of recurrence of takotsubo cardiomyopathy. Int J Cardiol. 2014 Jul 1. 174(3):696-701. [QxMD MEDLINE Link].
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. 2004 Dec 7. 141(11):858-65. [QxMD MEDLINE Link].
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Sharkey SW, Lesser JR, Garberich RF, Pink VR, Maron MS, Maron BJ. Comparison of Circadian Rhythm Patterns in Tako-tsubo Cardiomyopathy Versus ST-Segment Elevation Myocardial Infarction. Am J Cardiol. 2012 May 29. [QxMD MEDLINE Link].
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Media Gallery

Takotsubo (stress) cardiomyopathy (broken heart syndrome). Electrocardiogram of a patient with takotsubo cardiomyopathy demonstrating ST-segment elevation in the anterior and inferior leads.
Takotsubo (stress) cardiomyopathy (broken heart syndrome). Electrocardiogram (ECG) from the same patient discussed in the previous ECG, obtained several days after the initial presentation. This ECG demonstrates resolution of the ST-segment elevation, and now shows diffuse T-wave inversion and poor R-wave progression.
Takotsubo (stress) cardiomyopathy (broken heart syndrome). Coronary angiogram of a patient with takotsubo cardiomyopathy demonstrating normal coronary arteries.
Takotsubo (stress) cardiomyopathy (broken heart syndrome). Coronary angiogram of a patient with takotsubo cardiomyopathy demonstrating normal coronary arteries.
Takotsubo (stress) cardiomyopathy (broken heart syndrome). Ventriculogram during systole in a patient with takotsubo cardiomyopathy demonstrating apical akinesis.
Takotsubo (stress) cardiomyopathy (broken heart syndrome). Ventriculogram during diastole in a patient with takotsubo cardiomyopathy.
Takotsubo (stress) cardiomyopathy (broken heart syndrome). Echocardiogram of a patient with takotsubo cardiomyopathy during diastole several days after presenting to the emergency department.
Takotsubo (stress) cardiomyopathy (broken heart syndrome). Echocardiogram of a patient with takotsubo cardiomyopathy during systole, which demonstrates apical akinesis. The patient's ejection fraction was 40%.
Takotsubo (stress) cardiomyopathy (broken heart syndrome). Echocardiogram of the same patient with takotsubo cardiomyopathy during systole discussed in the previous image, nearly 2 months after presenting to the emergency department. Note the improved contractility of the apex. The ejection fraction increased from 40% to 65%.
Takotsubo (stress) cardiomyopathy (broken heart syndrome). Echocardiogram of a patient with takotsubo cardiomyopathy during diastole, approximately 2 months after presenting to the emergency department.
Takotsubo (stress) cardiomyopathy (broken heart syndrome). Echocardiogram focused on the left ventricle of a patient with takotsubo cardiomyopathy during diastole.
Takotsubo (stress) cardiomyopathy (broken heart syndrome). Echocardiogram focusing on the left ventricle of a patient with takotsubo cardiomyopathy during systole. Note the apical akinesis.
Takotsubo (stress) cardiomyopathy (broken heart syndrome). Echocardiogram focusing on the left ventricle of a patient with takotsubo cardiomyopathy during systole discussed in the previous image, approximately 2 months after presenting to the emergency department. Note the improved apical contraction.
Takotsubo (stress) cardiomyopathy (broken heart syndrome). Echocardiogram focusing on the left ventricle of a patient with takotsubo cardiomyopathy during diastole, approximately 2 months after presenting to the emergency department.

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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, 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, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

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

Christopher S Kang, MD, FACEP, FAAEM, FAWM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, Society of US Army Flight Surgeons, Washington State Medical Association, Wilderness Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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

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

Disclosure: Medical Director for: SironaHealth.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Additional Contributors

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

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

Disclosure: Nothing to disclose.

Sections Takotsubo (Stress) Cardiomyopathy (Broken Heart Syndrome)
Overview
Presentation
DDx
Workup
Treatment
Medication
Questions & Answers
Media Gallery
References

Takotsubo (Stress) Cardiomyopathy (Broken Heart Syndrome) Clinical Presentation

History

Physical Examination

References

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