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.
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Takotsubo (stress) cardiomyopathy (broken heart syndrome). Electrocardiogram of a patient with takotsubo cardiomyopathy demonstrating ST-segment elevation in the anterior and inferior leads.
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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.
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Takotsubo (stress) cardiomyopathy (broken heart syndrome). Coronary angiogram of a patient with takotsubo cardiomyopathy demonstrating normal coronary arteries.
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Takotsubo (stress) cardiomyopathy (broken heart syndrome). Coronary angiogram of a patient with takotsubo cardiomyopathy demonstrating normal coronary arteries.
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Takotsubo (stress) cardiomyopathy (broken heart syndrome). Ventriculogram during systole in a patient with takotsubo cardiomyopathy demonstrating apical akinesis.
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Takotsubo (stress) cardiomyopathy (broken heart syndrome). Ventriculogram during diastole in a patient with takotsubo cardiomyopathy.
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Takotsubo (stress) cardiomyopathy (broken heart syndrome). Echocardiogram of a patient with takotsubo cardiomyopathy during diastole several days after presenting to the emergency department.
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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%.
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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%.
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Takotsubo (stress) cardiomyopathy (broken heart syndrome). Echocardiogram of a patient with takotsubo cardiomyopathy during diastole, approximately 2 months after presenting to the emergency department.
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Takotsubo (stress) cardiomyopathy (broken heart syndrome). Echocardiogram focused on the left ventricle of a patient with takotsubo cardiomyopathy during diastole.
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Takotsubo (stress) cardiomyopathy (broken heart syndrome). Echocardiogram focusing on the left ventricle of a patient with takotsubo cardiomyopathy during systole. Note the apical akinesis.
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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.
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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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