Diagnostic Considerations

Physicians should be aware of the presentation of takotsubo (stress) cardiomyopathy (broken heart syndrome), because chest pain after a recent stressor is not necessarily due to anxiety. The chest pain may be more complicated and may deteriorate into dysrhythmias, shock, or both.

Patients with takotsubo cardiomyopathy do not usually have cardiac risk factors, but their pain should be taken seriously. Also, patients may present to the emergency department (ED) after a natural disaster, and healthcare providers should be aware that the incidence of takotsubo cardiomyopathy might increase soon afterward. These patients should be treated in the ED as having acute coronary syndrome (ACS), be provided supportive treatment, and undergo subsequent cardiology evaluation.^[32]

Takotsubo cardiomyopathy should also be a consideration in young patients who present with symptoms similar to those of coronary heart disease to avoid potentially unnecessary invasive interventions (eg, coronary artery stent placement).^[19]

Atypical forms of takotsubo cardiomyopathy have been described with varying wall-motion abnormalities, including right ventricular and basal/midventricular akinesia. Clinically, these patients tend to present similarly to the classic form.^[26]

Conditions to consider in the differential diagnosis of takotsubo cardiomyopathy include the following:

Esophageal spasm
Gastroesophageal reflux disease
Myocardial infarction
Myocardial ischemia
Myocarditis
Acute pericarditis
Pneumothorax
Cardiogenic pulmonary edema
Pulmonary embolism
Unstable angina

Differential Diagnoses

Workup

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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) Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

Tables

Contributor Information and Disclosures

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