Takotsubo Cardiomyopathy Treatment & Management

Updated: Jan 17, 2017
  • Author: Eric B Tomich, DO; Chief Editor: Erik D Schraga, MD  more...
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Treatment

Approach Considerations

Prehospital care

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

Inpatient care

Patients with TCM will require admission to the appropriate cardiology service. Treatment options are largely empiric 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 (LV) thrombus, which occurs in 5% of patients with TCM, require anticoagulation. [38]

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. [23, 39]

Consultations and transfer

Consultation with a cardiologist is necessary, in that 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. [26, 30, 31, 39]

Next:

Emergency Department Care

Patients should be treated as having ACS until proved otherwise. Addressing the airway, breathing, and circulation; establishing intravenous (IV) access, and providing supplemental oxygen and cardiac monitoring should take precedence. Testing in the emergency department should include ECG, chest radiography, cardiac biomarker levels, brain natriuretic peptide (BNP) level, and other appropriate laboratory studies.

If the patient continues to manifest a clinical picture consistent with ACS, 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 (CHF) may require diuresis, and patients with cardiogenic shock may require resuscitation with IV fluids and inotropic agents. If available, bedside echocardiography could show the characteristic wall-motion abnormality.

The insertion of an intra-aortic balloon pump (IABP) has also been reported as being a successful resuscitative intervention, because of LV 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.

Arrhythmias are common in TCM and are a major determinant of patient outcome. In a cohort of 286 consecutive TCM patients, Stiermaier et al assessed treatment strategies for arrhythmias, including ventricular fibrillation, ventricular tachycardia, asystole, pulseless electrical activity, and complete atrioventricular or sinoatrial block (mean follow-up, 3.3±2.4 years). [40] The results suggested that whereas bradyarrhythmias in the acute setting of TCM might necessitate permanent pacemaker implantation, polymorphic ventricular arrhythmias might be manageable with a temporary approach (eg, wearable cardioverter-defibrillators) until recovery of repolarization time and LV function.

Dysrhythmias and cardiopulmonary arrest should be treated according to current advanced cardiac life support (ACLS) protocols. Although thrombolytics will not benefit patients with TCM, their use should not be withheld when percutaneous coronary intervention (PCI) is not available and patients otherwise meet criteria. [26, 39]

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