Approach Considerations

Prehospital care

Because takotsubo (stress) cardiomyopathy (broken heart syndrome) mimics acute coronary syndrome and no initial electrocardiographic (ECG) finding reliably differentiates takotsubo cardiomyopathy 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 takotsubo cardiomyopathy 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 takotsubo cardiomyopathy, require anticoagulation.^[43]

Outpatient care

Close follow-up care with a cardiologist in the weeks after diagnosis is recommended for patients with takotsubo cardiomyopathy 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 takotsubo cardiomyopathy are unknown.^{[27, 44]}

Consultations and transfer for suspected takotsubo cardiomyopathy

Consultation with a cardiologist is necessary, in that coronary angiography is required for the diagnosis of takotsubo cardiomyopathy. Patients may need to be transferred to a facility with a cardiologist and a cardiac catheterization laboratory.^{[30, 34, 35, 44]}

Emergency Department Care

Patients with takotsubo (stress) cardiomyopathy (broken heart syndrome) should be treated as having acute coronary syndrome (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 electrocardiography (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 ST-segment elevation myocardial infarction (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 left ventricular (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 takotsubo cardiomyopathy and are a major determinant of patient outcome. In a cohort of 286 consecutive takotsubo cardiomyopathy 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).^[45]The results suggested that whereas bradyarrhythmias in the acute setting of takotsubo cardiomyopathymight 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.^[45]

Dysrhythmias and cardiopulmonary arrest should be treated according to current advanced cardiac life support (ACLS) protocols. Although thrombolytics will not benefit patients with takotsubo cardiomyopathy, their use should not be withheld when percutaneous coronary intervention (PCI) is not available and patients otherwise meet criteria.^{[30, 44]}

Medication

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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.