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Takotsubo

Ryan Sanford
2/15/09
The Name

A Japanese term, named after the jar used for trapping octopus
In Popular Culture

A mechanism of being scared to death?


o Ananias and Sapphira
o Legal
Larry Whitfield on trial for 1st degree murder while
holding 79F at gunpoint fear induced heart
attack
Willie Ingram convicted of murder for emotional
upset causing heart attack, a 64M
Mark Fisher convicted of murder of 89F for fear
induced heart attack
AKA

Broken Heart Syndrome


Transient Left Ventricular Apical
Ballooning
Stress Cardiomyopathy
Definition

An acute completely reversible systolic


heart failure
Typical: apical akinesia [ballooning] and
hypercontractile base
Atypical: midventricular akinesia and
hypercontractile base
No relevant CAD
Mimics symptoms of ACS
Causes/Epidemiology

Triggered by extreme emotional or


physical stress
o Deaths, accidents, surprise party, procedure,
arguments, legal, public speaking, armed
robbery
Strong predominance in postmenopausal
women
Under-recognized, ~2% of all ACS
Pathophysiology

1.Coronary Spasm Stunned myocardium


1.not favored
2.Wall involvement extends beyond single vascular
territory
3.Few patients demonstrate spasm with provocation
during catheterization
4.CEs only slightly elevated, not high enough
2.Microvascular Impairment
1.Certainly present
2.Correlative, but causation doubted
Pathophysiology

1.Catecholamine Cardiotoxicity
1.Plasma levels of Epi/NE increased, even
higher than in pts w/ similar HF.
2.Not uniformly present, but close
3.Pheochromocytoma can cause similar cardiac
event
4.Histological findings simliar to in other forms of
catecholamine cardiotoxicity
Pathophysiology
Signs / Symptoms

Think ACS
o CP, dyspnea, syncope
Complications
o Pulmonary edema and respiratory failure
o Cardiogenic shock
o Ventricular tachyarrhythmias
o Ventricular wall rupture
o Mural thrombus
Labs

CEs: normal or slightly elevated


Elevated BNP
High serum catecholamines
EKG
ST Elevation, TWI, Prolonged QT
Imaging
Figure 1 Selective coronary angiography. Left (A) and right (B) coronary arteries in a patient
presenting with tako-tsubo cardiomyopathy, excluding coronary artery disease. Left
ventriculography during diastole (C) and systole (D) demonstrate the typical left ventricular
apical ballooning and a hypercontractile base.

Nef, H. M et al. Heart 2007;93:1309-1315

Copyright 2007 BMJ Publishing Group Ltd.


Typical

Atypical
Figure 4 Transthoracic echocardiogram showing four-chamber views during diastole (A) and
systole (B) in a patient presenting with tako-tsubo cardiomyopathy. Real time three-dimensional
echocardiography shows the typical contractile pattern of tako-tsubo cardiomyopathy with
akinesia of apical segments and hypercontractility of the basal segments (diastole, C; systole,
D).

Nef, H. M et al. Heart 2007;93:1309-1315


Copyright 2007 BMJ Publishing Group Ltd.
Treatment

Supportive care according to


complications
Arrhythmias
Cardiogenic shock
Pulmonary edema
Careful use of pressors
Prognosis
~1% hospital mortality
~10% recur ??
Return of LVEF within
2-4 weeks
References
Nef HM et al. Tako-Tsubo Cardiomyopathy (Apical Ballooning). Heart
2007;93:1309-1315
Akashi YJ et al. Takotsubo Cardiomyopathy A New Form of Acute,
Reversible Heart Failure. Circulation 2008;118:2754-2762
Wittstein IS et al. Neurohumora Features of Myocardial Stunning Due
to Sudden Emotional Stress. NEJM 2005;352:539-548
Kurowski V et al. Apical and Midventricular Transient Left Ventricular
Dysfunction Syndreom (Tako-Tsubo Cardiomyopathy) Frequency,
Mechanisms, Prognosis. Chest 2007; 132:509-816
Hassan T et al. A Case of Tako-tsubo Cardiomyopathy. Heart
2008;94:177
UpToDate. Stress-induced (takotsubo) Cardiomyopathy. 2009.