Skip to Main Content

KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Classically, left ventricular apical "balloon" dilation and dysfunction with preserved basal wall motion on cardiac imaging

  • Emotional and/or physical stress frequently preceding symptoms of chest discomfort and/or dyspnea

  • No consensus diagnostic criteria

  • Catecholamine-stimulated myocardial stunning and evidence of inflammation on acute imaging

  • No significant stenosis on coronary angiography, and the regional wall motion abnormalities extend beyond a single coronary artery distribution

GENERAL CONSIDERATIONS

  • Transient left ventricular apical ballooning named for shape of Japanese octopus fishing pot

  • Mechanism unknown but probably related to sympathetic activation and catecholamine release

  • Probably shares a similar mechanism to "neurogenic stunned myocardium" described after subarachnoid hemorrhage and stroke

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Typically women over age 50 years

  • Chest discomfort and/or dyspnea frequently following emotional or physical stress

  • Syncope

  • Ventricular fibrillation cardiac arrest

PHYSICAL EXAM FINDINGS

  • Tachypnea

  • Tachycardia

  • Hypertension or hypotension

  • Cardiogenic shock

  • Elevated jugular venous pressure

  • Pulmonary rales

  • Prominent, diffuse, and sustained apical impulse

  • Gallop rhythms may be present

  • Edema

DIFFERENTIAL DIAGNOSIS

  • Acute myocardial infarction

  • Myocarditis

  • Cardiomyopathy following subarachnoid hemorrhage

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Cardiac enzymes may be normal or mildly elevated

  • Serum brain natriuretic peptide levels are elevated

ELECTROCARDIOGRAPHY

  • Sinus tachycardia

  • Prolonged PR interval in one-quarter

  • Prolonged QT interval in one-quarter

  • ST-segment elevations in the anterior precordial leads in 15–20%

  • Q waves in the anterior precordial leads in > one-third

  • Diffuse, deep T-wave inversions develop within 48 hours

IMAGING STUDIES

  • Chest x-ray:

    • – Cardiac silhouette may be normal or enlarged

    • – Pulmonary vascular congestion or edema may be present

  • Echocardiography: Classically, pattern of apical "balloon" dilation with akinesis or dyskinesis and preserved contractility of the basilar segments. Other patterns of akinesis include midventricular and basal or inverted variant

  • New data showing myocardial edema visualization on cardiac MRI

DIAGNOSTIC PROCEDURES

  • Cardiac catheterization:

    • – No angiographically significant epicardial coronary artery disease or spasm

    • – Left ventriculography reveals apical akinesis or dyskinesis

    • – Elevated left ventricular end diastolic pressure

    • – Right heart catheterization demonstrates variable elevations in pulmonary capillary wedge pressure, pulmonary artery pressure, right atrial pressure, and reduced cardiac output

TREATMENT

CARDIOLOGY REFERRAL

  • All patients

HOSPITALIZATION CRITERIA

  • Suspected acute coronary syndrome

  • Congestive heart failure

  • Syncope

  • Arrhythmias

MEDICATIONS

  • Supportive therapy including diuretics and vasodilators

  • Pressors and beta agonists are typically avoided in favor of mechanical support when needed

  • Chronic heart failure medications for persistent left ventricular dysfunction

THERAPEUTIC PROCEDURES

  • Mechanical support devices may be needed ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.