Cardiomyopathy, Takotsubo, or Stress Induced

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 ...