By Danielle Kerrigan, MD and Kristin Dwyer, MD

CASE

A 75 year-old female with a past medical history of hypertension, hyperlipidemia, SVT, chronic kidney disease, diabetes, lung cancer status post partial right lung resection, and remote history of breast cancer status post resection presented with chest pain. She awoke in the middle of the night after hearing a loud crash and found her husband lying on the ground unresponsive. She thought he was dead and felt an overwhelming sensation of fear, followed immediately by the onset of substernal chest pain radiating to the back associated with some shortness of breath. She denied fever, diaphoresis, nausea, vomiting, or palpitations. She denied any history of angina. Upon arrival to the emergency department she was given nitroglycerin with a subsequent improvement in her chest pain.

Her physical exam revealed hypertension with a systolic blood pressure in the 180s, baseline bradycardia in the 50s, and decreased breath sounds on the right consistent with her history of partial right lung resection. Her heart sounds were normal and she did not have any JVD or lower extremity edema, erythema, or swelling.

Her EKG showed a new left bundle branch block without ST segment changes. Her troponin was initially 1.246, then rose to 2.653. Her D-dimer was also elevated to 662. She declined a computed tomography (CT) with pulmonary embolism protocol because of a history of intractable vomiting induced by intravenous iodinated contrast.

Since the etiology of her chest pain remained unclear, point-of-care ultrasound echocardiography was performed to evaluate her cardiac function.

DIAGNOSIS

Takotsubo cardiomyopathy

DISCUSSION

What is Takotsubo cardiomyopathy? 

Takotsubo cardiomyopathy, known colloquially as broken heart syndrome, is an acute, transient stress-induced cardiomyopathy. First described in Japan in 1990 by Sato et al [1], Takotsubo cardiomyopathy is a condition characterized by apical ballooning of the left ventricle during systole. It is named for a Japanese octopus trap (“tako-tsubo”) because the shape of the trap, with its narrow neck and wide base, is similar to that of the heart during systole. It occurs more often in women and in patients over the age of 50.[2] The pathophysiology of Takotsubo cardiomyopathy remains unclear, however, several theories have been put forth. The most widely accepted theory postulates that an emotional or physical stressor causes an exaggerated sympathetic stimulation response and subsequent surge in catecholamines.[3] These catecholamines are cardiotoxic, both via induced microvascular spasm and direct catecholamine-associated myocardial toxicity.[2]

Signs and symptoms

Patients will often report symptoms concerning for acute coronary syndrome (ACS), including acute onset of chest pain or dyspnea. In fact, Takotsubo cardiomyopathy accounts for up to 2% of suspected ACS cases.[4] 89% of patients will have EKG changes, the most common being ST elevation or other ST segment or T wave changes. New left bundle branch blocks and arrhythmias have also been reported.[3] Patients will often have a modestly elevated troponin as well.[2] The important piece of history is the precipitant event, as in Takotsubo cardiomyopathy, these symptoms will be preceded by a physical or emotional stressor.[3]

Findings on ultrasound

In Takotsubo cardiomyopathy, the contractility of the left ventricle will appear normal on the parasternal short axis view. This is because the parasternal short axis view provides a cross-sectional view of the left ventricle, often the mid-section at the level of the papillary muscles or just below the mitral valve. This view does not allow visualization of the apex of the left ventricle, which is where the ballooning takes place.

In order to truly assess contractility at the apex of the heart, the apical 4 chamber view must be obtained.

Diagnosis, treatment, and prognosis

There is no consensus on diagnostic criteria for Takotsubo cardiomyopathy, although several guidelines have been published. Most of these guidelines agree that cardiac catheterization is required for diagnosis. The catheterization will show coronary arteries without evidence of occlusion. Furthermore, the wall motion abnormalities will extend beyond a single coronary vascular bed.[2] Since the presentation is similar to ACS, the initial management should include heparin, aspirin, oxygen, and beta blockers as would typically be given to treat myocardial ischemia.[2] The in-hospital mortality rate is fairly low, estimated at 0-8%.[5] Most patients will have a complete recovery within a month.[2] The likelihood of experiencing another episode of Takotsubo cardiomyopathy is very low, even with a stressful event.[6]

CASE RESOLUTION

The patient was treated with aspirin, ticagrelor, and heparin. She was taken for cardiac catheterization the next morning that showed normal coronary arteries and high suspicion for Takotsubo cardiomyopathy. Echocardiography showed multiple regional wall motion abnormalities, including an akinetic apex, and a newly reduced ejection fraction. She had no in-hospital complications and was discharged home on hospital day.[3]

TAKE-AWAYS

• Takotsubo cardiomyopathy should be considered in patients with ACS symptoms preceded by a stressful event

• Contractility may appear normal in the parasternal short axis view, so the apical 4 chamber view is necessary to visualize apical ballooning

• The diagnosis can only be confirmed with cardiac catheterization

Author: Dr. Danielle Kerrigan

Faculty Reviewer: Dr. Kristin Dwyer

 REFERENCES

1. Sato H, Tateishi H, Uchida T, et al. Takotsubo type cardiomyopathy due to multivessel spasm. In: Kodama K, Haze K, Hon M, editors. Clinical aspect of myocardial injury: from ischemia to heart failure. Kagaku Hyoronsha; Tokyo: 1990. pp. 56–64.

2. Ono R, Menezes Falcao L. Takotsubo cardiomyopathy systematic review: Pathophysiologic process, clinical presentation and diagnostic approach to Takotsubo cardiomyopathy. Int J Cardiol. 2016;209:196-205.

3. Dawson D. Acute stress-induced (takotsubo) cardiomyopathy. Heart. 2018;104(2):96-102

4. Bybee K, Kara T, Prasad A, et al. Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med. 2004;141(11):858-865.

5. Vivo R, Krim S, Hodgson J. It’s a trap! Clinical similarities and subtle ECG differences between takotsubo cardiomyopathy and myocardial infarction. J Gen Intern Med. 2008;23(11):1909-1913.

6. Sharkey S, Lesser J, Maron B. Cardiology Patient Page. Takotsubo (stress) cardiomyopathy. Circulation. 2011;124(18):e460-2.