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Takotsubo cardiomyopathy (TTC) is a unique acute syndrome characterized by transient left ventricular (LV) systolic dysfunction in the absence of significant coronary artery disease.
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TTC occurs mostly in postmenopausal women after an emotional and/or physical stress.
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Because the symptoms and signs are nonspecific, a high clinical index of suspicion is necessary to detect the disease in different clinical settings.
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Noninvasive multimodality imaging (ie, echocardiography, CT, and magnetic resonance)
Takotsubo Cardiomyopathy: Overview
Section snippets
Key points
Pathophysiology
The pathophysiology of TTC is not well understood. The broad clinical spectrum suggests heterogeneous and multifactorial pathophysiologic mechanisms are involved.6, 7 A rapid elevation of circulating catecholamine levels triggered by emotional and/or physical stress may play a key pathogenic role.8 The direct effects of catecholamines on the myocardium (cellular damage, contraction band necrosis, defects in perfusion, altered cellular metabolism, and negative inotropic effects of epinephrine
Epidemiology
Although TTC is still misdiagnosed, it is more often recognized in daily routine clinical practice and thus increasingly reported in literature.4, 21 The TTC current prevalence estimate is approximately 1% to 3% of patients (up to 6%–9% if only women are considered) with suspicion of ACSs.1, 22, 23, 24, 25, 26 It occurs mostly in postmenopausal women (90% of overall TTCs).27 The mean age ranges from 62 to 76 years in absence of significant differences between men and women.28 Recently, in the
Clinical presentation
The most common presenting clinical symptoms of TTC are chest pain and dyspnea, reported in 70% to 80% and 20% of patients, respectively.28, 35 Uncommon presenting symptoms include syncope, palpitations, hypotension and cardiogenic shock, nausea and vomiting, serious ventricular arrhythmias (ventricular fibrillation), and/or cardiac arrest.5, 28, 36 In a small proportion of patients, symptoms may be atypical or absent, and TTC is identified accidentally after ischemic ECG changes and/or cardiac
Diagnostic methods and imaging techniques
Given the nonspecific symptoms and signs, a high clinical index of suspicion followed by laboratory tests (troponin and BNP), ECG, and imaging study (echocardiography or MRI) is essential for prompt diagnosis of TTC. Coronary angiography remains, however, mandatory to differentiate TTC from AMI (Table 1).
Therapy
The optimal management of TTC is usually supportive, leading to spontaneous recovery. Because the differential diagnosis between TTC and AMI usually cannot be established prior coronary angiography, in the emergency setting, standard treatment of ACS should be implemented (aspirin, heparin, clopidogrel, and/or fibrinolytic drugs). In general, patients with TTC are treated with standard acute heart failure medications, including angiotensin-converting enzyme inhibitors, β-blockers, diuretics,
Prognosis
TTC patients have generally a good short-term prognosis, with a rapid improvement of LV systolic function in a period of days to few weeks.5, 36 The incidence of out-of-hospital mortality is currently unknown, even if TTC could probably be considered another important cause of sudden cardiac death. Owada and colleagues,96 in an autopsy study (91 patients; 85% men) of sudden cardiac death, reported that 19.8% of patients had cardiac dysfunction related to stress. In-hospital mortality rates
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Cited by (55)
Short- and medium-term prognosis of Takotsubo syndrome in a Portuguese population
2019, Revista Portuguesa de CardiologiaCitation Excerpt :In the primary subtype, cardiac symptoms are the primary reason for seeking medical care, while in the secondary subtype the patient has an underlying primary disease that precipitated TTS. Therapy is supportive, usually consisting of vasodilators, beta-blockers and diuretics.8 Although the syndrome has previously been described as benign, more recent series have revealed a significant rate of in-hospital complications, and the short- and medium-term prognosis may be less favorable than previously described.6
Acute Stress and Broken Heart Syndrome. A Case Report
2017, Revista Colombiana de PsiquiatriaCircadian Rhythm Effects on Cardiovascular and Other Stress-Related Events
2017, Stress: Neuroendocrinology and NeurobiologyTakotsubo: From Cardiomyopathy to Acute Reversible Heart Failure Syndrome
2016, Heart Failure ClinicsChronobiology of Takotsubo Syndrome and Myocardial Infarction: Analogies and Differences
2016, Heart Failure ClinicsCitation Excerpt :The underlying (but largely undefined) mechanisms responsible for TTS events are most likely linked to environmental triggers in this uniquely susceptible patient population. It is known that TTS occurs mostly in postmenopausal women after emotional and/or physical stress,1 although recent observation showed that emotional triggers is not as common as physical triggers, and approximately one-third of patients had no evident trigger.114 In comparison with subjects with acute coronary syndrome, patients who presented with TTS had higher levels of anxiety,115 and physical stress seems to be more frequent in men, whereas more women experience emotional or no stress.116
Is LAD encasement a common substrate component in Takotsubo cardiomyopathy?
2016, Journal of Electrocardiology
Funding Sources: None.
Conflict of Interest: None.