1. Takotsubo Cardiomyopathy
Richard Fox

2. Why Takotsubo?
• Takotsubo cardiomyopathy (TC) is an acute
cardiac syndrome, which presents like ACS
• Misdiagnosis poses a bleeding risk to the
patient through thrombolysis
• Awareness of TC and the at risk
demographic is therefore vital
• Clinicians should include TC in their
differential diagnosis in cases of ACS that
show no coronary artery stenosis

3. What is Takotsubo?
• TC is an acute cardiac syndrome, which
presents like ACS
• Transient LV apical ballooning in the absence
of coronary artery stenosis
• Often precipitated by acute emotional or
physical stress
• “Broken heart syndrome”

4. • Takotsubo; “Octopus pot” was first
documented in Japan in 1991
• It is so named due to the appearance of the
left ventriculogram is systole
Fig.1 A. Ventriculogram
showing left apical
ballooning.
B.Japanese octopus pot7

5. Prevalence
• Since 1991 the number of reported cases has
risen annually
• In a recent study in the US, TC accounted for
≈2.2% of STEMI cases
• The true prevalence is still uncertain

6. Women>Men
• Females are affected more than men
• 90% of cases involve women
• Majority are post-menopausal
• Mean age 68yrs

7. Presentation
Cannot distinguish between Takotsubo and
STEMI at presentation!!!

8. History
• Acute emotional stress
(25% of cases)
• Physical stressor
(30% of cases)
• Idiopathic
(30% of cases)
Unexpected death in the family
Confrontational argument
Severe anxiety
Asthma attack
Exhaustion
Sepsis

9. Investigation
• ECG
• Angiography
• Echocardiography
• Cardiac enzymes

10. ECG
• At presentation:
ST-elevation in pre-cordial leads

11. Repeat ECG
• Later that day
Resolution of ST-elevation
Development of T-wave inversion

12. Angiography
• The absence of coronary artery stenosis1
• Mid-ventricular wall akinesis/dyskinesis,
with hypercontractile basal segments
producing the characteristic appearance6
• Abnormalities in the apical wall, sparing
the base
Fig. Ventriculogram in
diastole (A)
and systole (B)6

13. Echocardiography
• Acutely reduced ejection fraction1
33 %
(Normal = 55-65%)

14. Cardiac enzymes
• TnI rises in Takotsubo
• In Takotsubo the peak TnI rise is
disproportionate to the level of LV dysfunction
Investigation Takotsubo STEMI
Initial TnI 1.1 1.9
Peak TnI 4.9 7.3
Ejection
fraction
33 25

15. Pathophysiology
• The pathophysiology of Takotsubo is poorly understood.
Several mechanisms for this reversible cardiomyopathy
have been proposed1:
Microvascular dysfunction:
coronary artery microspasm*
Excess plasma
catecholamines*
Myocardial stunning: Acute
sympathetic overactivity
Takotsubo
*Estrogen deficiency:
Increased sensitivity in post-
menopausal women

16. Pathophysiology cont….
• Increased plasma catecholamines
- front runner in explaining the mechanism in Takotsubo
- Catecholamine are 2-3 times higher in TC than in STEMI at
hospitalisation.
- Excess catecholamines are shown to cause myocardial
damage; focal mycytolysis seen in TC
- Epiphenomenon?
• Myocardial stunning
- Increased sympathetic activity, linked with emotional
stress, may be important in TC1.
- Excess cardiac adrenoreceptor stimulation causes left
ventricular hypocontraction in animal models1.

17. Estrogen
• Hormones are thought to be the key in
explaining the high proportion of cases in
PMW
• Estrogen may influence coronary artery
vasoreactivity and its absence may
increase risk of microspasm1

18. Diagnosing Takotsubo
Mayo clinic criteria4
New ECG
abnormalities * Absence of
obstructive coronary
artery disease
Transient LV
apical akinesis/
dyskinesis
* Without concurrent conditions; head injury/intracranial bleed/
pheochromocytoma/myocarditis/hypertrophic cardiomyopathy

19. Management
• At present, treatment is entirely empirical.
Management should follow that for ACS and
emergency angiography is advised1.
• Other possibilities for “broken heart
syndrome”?
http://www.youtube.com/watch?v=fbn75LITtlc&feature=related

20. Prognosis
• Very good; in the absence of comorbidity
• Systolic dysfunction resolves within days-weeks4
• At this time, repeat ECG classically shows resolution of all
abnormalities, though T-wave inversion may persist for longer.
• In-hospital mortality is low (1-2%), as is the rate of recurrence
(10%)1.
• Ventricular thrombosis and heart failure are possible
complications
• Long-term prognosis is unknown and future prospective studies
are required.

21. Summary
• TC is an acute cardiac syndrome, transiently
affecting LV function and presenting like ACS.
• It is impossible to differentiate the two at
presentation.
• TC should be included as a differential diagnosis
in patients who:
- meet the Mayo clinic criteria
- have a history of an acute emotional or
physical stressor
• Especially in post-menopausal women, who seem
to be more at risk.

22. References
1. Gianni M, Dentali F, Grandi AM, Summer G, Hiralal, Lonn E. Apical ballooning syndrome or Takotsubo
cardiomyopathy:systematic review.Eur Heart J.2006;27;1523-1529
2. Doke K, Sato H, Uchida T, Ishihara M.Myocardial stunning due to simultaneous multivessel coronary
spasms:a review of 5 cases.J Cardiol 1991;21;203-14
3. Bybee KA, Prasad A, Barsness GW, Lerman A, Jaffe AS, Murphy JG, et al Clinical characteristics and
thrombolysis in myocadial infarction frame counts in women with transient left ventricular apical
ballooning syndrome.Am J Cardiol.2004;94;343-346
4. Barker S, Solomon H, Bergin JD,Huff JS, Brady WJ.Electrocardiographic ST-segment elevation:
Takotsubo cardiomyopathy versus ST segment elevation myocardial infarction-A case series.Am J
Emerg Med 2009;27;220-226
5. Bybee KA, Prasad A.Stress related cardiomyopathy syndromes.Circulation.2008;118;397-409
6. Nielson LH, Munk K, Goetzsche O et al. Takotsubo cardiomopathyAn important differential diagnosis
to acute myocardial infarctio. Danish medical bulletin.2009;56;165-168
7. Kurisu S, Sato H, Kawagoe T, Ishihara M, Shimatani Y, Nishioka K, Kono Y, Umemura T, Nakamura S
(2002) Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac
syndrome mimicking acute myocardial infarction Am Heart J 143(3): 448-455