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Takotsubo cardiomyopathy

From Mediwikis


Takotsubo cardiomyopathy

Cardiomyopathies are defined as primary disorders of the myocardium, not due to pressure or volume overload. Takotsubo cardiomyopathy (TCM) is essentially a catecholaminergic-driven cardiomyopathy, which results in transient left ventricle (LV) dysfunction, and is often called “broken-heart syndrome.” This reflects its common clinical presentation of being caused by emotional or physical distress. TCM is estimated to be the underlying cause for 2% of cases treated as acute coronary syndromes (ACS).

The current pathophysiology is not clearly recognised but a number of factors are indicated such as excess sympathetic stimulation, coronary artery vasospasm and oestrogen deficiency.

Symptoms

TCM is often confused with ACS due to the very similar presentation. Although the classic patient is a post-menopausal female, TCM has also been reported in young females and in men.

Patients often complain of abrupt onset retrosternal chest pain and shortness of breath.

Investigations/diagnosis

Since most presentations of chest pain and dyspnoea result in investigations being carried out to rule out acute coronary syndromes, it would be more appropriate to describe the results relevant to TCM from these investigations. A cardiac echogram or MRI is the only one that requires a high clinical suspicion of TCM before being carried out.

  • Blood tests: There may be some elevation of cardiac enzymes, such as CK or Troponin, but these are very minimal and certainly not proportional to the size of the myocardial abnormality. High levels of plasma brain natriuretic peptide (BNP) and serum catecholamines have also often been reported.
  • ECG: The ECG results often mimic ACS, with ST segment elevation (especially in the anterior leads) and T wave inversion. Importantly, some patients may also present in acute cardiogenic shock or ventricular arrhythmia.
  • Imaging: Due to the similar presentation as ACS angiography is usually carried out, which will reveal no evidence of complete obstructive coronary disease or acute plaque rupture. Due to the age of many of the patients, there is likely to be some coronary artery disease, but it will certainly not be flow-limiting. Cardiac echogram or MRI is the ideal investigation for diagnosing TCM, and characteristically demonstrates apical akinesis of the LV, with reduced systolic function. Thus, such echogram findings in the absence of coronary artery disease, make TCM very likely. However, it is important to rule out phaeochromocytoma or myocarditis as an underlying cause for these changes.

Treatment/ Prognosis

Treatment for TCM is essentially conservative, with consistent monitoring advised to ensure patients do not develop complications such as cardiogenic shock. IV hydration and removal of the causal stress is paramount.

B-blockers are also often implicated to reduce the catecholamine surge associated with TCM.

TCM has a very good prognosis, with LV function returning to normal by 4–6 weeks.

Summary

Thus, in summary TCM is catecholaminergic-driven transient LV dysfunction, and is an important differential for doctors to consider in all post-menopausal women with a history of emotional/physical stress, who presents with chest pain. Prognosis is very good, but strict monitoring is required in the acute period to manage any complications that occur.