Takotsubo cardiomyopathy (TC), also known as broken heart syndrome, is a temporary heart condition caused by severe emotional or physical stress that causes the left ventricle of the heart to balloon out at the bottom and contract abnormally. It most often affects post-menopausal women and can cause chest pain and symptoms similar to a heart attack. While the exact cause is unknown, it is thought to involve an extreme surge of stress hormones that stuns the heart muscle. The prognosis is generally good with most people making a full recovery within weeks.

1. Can We Really
Die from a
Broken Heart?

2. Takotsubo
Cardiomyopathy
W. P. Rivindu H. Wickramanayake
Group no. 04a
4th Year 2nd Semester – 2018 October
Tbilisi State Medical University, Georgia

3. ● Takotsubo Cardiomyopathy (TCM) is a transient cardiac syndrome
● that involves left ventricular apical akinesis
● and mimics acute coronary syndrome (ACS).
● It was first described in Japan in 1990 by Sato et al.
● The Japanese word takotsubo translates to "octopus pot," resembling
the shape of the left ventricle during systole on imaging studies.

4. Pathophysiology
● Normal myocardium – 90% energy from fatty acid metabolism.
● During ischemia, this pathway is suppressed, and glucose is largely utilized
instead, which results in impaired cardiac function.
● Patients with TCM are found to shift toward the glucose pathway despite
relatively normal myocardial perfusion and lack of ischemia in LV segments.
● Mechanism for TCM;
 Stress-induced catecholamine release, with toxicity to and subsequent
stunning of the myocardium.
 Endomyocardial biopsy of patients with TCM demonstrates reversible focal
myocytolysis, mononuclear infiltrates, and contraction band necrosis.
 A unifying hypothesis - in susceptible individuals, notably women,
Neurohormonal Stimulation results in acute myocardial dysfunction,
 as reflected by the characteristic LV wall-motion abnormality of TCM.
But can see them even in left anterior descending (LAD) lesions.

5. ● Cases of TCM have been reported in the literature following; Cocaine,
Methamphetamine, and Excessive Phenylephrine use.
● Exercise stress testing --> increased levels of catecholamines, has resulted in
false positives attributable to TCM.
● Patients with TCM have, higher levels of serum catecholamines
(norepinephrine, epinephrine, and dopamine) than do patients with MI.
● Apical portions of LV have the highest concentration of sympathetic
innervation in the heart & may explain why excess catecholamines seem to
selectively affect its function.
● The exact etiology of TCM is still unknown ; Theories ;
 Multivessel coronary artery spasm
 Impaired cardiac microvascular function
 Impaired myocardial fatty acid metabolism
 ACS with reperfusion injury
 Endo. catecholamine-induced myocardial stunning & micro-infarction

7. Risk Factors
●A significant emotional or physical stressor or neurologic injury. Stressors
 Learning of a death of a loved one
 Bad financial news
 Legal problems
 Natural disasters
 Motor vehicle collisions
 Exacerbation of a chronic medical illness
 Newly diagnosed, significant medical condition
 Surgery
 Intensive care unit (ICU) stay
 Use of or withdrawal from illicit drugs
● TCM has also been reported after near-drowning episodes.
● Seizures may also trigger TCM,
● but rare to result in sudden unexpected death in epilepsy (SUDEP).

8. ● The International Takotsubo Registry reported that patients with TCM,
as compared with ACS patients, more likely to be female (89.8%)
● More physical triggers than emotional triggers (36% vs 27.7%),
though more than one quarter (28.5%) had no clear triggers.
● Patients with TCM also had ;
- higher rates of neurologic or psychiatric disorders and
- a significantly lower LV ejection fraction (LVEF).
● The two groups (TCM and ACS) had;
- similar rates of severe inpatient complications (eg, shock, death),
- and independent predictors of such complications included;
- physical triggers,
- acute neurologic/psychiatric diseases,
- elevated troponin levels, and
- low LVEF.

9. ● Studies reported that 1.7-2.2% of
patients who’d suspected ACS were
subsequently diagnosed with TCM.
● Patients are typically Asian or
Caucasian.
- 57.2% - Asian,
- 40% - Caucasian,
- 2.8% - other races.
● A mean patient age of 67 years,
though have occurred in children and
young adults.
● Nearly 90% of reported cases involve
postmenopausal women.
EpidemiologyPrognosis
● Typically excellent, nearly 95%,
complete recovery within 4-8 weeks.
● Complications - 20%, particularly in
the early stage, the following
 Left heart failure with and
without pulmonary edema
 Cardiogenic shock
 LV outflow obstruction
 Mitral regurgitation
 Ventricular arrhythmias
 LV mural thrombus formation
 LV free-wall rupture
 Death

10. ● Indistinguishable from acute coronary syndrome.
● The most common presenting symptoms ;
- Chest pain and Dyspnea, Palpitations,
- Nausea, Vomiting, Syncope,
- Cardiogenic shock – Rarely
● Association with a preceding emotionally or
physically stressful trigger event, occurring in
approximately two thirds of patients. – Unique
feature
● Unlike ACS, TCM events are most prevalent in
the afternoon, when stressful triggers are more
likely to take place.
● Lower incidence of traditional cardiac risk
factors, such as hypertension, hyperlipidemia,
diabetes, smoking, or positive family history for
cardiovascular disease.
Clinical Presentation
● Nonspecific and often normal
● May exhibit the clinical appearance of
ACS/ acute congestive heart failure.
● Patients appear anxious and diaphoretic.
● Tachydysrhythmias and
bradydysrhythmias, but the average
heart rate is around 102 bpm.
● Hypotension - occur from a reduction
in stroke volume because of acute left
ventricular (LV) systolic dysfunction or
outflow tract obstruction.
● Murmurs and rales may be present on
auscultation in the setting of acute
pulmonary edema.
Physical Examination

11. ● Atypical forms of TCM have been described
with varying wall-motion abnormalities,
including right ventricular and
basal/midventricular akinesia.
● Clinically, these patients tend to present
similarly to the classic form.
● Conditions for Differential diagnosis of TCM:
a. Esophageal spasm
b. Gastroesophageal reflux disease (GERD)
c. Myocardial infarction (MI)
d. Myocardial ischemia
e. Myocarditis
f. Acute pericarditis
g. Pneumothorax
h. Cardiogenic pulmonary edema
i. Pulmonary embolism (PE)
j. Unstable angina
Differential
Diagnoses
● Acute Coronary Syndrome
● Angina Pectoris
● Aortic Dissection
● Boerhaave Syndrome
● Cardiac Tamponade
● Cardiogenic Shock
● Cocaine-Related Cardiomyopathy
● Coronary Artery Vasospasm
● Dilated Cardiomyopathy
● Hypertrophic Cardiomyopathy

12. ● Cardiac markers, specifically troponin I (TnI) and tropnin T
(TnT), are elevated in 90% of patients with takotsubo
cardiomyopathy (TCM),
● though to a lesser magnitude than is seen in ST-segment elevation
myocardial infarction (STEMI).
● The brain natriuretic peptide (BNP) level is frequently elevated.
● Electrocardiography (ECG) should be the initial test.
● Transthoracic Echocardiography (TTE) provides
- a quick method of diagnosing wall-motion abnormalities
typically seen in TCM, specifically hypokinesis or akinesis of the
mid-segment and apical segment of the left ventricle (LV).
● The diagnosis of TCM is confirmed with Cardiac Angiography.
Diagnosis

13. ● Can be applied to a patient at the time of presentation.
● The diagnosis requires the presence of all four of the following :
1) Transient hypokinesis, dyskinesis, akinesis of the LV mid-
segments, with or without apical involvement; regional wall-
motion abnormalities beyond a single epicardial vascular
distribution, & a stressful trigger is often, but not always present
2) Absence of obstructive coronary disease or angiographic
evidence of acute plaque rupture
3) New ECG abnormalities (either ST-segment elevation and/or T-
wave inversion) or modest elevation in the cardiac troponin level
4) Absence of pheochromocytoma or myocarditis
Modified Mayo Clinic Criteria for Diagnosis of TCM

14.  Ventriculogram during systole
in a patient with TCM
demonstrating apical akinesis.
 Electrocardiogram of a patient with
TCM demonstrating ST-segment
elevation in anterior and inferior leads.

15.  Echocardiogram of a patient
with TCM during diastole
several days after presenting
to the emergency department.
 Echocardiogram of a patient with
TCM during systole, which
demonstrates apical akinesis.
 Ejection fraction is 40%.

16. ● Patients should be treated as having ACS until proved otherwise.
● Addressing the airway, breathing, & circulation; establishing (IV) access,
providing supplemental oxygen & cardiac monitoring should take precedence.
● Testing should include ECG, chest radiography, cardiac biomarker levels, brain
natriuretic peptide (BNP) level, and other appropriate laboratory studies.
● If continues to manifest a clinical picture consistent with ACS, especially
STEMI, then standard therapies, such as the following, may be indicated:
 Aspirin
 Beta blockers
 Nitrates
 Heparin or enoxaparin
 Morphine
 Clopidogrel
 Platelet glycogen (GP) IIb/IIIa inhibitors
Treatment

17. ● Acute congestive heart failure (CHF)  diuresis,
● Cardiogenic shock  resuscitation with IV fluids and inotropic agents.
● Bedside echocardiography show the characteristic wall-motion abnormality.
● The insertion of an intra-aortic balloon pump (IABP)  a successful resuscitative
intervention, because of LV outflow obstruction that can result from a hyperkinetic basal
segment and dyskinetic apex.
● Fluids and beta blockers, or calcium-channel blockers, are beneficial, whereas inotropes
may exacerbate the problem and should be used with caution.
● Arrhythmias are common in TCM and are a major determinant of patient outcome 
ventricular fibrillation, ventricular tachycardia, asystole, pulseless electrical activity, and
complete atrioventricular or sinoatrial block.
● Bradyarrhythmias in the acute setting  permanent pacemaker implantation,
● Polymorphic ventricular arrhythmias  a temporary approach (eg, wearable
cardioverter-defibrillators) until recovery of repolarization time and LV function.
● Dysrhythmias and cardiopulmonary arrest  advanced cardiac life support (ACLS)
protocols.
● Thrombolytics  when percutaneous coronary intervention (PCI) is not available
and patients otherwise meet criteria.

18. ● https://emedicine.medscape.com/article/1513631-medication#3
● https://reference.medscape.com/medline/abstract/25131525
● https://reference.medscape.com/medline/abstract/26266349
● https://reference.medscape.com/medline/abstract/19152137
● https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847940/
● https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4110608/
● https://www.mayoclinic.org/diseases-conditions/broken-heart-
syndrome/symptoms-causes/syc-20354617
References