INTRODUCTION
Stress cardiomyopathy (also called apical ballooning syndrome, takotsubo cardiomyopathy, broken heart syndrome, and stress-induced cardiomyopathy) is a syndrome characterized by transient regional systolic dysfunction, principally, of the left ventricle (LV), mimicking myocardial infarction (MI), but in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture [1,2]. In most cases of stress cardiomyopathy, the regional wall motion abnormality extends beyond the territory perfused by a single epicardial coronary artery. The term "takotsubo" is taken from the Japanese name for an octopus trap, which has a shape that is similar to the systolic apical ballooning appearance of the LV in the most common and typical form of this disorder (movie 1 and movie 2); mid and apical segments of the LV are hypokinetic/akinetic, and there is hyperkinesis of the basal walls. A midventricular type (movie 3) and other variants have also been described. (See 'Approach to diagnosis' below.)This topic will review the epidemiology, pathogenesis, clinical manifestations, and diagnosis of stress cardiomyopathy. The management and prognosis of stress cardiomyopathy is discussed separately. (See "Management and prognosis of stress (takotsubo) cardiomyopathy".)
EPIDEMIOLOGY
Stress cardiomyopathy was first described in 1990 in Japan and has since been increasingly recognized around the world [1,3-9]. Stress cardiomyopathy occurs in approximately 1 to 2 percent of patients presenting with troponin-positive suspected acute coronary syndrome (ACS) or suspected ST-elevation MI [9-11]. A prevalence of 1.2 percent was reported from a registry of 3265 patients with troponin-positive ACS [9]. Similarly, stress cardiomyopathy accounted for 1.7 to 2.2 cases presenting with suspected ACS or ST-elevation infarction in a systematic review [10].The incidence of stress cardiomyopathy among individuals exposed to physical or emotional stress is not known. A prospective study of 92 patients admitted to a medical intensive care unit with a noncardiac diagnosis and no prior history of cardiac disease found that 26 patients (28 percent) had LV apical ballooning consistent with stress cardiomyopathy [12]. LV function normalized in 20 of these patients at a mean of seven days. In multivariable analysis, sepsis was the only predictor of LV apical ballooning. The high incidence of transient LV apical ballooning in this series requires validation in larger series, but it appears that this phenomenon is not uncommon in a medical intensive care unit population.
Stress cardiomyopathy is much more common in women than men and occurs predominantly in older adults. [5,8,9,13-15]. In the International Takotsubo Registry (a consortium of 26 centers in Europe and the United States) of 1750 patients with stress cardiomyopathy, 89.9 percent were women and mean age was 66.4 years [8]. Similarly, in a review of 10 small prospective series, women accounted for 80 to 100 percent of cases, with a mean age of 61 to 76 years [15].