UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Management and prognosis of stress (takotsubo) cardiomyopathy

Authors
Guy S Reeder, MD
Abhiram Prasad, MD
Section Editor
William J McKenna, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC

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 of the left ventricle (LV), mimicking myocardial infarction, but in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture [1-16]. In most cases of stress cardiomyopathy, the regional wall motion abnormality extends beyond the territory perfused by a single epicardial coronary artery.

Stress cardiomyopathy was first described in 1990 in Japan and has since been increasingly recognized around the world [1,2,6,7,9,10,16,17]. 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 (image 1 and movie 1); mid and apical segments of the LV are depressed, and there is hyperkinesis of the basal walls. (See "Clinical manifestations and diagnosis of stress (takotsubo) cardiomyopathy", section on 'Approach to diagnosis'.)

This topic will review the management and prognosis of stress cardiomyopathy. The epidemiology, pathogenesis, clinical manifestations, and diagnosis of stress cardiomyopathy are discussed separately. (See "Clinical manifestations and diagnosis of stress (takotsubo) cardiomyopathy".)

MANAGEMENT

Approach to management — Stress cardiomyopathy is generally a transient disorder that is managed with supportive therapy. Conservative treatment and resolution of the physical or emotional stress usually result in rapid resolution of symptoms, although some patients develop acute complications such as shock and acute heart failure that require intensive therapy. Appropriate management of shock varies depending upon whether significant left ventricular outflow tract (LVOT) obstruction is present. Heart failure management during acute presentation and following stabilization is generally performed according to standard guidelines except that particular care is taken to avoid volume depletion and vasodilator therapy in patients with LVOT obstruction. Recommendations for anticoagulation to prevent thromboembolism in patients with stress cardiomyopathy with LV thrombus or severe LV systolic dysfunction are similar to those for patients post-myocardial infarction.

Hypotension and shock — Approximately 10 percent of patients with stress cardiomyopathy develop cardiogenic shock [16]. The development of shock may not correlate with the extent of left or right ventricular systolic dysfunction [18]. One explanation for discordance between ventricular dysfunction and risk of shock is that some shock is caused by LVOT obstruction, which has been described in 10 to 25 percent of patients with stress cardiomyopathy [3,19-21].

       

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Fri Oct 02 00:00:00 GMT+00:00 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Sato H, Taiteishi H, Uchida T. Takotsubo-type cardiomyopathy due to multivessel spasm. In: Clinical aspect of myocardial injury: From ischemia to heart failure, Kodama K, Haze K, Hon M (Eds), Kagakuhyouronsha, Tokyo 1990. p.56.
  2. Dote K, Sato H, Tateishi H, et al. [Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases]. J Cardiol 1991; 21:203.
  3. Bybee KA, Kara T, Prasad A, et al. Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med 2004; 141:858.
  4. Tsuchihashi K, Ueshima K, Uchida T, et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigations in Japan. J Am Coll Cardiol 2001; 38:11.
  5. Abe Y, Kondo M, Matsuoka R, et al. Assessment of clinical features in transient left ventricular apical ballooning. J Am Coll Cardiol 2003; 41:737.
  6. Hachamovitch R, Chang JD, Kuntz RE, et al. Recurrent reversible cardiogenic shock triggered by emotional distress with no obstructive coronary disease. Am Heart J 1995; 129:1026.
  7. Sharkey SW, Lesser JR, Zenovich AG, et al. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation 2005; 111:472.
  8. Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005; 352:539.
  9. Desmet WJ, Adriaenssens BF, Dens JA. Apical ballooning of the left ventricle: first series in white patients. Heart 2003; 89:1027.
  10. Bybee KA, Prasad A, Barsness GW, et al. Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome. Am J Cardiol 2004; 94:343.
  11. Dec GW. Recognition of the apical ballooning syndrome in the United States. Circulation 2005; 111:388.
  12. Aurigemma GP, Tighe DA. Echocardiography and reversible left ventricular dysfunction. Am J Med 2006; 119:18.
  13. Bybee KA, Prasad A. Stress-related cardiomyopathy syndromes. Circulation 2008; 118:397.
  14. Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J 2008; 155:408.
  15. Akashi YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo cardiomyopathy: a new form of acute, reversible heart failure. Circulation 2008; 118:2754.
  16. Templin C, Ghadri JR, Diekmann J, et al. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N Engl J Med 2015; 373:929.
  17. Kurowski V, Kaiser A, von Hof K, et al. Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): frequency, mechanisms, and prognosis. Chest 2007; 132:809.
  18. Singh K, Neil CJ, Nguyen TH, et al. Dissociation of early shock in takotsubo cardiomyopathy from either right or left ventricular systolic dysfunction. Heart Lung Circ 2014; 23:1141.
  19. Villareal RP, Achari A, Wilansky S, Wilson JM. Anteroapical stunning and left ventricular outflow tract obstruction. Mayo Clin Proc 2001; 76:79.
  20. De Backer O, Debonnaire P, Gevaert S, et al. Prevalence, associated factors and management implications of left ventricular outflow tract obstruction in takotsubo cardiomyopathy: a two-year, two-center experience. BMC Cardiovasc Disord 2014; 14:147.
  21. De Backer O, Debonnaire P, Muyldermans L, Missault L. Tako-tsubo cardiomyopathy with left ventricular outflow tract (LVOT) obstruction: case report and review of the literature. Acta Clin Belg 2011; 66:298.
  22. Madhavan M, Rihal CS, Lerman A, Prasad A. Acute heart failure in apical ballooning syndrome (TakoTsubo/stress cardiomyopathy): clinical correlates and Mayo Clinic risk score. J Am Coll Cardiol 2011; 57:1400.
  23. Kurisu S, Sato H, Kawagoe T, et al. Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction. Am Heart J 2002; 143:448.
  24. Sharkey SW, Windenburg DC, Lesser JR, et al. Natural history and expansive clinical profile of stress (tako-tsubo) cardiomyopathy. J Am Coll Cardiol 2010; 55:333.