Cardiac Case Study: July 2008

Takotsubo Cardiomyopathy: Fixing a Broken Heart

Takotsubo Cardiomyopathy: Fixing a Broken Heart

By Dale Yoo, MD, Cardiology Fellow, Emory University School of Medicine

A 46-year-old female presented to the emergency department (ED) with sudden onset retrosternal chest pain with radiation to her jaw and left arm. The initial episode lasted 10 to 20 minutes and was relieved with acetylsalicylic acid (ASA), but intermittent pain persisted until arrival at the ED. The patient reported a family history of hypertension but no significant social history, no current medications and no known drug allergies. Her past medical history revealed only mild mitral valve prolapse (MVP).

In the ED, the patient was given ASA, morphine, nitroglycerin, simvastatin and an IV of metoprolol. Following these interventions she remained chest pain-free. Serial electrocardiographs (EKGs), however, revealed dynamic ST-T changes, suggesting ongoing myocardial ischemia (Figure 1).

EKG illustrating ST-T changes

A transthoracic echocardiogram (TTE) was performed in the ED, which confirmed the initial suspicion of myocardial ischemia as demonstrated by a regional wall motion abnormality in the left ventricular apex (Figure 2).

TTE illustrating intact basal contraction and apical akinesia

Due to concern for an acute coronary syndrome (ACS), the patient was transferred to the cardiac catheterization laboratory. She underwent a left heart catheterization, which revealed no coronary thrombosis. Subsequently, the patient was diagnosed with Takotsubo cardiomyopathy and admitted for observation. The following day, a cardiac MRI was performed to determine if the patient had suffered myocardial damage. The cardiac MRI was normal except for an akinetic apex, consistent with the diagnosis of Takotsubo cardiomyopathy (Figure 3). The patient was discharged the following day.

Cardiac MRI illustrating classic lack of apical contractility. The left and right panels, respectively, show diastolic and systolic images. Note the preserved basal contraction with apical akinesia.

In recent years, a number of cases have described patients presenting with distinct left ventricular dysfunction that resembles an ACS, but in the absence of coronary artery disease or obstruction.1,2 First documented in Japan in 1991,3 the telltale feature of this syndrome is a wall motion abnormality in the left ventricular apex and mid-ventricle. The abnormality is in a shape initially described as resembling a takotsubo, a Japanese pot used to trap octopi.2 Hyperkinesis of the basal left ventricular segments also is common.2

The cause of this transient heart failure is unknown, but initial research indicates it is most likely to occur in post-menopausal women and usually is associated with stressful life events, either physiological or emotional.2 For this reason, the condition also is known as "broken-heart syndrome."4

Patients often present with ST-segment elevation or T-wave inversion and pathological Q waves.2,3 Minor elevations of cardiac enzymes and biomarkers are not uncommon.2 Some data suggest Takotsubo cardiomyopathy may be the result of diffuse microvascular abnormalities usually attendant on presentation that cause catecholamine-mediated myocardial stunning.2

heart in hands

In establishing a differential diagnosis for the symptoms and laboratory results often associated with an ACS, it remains very important to consider other syndromes as well because treatments often are quite different. Distinguishing Takotsubo cardiomyopathy from acute myocardial infarction and ischemia is particularly important because the condition usually resolves without treatment within days or weeks, and the use of thrombolytic agents may expose the patient to unnecessary risk of bleeding.2,3 It, however, also is necessary to proceed promptly while developing the differentialdiagnosis because “time is muscle” with respect to myocardial ischemia and cardiac function. Fortunately, the majority of patients with Takotsubo cardiomyopathy improve over time. If the patient survives the initial cardiac failure, mortality rates are generally low, estimated between 0% and 8%.1,2

References

  1. 1. Akashi YJ, Nakazawa K, Sakakibara M, Miyake F, Koike H, Sasaka K. The clinical features of Takotsubo cardiomyopathy. QJM. 2003;96:563-573.
  2. 2. 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;141:858–865.
  3. 3. GianniM, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J. 2006;27 13):1523-1529.
  4. 4. Virani SS, Khan AN, Mendoza CE, Ferreira AC, de Marchena E. Takotsubo cardiomyopathy, or broken-heart syndrome. Tex Heart Inst J. 2007;34(1):76-79.

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