We discussed a case of an elderly woman with history of HTN and pre-diabetes, who presented with acute hypertensive emergency and dizziness, found to have evolving EKGs (ST elevations in anterior/lateral precordial leads) and elevated troponins concerning for STEMI, due to Takotsubo cardiomyopathy.

Takotsubo cardiomyopathy

• Transient regional LV systolic dysfunction
• Absence of angiographic evidence of obstructive CAD or acute plaque rupture
• Affects women > men
• Typically seen in older adults (~60s)

Pathogenesis

• Pathogenesis is not completely known, but theorized to be due to catecholamine excess. This leads to diffuse catecholamine-induced microvascular spasm / dysfunction.

Signs and symptoms

• Physical or emotional stress trigger (not always present! one study reported lack of stress trigger in 28.5% of cases)
• Presents like ACS

Complications to watch out for

• Heart failure
• Arrhythmias
• Mitral regurgitation
• Cardiogenic shock, cardiac arrest
• Stroke (embolization from an apical thrombus that forms due to severe systolic heart failure)

Workup

• EKG findings
  • ST elevations (most common) >>> ST depressions > other nonspecific findings (e.g. QT prolongation, T wave inversions)
• Elevated troponin
• Elevated NT pro-BNP

Diagnosis
Mayo Clinic Criteria can help with diagnosis of takotsubo cardiomyopathy.
All four criteria are required for diagnosis.

Echo

• Apical ballooning of LV reflecting regional wall motion abnormalities
• Reduced EF

Treatment

• Conservative, supportive treatment
  
• Thromboembolism
  Treatment recommendations are extrapolated from studies of patients who’ve suffered an MI and subsequently developed intraventricular thrombus
  • Presence of intraventricular thrombus
    • Treat with Vitamin K antagonist (Warfarin) for ~3 months
  • In patients with low bleed risk and severe systolic dysfunction (LV EF <30%) and no evidence of intraventricular thrombus
    • Can consider prophylaxis with Vitamin K antagonist (Warfarin) until LV dysfunction resolves OR for 3 months (whichever is shorter)