Takotsubo cardiomyopathy

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
Apical ballooning seen on cardiac cath. Notice the lack of contraction at the LV apex vs the level of contraction at the LV base.
Apical 4 chamber view of a patient with Takotsubo cardiomyopathy

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)

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