Stress (Takotsubo) Cardiomyopathy

Presentation

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  Stress cardiomyopathy (SCM) is a generally reversible acute cardiac syndrome that was originally described in the Japanese population over 30 years ago.

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    Hence, the term takotsubo (an octopus trap with a narrow neck and round bottom) cardiomyopathy ( Fig. 9.1 ).

    

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    SCM is also known as apical ballooning syndrome (ABS) and broken heart syndrome.

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  The clinical features mimic acute coronary syndrome (ACS).

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  The typical patient is a postmenopausal woman with symptoms of myocardial ischemia following a stressful event, with positive cardiac biomarkers and/or an electrocardiogram (ECG) demonstrating ischemia.

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  SCM is the final diagnosis in approximately 1% to 2% of all patients initially suspected of ACS, and in up to 12% in women with ST elevation myocardial infarction (STEMI) and in 8% of patients with cardiogenic shock.

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  Approximately 90% of all cases are in postmenopausal women.

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  Patients who are conscious typically have symptoms that are similar to those associated with MI, with angina-like chest pain, present in approximately 50% of cases; less common symptoms include dyspnea, syncope, or loss of consciousness from cardiac arrest.

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  Typically, the ejection fraction is reduced to 30% to 40%, which may be accompanied by significant diastolic dysfunction and elevated left ventricular end-diastolic pressure (LVEDP).

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  Acute heart failure is a frequent complication, and cardiogenic shock may develop in approximately 10% to 15% of patients.

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  Atrial fibrillation occurs in 5% of cases, whereas ventricular tachyarrhythmias have been reported in 3% to 4% of patients and asystole in 0.5%.

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  Rare complications include LV thrombus, thromboembolism, and cardiac rupture.

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  Hypotension may be owing to the reduction in stroke volume and, in some cases, dynamic left ventricular outflow tract obstruction (LVOTO).

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  The ventricular dysfunction usually resolves over days to weeks, with complete recovery by 4 to 8 weeks.

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  The prognosis of SCM is good in the absence of significant underlying comorbid conditions.

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  In-hospital mortality is approximately 3% to 5%.

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  The subgroup of patients in whom there is a physical trigger—such as major surgery, malignancy, and fractures—appears to have a worse prognosis.

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  The recurrence rate is approximately 1% to 2% per year.