The entity of stress cardiomyopathy , other wise referred to as Takotsubo cardiomyopathy is a popular clinical entity in recent decades.The heart and mind are closely linked entities even though they are situated apart physically . Extensive neural and hormonal control mechanisms exist.
In extreme stress ,the hyper- sympathetic drive triggers a rush of adrenaline , which some how makes the left ventricle to bulge out !
The clinical features are varied .
- It can exactly mimic an acute coronary syndrome .
- ECG may show ST elevation and mimic an anterior STEMI
- Echo shows a wall motion abnormality classically described as the apex alone dilates /Bulges or elongates
- LV may acquire a shape of a banana. (See below )
A 45 year old man came to the ER with severe chest pain , dyspnea and minimal ST elevation in anterior leads. He was a smoker and was experiencing recent major office stress . Echo showed an elongated LV apex with some thinning .We made a diagnosis of stress cardiomyopathy .( It was disputed by my professor as the LV apex was contracting well ! but we learnt later there are many varieties of Takatsubo )
Echo showed an elongated LV apex with some thinning . Note the LV apex goes out of plane with RV apex.
Color Doppler revealed Trivial Mitral regurgitation
Follow up
He underwent coronary angiogram. Had no significant lesions , in 48 hours time the wall motion defect disappeared and was discharged with beta blockers.
Incidence
Up to 2 % of ACS could be related to Takatsubo . More common in women especially post menopausal , with stressful/emotional background like loss of loved ones.
Synonyms
Apical ballooning , Broken heart syndrome , Stress cardiomyopathy.
Mechanism
Not clear . Microvascular spasm , excessive catecholamines , are thought to be major culprits.
Echocardiography
Hyperkinetic base and akinetic or dyskinetic LV apex .
Lots of variations are reported .
Courtesy : Shimizu et al J Cardiol. 2006 Jan;47(1):31-7.
- Apical akinesia and basal hyperkinesia,
- Reverse Takotsubo (Basal akinesia and apical hyperkinesia)
- Mid-ventricular ballooning with basal and apical hyperkinesia
- Localised to any one segment
*The Banana type which is described here (Elongation of LV apex > Widening )
Histopathology
Focal myocytolysis are described. (Broken heart) Monocytic infiltrations are common.These are believed to be transient .
How to differentiate it between a STEMI ?
- Enzymes are only mildly elevated.
- Wall motion defect do not confine to a specific arterial territory.
- Most importantly coronary angiogram do not reveal any significant obstructions.
Prognosis and outcome
- Generally good
- The initial presentation may be turbulent in few with cardiac failure or arrhythmia .Other wise these patients do well
Treatment
- Mainly supportive
- Major principle is to avoid inotropic agents as they are already heavily expose to it
- Beta blockers could be the mainstay therapy .
Final messge
Think about Takatsubo whenever an acute coronary syndrome presents atypically . Not surprisingly few of them land in the cath lab !
Reference
Dr.S.Venkatesan MD 