Takotsubo cardiomyopathy

Jump to: navigation, search
Takotsubo cardiomyopathy
Synonyms Transient apical ballooning syndrome,[1] apical ballooning cardiomyopathy,[2] stress-induced cardiomyopathy, Gebrochenes-Herz-Syndrom, broken-heart syndrome
Schematic representation of takotsubo cardiomyopathy (A) compared to a normal heart (B)
Specialty Cardiology

Takotsubo cardiomyopathy, also known as stress cardiomyopathy, is a type of non-ischemic cardiomyopathy in which there is a sudden temporary weakening of the muscular portion of the heart.[3] This weakening may be triggered by emotional stress, such as the death of a loved one, a break-up, rejection from a partner or constant anxiety. This leads to one of the common names, broken heart syndrome.[4] Stress cardiomyopathy is now a well-recognized cause of acute heart failure, lethal ventricular arrhythmias, and ventricular rupture.[5]

The name "takotsubo syndrome" comes from the Japanese word for a kind of octopus trap: , because the left ventricle takes on a shape resembling a fishing pot.[5]

Signs and symptoms

The typical presentation of takotsubo cardiomyopathy is a sudden onset of chest pain associated with ECG changes mimicking a myocardial infarction of the anterior wall. During the course of evaluation of the patient, a bulging out of the left ventricular apex with a hypercontractile base of the left ventricle is often noted. It is the hallmark bulging out of the apex of the heart with preserved function of the base that earned the syndrome its name "tako tsubo", or octopus pot in Japan, where it was first described.[6]

Stress is the main factor in takotsubo cardiomyopathy, with more than 85% of cases set in motion by either a physically or emotionally stressful event that prefaces the start of symptoms.[7] Examples of emotional stressors include grief from the death of a loved one, fear of public speaking, arguing with a spouse, relationship disagreements, betrayal, and financial problems.[7] Acute asthma, surgery, chemotherapy, and stroke are examples of physical stressors.[7] In a few cases, the stress may be a happy event, such as a wedding, winning a jackpot, a sporting triumph, a reunion, or a birthday.[8][9]

Takotsubo cardiomyopathy is more commonly seen in postmenopausal women.[10] Often there is a history of a recent severe (usually negative, sometimes happy) emotional or physical stress.[10]

Causes

The cause of takotsubo cardiomyopathy is not fully understood, but several mechanisms have been proposed.[11]

  1. Transient vasospasm: Some of the original researchers of takotsubo suggested that multiple simultaneous spasms of coronary arteries could cause enough loss of blood flow to cause transient stunning of the myocardium.[12] Other researchers have shown that vasospasm is much less common than initially thought.[13][14][15] It has been noted that when there are vasospasms, even in multiple arteries, that they do not correlate with the areas of myocardium that are not contracting.[16]
  2. Microvascular dysfunction: The theory gaining the most traction is that there is dysfunction of the coronary arteries at the level where they are no longer visible by coronary angiography. This could include microvascular vasospasm, however, it may well have some similarities to diseases such as diabetes mellitus. In such disease conditions the microvascular arteries fail to provide adequate oxygen to the myocardium.
  3. Mid-ventricular obstruction, apical stunning: It has been suggested that a mid-ventricular wall thickening with outflow obstruction is important in the pathophysiology.[17]

It is likely that there are multiple factors at play that could include some amount of vasospasm, failure of the microvasculature, and an abnormal response to catecholamines (such as epinephrine and norepinephrine, released in response to stress).[18]

Case series looking at large groups of patients report that some patients develop takotsubo cardiomyopathy after an emotional stress, while others have a preceding clinical stressor (such as an asthma attack or sudden illness). Roughly one-third of patients have no preceding stressful event.[19] A 2009 large case series from Europe found that takotsubo cardiomyopathy was slightly more frequent during the winter season. This may be related to two possible/suspected pathophysiological causes: coronary spasms of microvessels, which are more prevalent in cold weather, and viral infections – such as Parvovirus B19 – which occur more frequently during the winter.[1]

Diagnosis

Transient apical ballooning syndrome or Takotsubo cardiomyopathy is found in 1.7–2.2% of patients presenting with acute coronary syndrome.[1] While the original case studies reported on individuals in Japan, Takotsubo cardiomyopathy has been noted more recently in the United States and Western Europe. It is likely that the syndrome previously went undiagnosed before it was described in detail in the Japanese literature. Evaluation of individuals with Takotsubo cardiomyopathy typically includes a coronary angiogram, which will not reveal any significant blockages that would cause the left ventricular dysfunction. Provided that the individual survives their initial presentation, the left ventricular function improves within two months.

The diagnosis of takotsubo cardiomyopathy may be difficult upon presentation. The ECG findings often are confused with those found during an acute anterior wall myocardial infarction.[20][21] It classically mimics ST-segment elevation myocardial infarction, and is characterised by acute onset of transient ventricular apical wall motion abnormalities (ballooning) accompanied by chest pain, shortness of breath, ST-segment elevation, T-wave inversion or QT-interval prolongation on ECG. Cardiac enzymes are usually negative and are moderate at worst, and cardiac catheterization usually shows absence of significant coronary artery disease.[1]

The diagnosis is made by the pathognomonic wall motion abnormalities, in which the base of the left ventricle is contracting normally or is hyperkinetic while the remainder of the left ventricle is akinetic or dyskinetic. This is accompanied by the lack of significant coronary artery disease that would explain the wall motion abnormalities. Although apical ballooning has been described classically as the angiographic manifestation of takotsubo, it has been shown that left ventricular dysfunction in this syndrome includes not only the classic apical ballooning, but also different angiographic morphologies such as mid-ventricular ballooning and, rarely, local ballooning of other segments.[1][22][23][24][25]

The ballooning patterns were classified by Shimizu et al. as Takotsubo type for apical akinesia and basal hyperkinesia, reverse Takotsubo for basal akinesia and apical hyperkinesia, mid-ventricular type for mid-ventricular ballooning accompanied by basal and apical hyperkinesia, and localised type for any other segmental left ventricular ballooning with clinical characteristics of Takotsubo-like left ventricular dysfunction.[23]

In short, the main criteria for the diagnosis of Takotsubo cardiomyopathy are: the patient must have experienced a stressor before the symptoms began to arise; the patient’s ECG reading must show abnormalities from a normal heart; the patient must not show signs of coronary blockage or other common causes of heart troubles; the levels of cardiac enzymes in the heart must be elevated or irregular; and the patient must recover complete contraction and be functioning normally in a short amount of time.[26]

Treatment

The treatment of takotsubo cardiomyopathy is generally supportive in nature, for it is considered a transient disorder.[28] Treatment is dependent on whether patients experience heart failure or acute hypotension and shock. In many individuals, left ventricular function normalizes within two months.[29][30] Aspirin and other heart drugs also appear to help in the treatment of this disease, even in extreme cases.[31][32] After the patient has been diagnosed, and myocardial infarction (heart attack) ruled out, the aspirin regimen may be discontinued, and treatment becomes that of supporting the patient.[33]

While medical treatments are important to address the acute symptoms of Takotsubo cardiomyopathy, further treatment includes lifestyle changes.[34] It is important that the individual stay physically healthy while learning and maintaining methods to manage stress, and to cope with future difficult situations.

Although the symptoms of Takotsubo cardiomyopathy usually go away on their own and the condition completely resolves itself within a few weeks, some serious complications can happen that must be treated.[35] These most commonly include congestive heart failure and very low blood pressure, and less commonly include blood clotting in the apex of the left ventricle, irregular heart beat, and tearing of the heart wall.[35]

Heart failure

For patients in acute heart failure, ACE inhibitors, angiotensin receptor blockers, and beta blockers, are considered mainstays of heart failure treatment. But use of beta blockers specifically for takotsubo cardiomyopathy is controversial, because they may confer no benefit.[28]

Low blood pressure

For people with cardiogenic shock, medical treatment is based on whether a left ventricular outflow tract (LVOT) obstruction is present.[36] Therefore, early echocardiography is necessary to determine proper management. For those with obstructed LVOTs inotropic agents should not be used, but instead should be managed like patients with hypertrophic cardiomyopathy, (e.g. phenylephrine and fluid resuscitation).[28] For cases in which the LVOT is not obstructed, inotropic therapy (e.g. dobutamine and dopamine) may be used, but with the consideration that takotsubo is caused by excess catecholamines.[36]

Furthermore, mechanical support with an intra-aortic balloon pump (IABP) is well-established as supportive treatment.[36][37]

Prognosis

Despite the grave initial presentation in some of the patients, most of the patients survive the initial acute event, with a very low rate of in-hospital mortality or complications. Once a patient has recovered from the acute stage of the syndrome, they can expect a favorable outcome and the long-term prognosis is excellent.[1][6][22] Even when ventricular systolic function is heavily compromised at presentation, it typically improves within the first few days and normalises within the first few months.[1][13][14][15] Although infrequent, recurrence of the syndrome has been reported and seems to be associated with the nature of the trigger.[1][19]

Epidemiology

Takotsubo cardiomyopathy is rare, affecting between 1.2% and 2.2% of people in Japan and 2% to 3% in western countries who suffer a myocardial infarction. It also affects far more women than men with 90% of cases being women, most postmenopausal. Scientists believe one reason is that estrogen causes the release of catecholamine and glucocorticoid in response to mental stress. It is not likely for the same recovered patient to experience the syndrome twice, although it has happened in rare cases.[38] The average ages at onset are between 58 and 75 years. Less than 3% of cases occurred in patients under age 50.[39]

History

The Japanese octopus traps after which this disease is named[5]

Although the first scientific description of Takotsubo cardiomyopathy was not until the 1990s, Cebelin and Hirsch wrote about human stress cardiomyopathy in 1980. The two looked at homicidal assaults that had happened in Cuyahoga County, Ohio the past 30 years, specifically those with autopsies who had no internal injury, but had died of physical assault. They found that 11 of 15 had myofibrillar degeneration similar to animal stress studies. In the end, they concluded their data supported "the theory of catecholamine mediation of these myocardial changes in man and of the lethal potential of stress through its effect on the heart".[40]

The first studied case of Takotsubo cardiomyopathy was in Japan in 1991 by Sato et al. More cases of the syndrome appeared in Japan within the next decade, although western medicine had still not acknowledged it. The syndrome finally occurred in 1997 when Pavin et al. wrote about two cases of "reversible LV dysfunction precipitated by acute emotional stress." The western world had not heard of such a thing at the time, as it was incredibly rare and often misdiagnosed. The Japanese at last reported about the syndrome to the west in 2001 under the name "transient LV apical ballooning" though at this point the west had already heard of numerous cases. The syndrome reached international audiences through the media in 2005 when the New England Journal of Medicine wrote about the syndrome.[41]

Cultural references

A case of what is evidently takotsubo syndrome is a central motif of the end of the novel Blossoms in Autumn (Slovene: Cvetje v jeseni: 1917) by Slovene writer Ivan Tavčar and the film Blossoms in Autumn (1973) shot after it. A village girl named Meta suddenly dies after she had been asked by Janez, a lawyer from Ljubljana that she had spent summer with, to marry him. At her funeral, her father states that she was never very healthy, and that she had a heart defect. Her mother states: "She has died from happiness."[42][43]

References

  1. ^ a b c d e f g h Eshtehardi P, Koestner SC, Adorjan P, Windecker S, Meier B, Hess OM, Wahl A, Cook S (July 2009). "Transient apical ballooning syndrome--clinical characteristics, ballooning pattern, and long-term follow-up in a Swiss population". Int. J. Cardiol. 135 (3): 370–5. doi:10.1016/j.ijcard.2008.03.088. PMID 18599137. 
  2. ^ Bergman BR, Reynolds HR, Skolnick AH, Castillo D (August 2008). "A case of apical ballooning cardiomyopathy associated with duloxetine". Ann. Intern. Med. 149 (3): 218–9. doi:10.7326/0003-4819-149-3-200808050-00021. PMID 18678857. 
  3. ^ Zamir, M (2005). The Physics of Coronary Blood Flow. Springer Science and Business Media. p. 387. ISBN 978-0387-25297-1. 
  4. ^ "Mayo Clinic Research Reveals 'Broken Heart Syndrome' Recurs In 1 Of 10 Patients". Medical News Today, MediLexicon International Ltd. 
  5. ^ a b c Akashi YJ, Nef HM, Möllmann H, Ueyama T (2010). "Stress cardiomyopathy". Annu. Rev. Med. 61: 271–86. doi:10.1146/annurev.med.041908.191750. PMID 19686084. 
  6. ^ a b Gianni M, Dentali F, et al. (December 2006). "Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review". European Heart Journal. Oxford University Press. 27 (13): 1523–1529. doi:10.1093/eurheartj/ehl032. PMID 16720686. Retrieved 2008-04-23. 
  7. ^ a b c Sharkey, S., Lesser, J., & Maron, B. (2011). Takotsubo (stress) cardiomyopathy. American Heart Association. Retrieved from http://circ.ahajournals.org/content/124/18/e460.full
  8. ^ "Shock of good news can hurt your heart as much as grief". New Scientist. March 12, 2016. 
  9. ^ Jelena Ghadri; et al. (March 2016). "Happy heart syndrome: role of positive emotional stress in takotsubo syndrome". European Heart Journal: ehv757. doi:10.1093/eurheartj/ehv757. 
  10. ^ a b Pelliccia, Francesco; Parodi, Guido; Greco, Cesare; Antoniucci, David; Brenner, Roman; Bossone, Eduardo; Cacciotti, Luca; Capucci, Alessandro; Citro, Rodolfo (June 2015). "Comorbidities frequency in Takotsubo syndrome: an international collaborative systematic review including 1109 patients". The American Journal of Medicine. 128 (6): 654.e11–19. doi:10.1016/j.amjmed.2015.01.016. ISSN 1555-7162. PMID 25660245. 
  11. ^ Veillet-Chowdhury, M; Hassan, SF; Stergiopoulos, K (March 2014). "Takotsubo cardiomyopathy: a review". Acute cardiac care. 16 (1): 15–22. doi:10.3109/17482941.2013.869346. PMID 24552225. 
  12. ^ Kurisu S, Sato H, Kawagoe T, et al. (2002). "Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction". American Heart Journal. 143 (3): 448–55. doi:10.1067/mhj.2002.120403. PMID 11868050. 
  13. ^ a b Tsuchihashi K, Ueshima K, Uchida T, Oh-mura N, Kimura K, Owa M, Yoshiyama M, Miyazaki S, Haze K, Ogawa H, Honda T, Hase M, Kai R, Morii I (July 2001). "Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigations in Japan". Journal of the American College of Cardiology. 38 (1): 11–8. doi:10.1016/S0735-1097(01)01316-X. PMID 11451258. 
  14. ^ a b Kawai et al. JPJ 2000
  15. ^ a b Desmet, WJ; Adriaenssens, BF; Dens, JA (September 2003). "Apical ballooning of the left ventricle: first series in white patients". Heart (British Cardiac Society). 89 (9): 1027–31. doi:10.1136/heart.89.9.1027. PMC 1767823Freely accessible. PMID 12923018. 
  16. ^ Abe, Y; Kondo, M; Matsuoka, R; Araki, M; Dohyama, K; Tanio, H (2003-03-05). "Assessment of clinical features in transient left ventricular apical ballooning". Journal of the American College of Cardiology. 41 (5): 737–42. doi:10.1016/S0735-1097(02)02925-X. PMID 12628715. 
  17. ^ Merli, E; Sutcliffe, S; Gori, M; Sutherland, GG (January 2006). "Tako-Tsubo cardiomyopathy: new insights into the possible underlying pathophysiology". European Journal of Echocardiography. 7 (1): 53–61. doi:10.1016/j.euje.2005.08.003. PMID 16182610. 
  18. ^ Pelliccia, Francesco; Kaski, Juan Carlos; Crea, Filippo; Camici, Paolo G. (2017-06-13). "Pathophysiology of Takotsubo Syndrome". Circulation. 135 (24): 2426–2441. doi:10.1161/CIRCULATIONAHA.116.027121. ISSN 1524-4539. PMID 28606950. 
  19. ^ a b Elesber, AA; Prasad, A; Lennon, RJ; Wright, RS; Lerman, A; Rihal, CS (July 2007). "Four-Year Recurrence Rate and Prognosis of the Apical Ballooning Syndrome". J Amer Coll Card. 50 (5): 448–52. doi:10.1016/j.jacc.2007.03.050. PMID 17662398. 
  20. ^ Azzarelli S, Galassi AR, Amico F, Giacoppo M, Argentino V, Tomasello SD, Tamburino C, Fiscella A (2006). "Clinical features of transient left ventricular apical ballooning". Am J Cardiol. 98 (9): 1273–6. doi:10.1016/j.amjcard.2006.05.065. PMID 17056345. 
  21. ^ Bybee KA, Motiei A, Syed IS, Kara T, Prasad A, Lennon RJ, Murphy JG, Hammill SC, Rihal CS, Wright RS (2006). "Electrocardiography cannot reliably differentiate transient left ventricular apical ballooning syndrome from anterior ST-segment elevation myocardial infarction". J Electrocardiol. 40 (1): 38.e1–6. doi:10.1016/j.jelectrocard.2006.04.007. PMID 17067626. 
  22. ^ a b Pilgrim TM, Wyss TR (March 2008). "Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: A systematic review". Int. J. Cardiol. 124 (3): 283–92. doi:10.1016/j.ijcard.2007.07.002. PMID 17651841. 
  23. ^ a b Shimizu M, Kato Y, Masai H, Shima T, Miwa Y (August 2006). "Recurrent episodes of takotsubo-like transient left ventricular ballooning occurring in different regions: a case report". J. Cardiol. 48 (2): 101–7. PMID 16948453. 
  24. ^ Hurst RT, Askew JW, Reuss CS, Lee RW, Sweeney JP, Fortuin FD, Oh JK, Tajik AJ (August 2006). "Transient midventricular ballooning syndrome: a new variant". J. Am. Coll. Cardiol. 48 (3): 579–83. doi:10.1016/j.jacc.2006.06.015. PMID 16875987. 
  25. ^ Yasu T, Tone K, Kubo N, Saito M (June 2006). "Transient mid-ventricular ballooning cardiomyopathy: a new entity of Takotsubo cardiomyopathy". Int. J. Cardiol. 110 (1): 100–1. doi:10.1016/j.ijcard.2005.05.060. PMID 15996774. 
  26. ^ Golabchi, A; Sarrafzadegan, N. (2011). "Takotsubo cardiomyopathy or broken heart syndrome: A review article". J. Res. Med. Sci. 16 (3): 340–345. 
  27. ^ "UOTW #74 - Ultrasound of the Week". Ultrasound of the Week. 20 September 2016. Retrieved 27 May 2017. 
  28. ^ a b c Current medical diagnosis & treatment 2017. Papadakis, Maxine A.,, McPhee, Stephen J.,, Rabow, Michael W., (Fifty-sixth ed.). New York. ISBN 1259585115. OCLC 957316517. 
  29. ^ Akashi YJ, Nakazawa K, Sakakibara M, Miyake F, Koike H, Sasaka K (2003). "The clinical features of takotsubo cardiomyopathy". QJM. 96 (8): 563–73. doi:10.1093/qjmed/hcg096. PMID 12897341. 
  30. ^ Nyui N, Yamanaka O, Nakayama R, Sawano M, Kawai S (2000). "'Tako-Tsubo' transient ventricular dysfunction: a case report". Jpn Circ J. 64 (9): 715–9. doi:10.1253/jcj.64.715. PMID 10981859. 
  31. ^ "BBC NEWS | Health | Medics 'can mend a broken heart'". news.bbc.co.uk. Retrieved 2017-06-29. 
  32. ^ Shah, Sandy; Bhimji, Steve (2017). StatPearls. Treasure Island (FL): StatPearls Publishing. PMID 28613549. [1]
  33. ^ Derrick, Dawn. "The "Broken Heart Syndrome": Understanding Takotsubo Cardiomyopathy". Critical Care Nurse. 
  34. ^ http://www.nhlbi.nih.gov/health/health-topics/topics/broken-heart-syndrome/treatment
  35. ^ a b Kurisu, S; Kihara, Y (2014). "Clinical management of takotsubo cardiomyopathy". Circulation journal : official journal of the Japanese Circulation Society. 78 (7): 1559–66. PMID 24964980. 
  36. ^ a b c "Management and prognosis of stress (takotsubo) cardiomyopathy". www.uptodate.com. Retrieved 2017-10-21. 
  37. ^ Akashi, Yoshihiro J.; Goldstein, David S.; Barbaro, Giuseppe; Ueyama, Takashi (2008-12-16). "Takotsubo Cardiomyopathy: A New Form of Acute, Reversible Heart Failure". Circulation. 118 (25): 2754–2762. doi:10.1161/CIRCULATIONAHA.108.767012. ISSN 0009-7322. PMID 19106400. 
  38. ^ Schneider B.; Athanasiadis A.; Sechtem U. (2013). "Gender-Related differences in Takotsubo Cardiomyopathy". Heart Failure Clinics. 9 (2): 137–146. doi:10.1016/j.hfc.2012.12.005. 
  39. ^ Prasad A, Lerman A, Rihal CS (March 2008). "Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): A mimic of acute myocardial infarction". American Heart Journal. 155 (3): 408–17. doi:10.1016/j.ahj.2007.11.008. PMID 18294473. 
  40. ^ Cebelin, Hirsch (1980). "Human stress cardiomyopathy. Myocardial lesions in victims of homicidal assaults without internal injuries". Human Pathology. 11 (2): 123–32. doi:10.1016/s0046-8177(80)80129-8. PMID 7399504. 
  41. ^ Wittstein I (2007). "The broken heart syndrome". Cleveland Clinical Journal of Medicine. 74 (1): S17–S22. doi:10.3949/ccjm.74.Suppl_1.S17. 
  42. ^ Tavčar, Ivan (1917). "Cvetje v jeseni" [Blossoms in Autumn] (in Slovene). 
  43. ^ "Cvetje v jeseni" [Blossoms in Autumn] (in Slovene). 1973. 

External links

Classification
External resources