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Takotsubo Cardiomyopathy

Tako-tsubo cardiomyopathy, Broken heart syndrome, Stress cardiomyopathy, Apical ballooning syndrome

Takotsubo Cardiomyopathy

• Cardiomyopathy (CMP) is a group of diseases that primarily affect the myocardium
  
  
• Takotsubo cardiomyopathy (TTC)
• TTC was first described by Japanese doctors, who observed that the left ventricle resembled a Takotsubo (jar) on ventriculography
• It is very rare (prevalence about 0.02%)
• 80% of all TTC cases affect postmenopausal women
• It occurs during extreme stress (death in the family, divorce, work problems, etc.)
• There is dilatation of the apex, and hypercontraction of the base of the left ventricle
• The apex is hypokinetic and the base is hyperkinetic
• There are very rare forms (apex hyperkinetic and base akinetic, or the entire left ventricle is hypokinetic)
• Usually, the left ventricle spontaneously normalizes within 4-6 weeks; no specific treatment exists
• There is an increased risk of malignant ventricular tachycardia and rupture of the left ventricle

• (A) Tako Tsubo Cardiomyopathy
• Hypokinesis and dilatation of the apex
• Hyperkinesis of the base
• (B) Normal Left Ventricle

• (A) Left Ventricle Ventriculography
• Hypokinesis and dilatation of the apex
• Hyperkinesis of the base
• (B) Takotsubo (Jar)

• Ventriculography
• Left ventricle

Stress Cardiomyopathies

• They occur due to the massive release of catecholamines, which bind to the myocardium and often cause
• Myocardial kinetic disorders
• ECG changes
• The most well-known stress cardiomyopathies:
• Stunned Myocardium (Neurogenic stunned myocardium)
• Takotsubo cardiomyopathy
  
  
• Stunned Myocardium (Neurogenic stunned myocardium)
• Occurs with acute intracranial hypertension
• Norepinephrine is released from nerve endings, which mainly causes
• Kinetic disorder of almost the entire left ventricle
• ECG changes
• Lasts approximately 2 weeks
  
  
• Takotsubo cardiomyopathy
• Occurs with extreme stress without intracranial hypertension
• Mainly affects women after menopause
• Released adrenaline in the circulation mainly causes
• Kinetic disorders mainly of the apex
• ECG changes
• Lasts approximately 4-6 weeks

Takotsubo Cardiomyopathy vs. Anterior Wall STEMI

• TTC often presents with symptoms and an identical ECG image as anterior wall STEMI
• TTC does not have (> 50%) stenosis on coronary angiography of the coronary arteries
• TTC does not have elevated cardiac markers of myocardial necrosis (troponin, CK, CK-MB)
• TTC does not cause myocardial necrosis like STEMI does
• Apical hypokinesis in TTC does not correspond to the supply of the respective vessel
  • Anterior STEMI with occlusion of the LAD (Left Anterior Descending artery) causes hypokinesis of the part of the anterior wall that the LAD supplies
  • STEMI does not cause hypokinesis of the entire apex
  • because the apex is supplied by multiple vessels and their simultaneous stenosis/occlusion is unlikely
  • TTC causes hypokinesis of the entire apex, and the apical area exceeds the vascular supply of a single vessel

Takotsubo Cardiomyopathy

• A postmenopausal patient experiencing a stressful period
• Suddenly developed chest pain
• Prolonged QT interval (0.64s)
• Wide and negative T waves (I, II, III, aVF, V2-6) - red arrows
• U waves (V1-6) - blue arrows - deforming the terminal parts of the T waves
• Coronary angiography showed no stenosis of the coronary arteries
• Cardio-specific markers of myocardial necrosis (troponin, CK, CK-MB) were normal
• Echocardiography showed akinesis of the apex and hyperkinesis of the base of the left ventricle
• The patient had Takotsubo cardiomyopathy

Takotsubo Cardiomyopathy

• A postmenopausal patient experiencing a stressful period
• Suddenly developed chest pain
• The ECG showed a pattern of anterior wall STEMI
• ST elevations (V2-V6)
• Coronary angiography showed no stenosis of the coronary arteries
• Cardio-specific markers of myocardial necrosis (troponin, CK, CK-MB) were normal
• Echocardiography showed akinesis of the apex and hyperkinesis of the base of the left ventricle
• The patient had Takotsubo cardiomyopathy and not an anterior wall STEMI