AKT · Cardiovascular/Failure & myocardiumlow yield

Takotsubo cardiomyopathy

Acute, reversible stress-induced left ventricular dysfunction (catecholamine surge) with unobstructed coronaries

Overview

A transient, stress-induced cardiomyopathy ('broken-heart syndrome', apical ballooning syndrome) in which an intense emotional or physical stressor triggers acute left ventricular dysfunction that mimics an acute MI — chest pain, ST changes and a raised troponin — but with UNOBSTRUCTED coronary arteries and characteristic apical ballooning. It is usually reversible with supportive care.

Recognise

Acute chest pain and/or breathlessness, classically in a post-menopausal woman after an intense emotional or physical stressor (bereavement, acute illness)
ECG changes (ST elevation/T-wave inversion) and a raised troponin that mimic ACS
Echo/ventriculography: apical ballooning ('octopus pot') with a hyperdynamic base; coronary angiography is normal/unobstructed

Red flags

Acute heart failure, cardiogenic shock, LV outflow obstruction or arrhythmia can complicate the acute phase
It is a diagnosis made AFTER excluding ACS — do not assume it without coronary assessment

Differentials & how to tell them apart

Acute coronary syndromeobstructive coronary disease on angiography; wall-motion abnormality fits a coronary territory

Myocarditisviral prodrome, MRI myocardial oedema/late gadolinium; also normal coronaries

Phaeochromocytomacatecholamine excess can precipitate a similar picture — consider if paroxysmal symptoms

Investigations

ECG and troponin (mimic ACS); coronary angiography (UNOBSTRUCTED arteries — the key discriminator); echo/ventriculography (apical ballooning, regional dysfunction not matching a single coronary territory); cardiac MRI (no infarction); identify the precipitating stressor.

Management

Exclude ACS by angiography; supportive heart-failure therapy — usually recovers

1It presents like ACS (chest pain, ECG changes, troponin rise) → investigate as ACS with coronary angiography. Unobstructed coronaries + apical ballooning = Takotsubo.Gate: Takotsubo is diagnosed only AFTER excluding obstructive coronary disease — don't label stress-induced chest pain as Takotsubo without coronary assessment.
2Supportive heart-failure therapy and remove the stressor; LV function usually recovers within weeks. Manage complications (shock, outflow obstruction, apical thrombus).

Supportive heart-failure therapy (ACE inhibitor, beta-blocker, diuretic) during recovery — most recover LV function within weeks; treat heart failure symptomatically

Treat/remove the precipitating stressor — and manage the acute medical trigger

Cautious management of LV outflow obstruction/shock — inotropes may worsen dynamic obstruction — specialist care

Anticoagulation if apical thrombus — for a large apical aneurysm/thrombus

Key points

Post-menopausal woman + intense emotional/physical stressor + chest pain with ECG changes and raised troponin but UNOBSTRUCTED coronaries + apical ballooning = Takotsubo ('broken-heart') cardiomyopathy → supportive care, usually reversible. A key ACS mimic (with myocarditis).

Monitor & prognosis

Serial echo for recovery of LV function; arrhythmia/complication surveillance.

Usually reversible with recovery over weeks; small risk of acute complications and recurrence.

Source: ESC; cross-ref the ACS/myocarditis mimics