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Takotsubo
- 1. Takotsubo Cardiomyopathy Stress-Induced Cardiomyopathy
- 2. Overview • Left ventricular apical akinesis • Octopus trap • Mimics acute coronary syndrome • ST elevation • Elevated troponin • No Coronary Stenosis • Unknown Etiology • Triggered by emotional stressor
- 3. Overview • 1.7-2.2% of patients who had suspected ACS • Women 90% • Asian or Caucasian. • 57.2% were Asian, • 40% were Caucasian • 2.8% were other races. • Postmenopausal 90%.
- 4. Etiology • Unknown. • Proposed mechanisms: • Multi-vessel coronary artery spasm, • Impaired cardiac microvascular function, • Impaired myocardial fatty acid metabolism, • ACS with reperfusion injury • Endogenous catecholamine-induced myocardial stunning and microinfarction
- 5. Presentation • Most common ACS • chest pain • Dyspnea • Less common • Palpitations, • Nausea/vomiting • Syncope • Rare • Cardiogenic shock
- 6. Reported triggers • Emotional • Death of a loved one (including pets) • Surprise party • Family member being arrested • Fierce argument • Robbery • Public speaking • Surgery – Hysterectomy, Cholecystectomy • Stress echo with dobutamine • Opiate withdrawal • Thyrotoxicosis • Physical exhaustion ( triathlon, sexual, gym)- males
- 7. Differential diagnosis • Acute Coronary Syndromes • Angina Pectoris • Aortic Dissection • Boerhaave Syndrome • Cardiac Tamponade • Cardiogenic Shock • Cardiomyopathy • Cocaine Dilated Hypertrophic • Coronary Artery Vasospasm
- 8. Workup • EKG • Anterior precordial leads • ST elevation 67-75% • T wave inversion 61% • Cardiac enzymes • BNP • Circulating catecholamines • Echocardiogram – apical akinesis ( ballooning) • Angiography- normal coronary/abnormal ventriculography • Chest X-ray, normal or pulmonary edema.
- 9. Treatment • Pre-hospital must be treated as ACS • Emergency Department, treated as ACS until proven otherwise. ASA, clopidogrel, nitrates, -blockers, etc • Cardiology admission- cardiac catheterization facilities. • Medication- No RCT studies • ACE Inhibitors • -blockers
- 10. Prognosis • 95% complete recovery within 4-8 weeks. • 3% recurrence • Complications • Death 1% • Left heart failure with and without pulmonary edema • Cardiogenic shock • Left ventricular outflow obstruction • Mitral regurgitation • Ventricular arrhythmias • Left ventricular mural thrombus formation • Left ventricular free-wall rupture