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Takotsubo Cardiomyopathy

 

Takotsubo cardiomyopathy is a temporary heart condition occurring predominantly in women colloquially referred to as “broken heart syndrome.”  It is characterized by a weakening of the left ventricle after severe emotional or physical stress.  Morphologically, the left ventricle balloons atypically during systole while the base contracts normally.  This unique shape is similar to that of a Japanese vessel used to catch octopi known as a takotsubo.  Possible mechanism:  sudden surge in stress hormones (eg: adrenaline) triggers changes in heart muscle cells and/or coronary blood vessels, which causes the abnormal left ventricular contraction.  Older women are more vulnerable likely due ot the reduced levels of estrogen after menopause.  Average age of onset: 58-75 years.  Takotsubo cardiomyopathy can potentially lead to acute heart failure, ventricular rupture, ventricular arrhythmias, and possible cardiac arrest.  Despite the potentially severe consequences, the condition generally resolves within a month.

 

Signs and Symptoms include chest pain, shortness of breath after severe stress, ballooning of the left ventricle, ST-segment elevation on EKG, small but rapid rise in cardiac enzymes.  Because of this, it is essentially indistinguishable from a myocardial infarction.  An echocardiogram can demonstrate the tell-tale ventricular ballooning.

Treatment includes beta-blockers, ACE inhibitors and diuretics.  The condition generally resolves within a month, but beta-blockers can be continued long-term to prevent recurrence.  Addressing the underlying physical or emotional stress is of paramount importance as well.

 

 

Indications for Coronary Angiography

  1. Persistent angina pectoris
    1. Described often as discomfort, pressure, squeezing
    2. Often localized to substernal region, precardium, epigastrium with radiation to left arm, jaw, or neck
    3. Provoked by exertion, eating, smoking
    4. Relieved by rest, sublingual nitrates
    5. Lasts a few minutes, rarely lasts over 20-30 minutes
  2. Angina Pectoris with markedly positive stress test
    1. Positive stress test
      1. More than 2 mm ST depression on exercise EKG
      2. Persistent ST depression throughout 5 minutes of recovery
  • Exercise induced hypotension
  1. Unstable angina pectoris
  2. Positive stress test following MI
  3. Strong family history of CAD or early death in young patients
  4. Prinzmetal Angina
  5. Preoperative evaluation of valvular heart disease
  6. LV aneurysm indicated by CXR or persistent ST elevation on EKG
  7. s/p CABG if pts have recurrent angina pectoris
  8. Resuscitation from SCD

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