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Takotsubo cardiomyopathy: Clinical science catches up to clinical practice
It's been six years since the publication of the proposed criteria for diagnosis of Takotsubo (or stress-induced) cardiomyopathy, and although it is relatively rare—representing two to three cases per year in my practice—the diagnostic certainty is reassuring and a good example of clinical science catching up to clinical practice.
What has been your experience with Takotsubo cardiomyopathy? Are you able to diagnose a priori? Or do you rely on a coronary angiogram and left ventriculogram to definitively exclude coronary disease? What has been your experience with treatment?
See:
Bybee KA, Kara T, Prasad A, et al. Systematic review: Transient left ventricular apical ballooning: A syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med. 2004;141:858-865. Available here.
Hurst RT, Prasad A, Askew JW, et al. Takotsubo cardiomyopathy: A unique cardiomyopathy with variable ventricular morphology. J. Am. Coll. Cardiol. Img. 2010;3;641-649. Available here.
Kosuge M, Ebina T, Hibi K, et al. Simple and accurate electrocardiographic criteria to differentiate takotsubo cardiomyopathy from anterior acute myocardial infarction. J Am Coll Cardiol. 2010;55;2514-2516. Available here.
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Dr Bilazarian performs coronary and peripheral interventions at Lahey Clinic and Massachusetts General Hospital. He has been an investigator in the interventional laboratory for new devices including drug-eluting stents, distal protection devices, imaging devices (OCT and InfraRed), and anticoagulant pharmacotherapy.
Dr Bilazarian is an active participant in clinical trials in congestive heart failure, hypertension, coronary disease prevention, prediabetes management, anemia, atrial fibrillation, and anticoagulation/antiplatelet therapies in the outpatient setting. He has authored numerous papers and book chapters in clinical cardiology. He was appointed as a physician advisor to the circulatory device panel of the FDA in 2008.
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Comments
I belong to an e-group group of about 85 women who have experienced this condition ("scad") and it seems the most recent patients receive medical management only; usually a repeat angiogram will show healing of the artery. Sometimes the condition is also associated with coronary artery spasm. Still there is very little known about cause or prevention.
For those patients you've followed with clean coronaries and subsequent LV recovery, what has the echocardiogram or the LV-gram looked like? If the echo shows the classic octopus trap, in an age/gender/emotionally stressed population, would it be safe to postpone the cath? wait and see if spontaneous recovery occurs?
In your experience, how many takotsubo shaped LV's have not recovered?
I've heard of male instances of takotsubos, but female prevelance predominates...so maybe in the male population, until further data validates, you r/o CAD more expediently.
Well, I, as a patient, have had recurrent Takotsubo – see my post above. After the first, undiagnosed, attack, I opted to take propanolol for a bit longer than the original prescription, solely for its anti-adrenalin effect. I was on it for about six months altogether, during which time I noticed occasional short-lived arrythmias. These gradually petered out before a year was up.
Almost exactly nine years after the first attack I was diagnosed with Ca. colon, and soon afterwards developed palpitations and arrythmias. Holter monitoring showed these to be PACs, PVCs etc. and not atrial fibrillation. After my second Takotsubo attack, diagnosed at the time as an MI, I was given atenolol, and took this for three years. Not long before the end of this time when I was out walking one day, I suddenly felt immense fatigue – as had preceded the previous attack – and waited for the start of the tingling of hand and arm, retrosternal pain, vomiting etc., but nothing happened. I felt it was a “near miss”. During the time I was on atenolol I frequently noticed arrythmias, and in retrospect these were diagnosed as atrial fibrillation. I was weaned off atenolol because of peripheral vascular problems, including chilblains, and bradycardia. At the same time the retrospective diagnosis of Takotsubo was made.
In the year since then I have experienced AF less frequently – I’d call it “lone AF”, but as I’m a woman of 74, and not a young man, that might be cheating – but I do blame the atenolol for starting it. Just my opinion, but atenolol has been known to act as a pro- as well as an anti-arrhythmic.
It is now four years since my second Takotsubo event and I, too, worry about a further episode. I have little stress in my life, but I do keep Ativan at the ready just in case. I also use it to counteract the rush of adrenalin which accompanies AF.While the combination of ECG criteria with exclusion of other causes such as coronary artery disease sounds straightforward, it may not be easy to establish or rule out the diagnosis, especially given the relative urgency caused by the acuity of the disease. Furthermore, the presence of coronary artery disease is unlikely to protect from Takotsubo CMP, therefore it may be difficult to verify the disease in the presence of (some) LAD disease.
In our and other institution, the use of Cardiac MRI proved to be extremely efficient in these patients.
As previously reported (Abdel-Aty et al. Myocardial edema is a feature of Tako-Tsubo cardiomyopathy and is related to the severity of systolic dysfunction: insights from T2-weighted cardiovascular magnetic resonance. Int J Cardiol 2009;132:291-3; Eitel et al. Inflammation in takotsubo cardiomyopathy: insights from cardiovascular magnetic resonance imaging. Eur Radiol 2009;20:422-431), the combination of the typical pattern of systolic dysfunction with myocardial edema in the mid and apical segments and the lack of ischemic necrosis takes less than 30 minutes of scanner time and - in our bi-center experience of more than 100 patients - has a diagnostic accuracy of close to 100%.
In centers with access to cardiac MRI, this method is a very (cost-)efficient approach.
I have seen two people with full classical Takotsubo cardiomyopathy, one of then who has suffered a recurrence, both women. The individual with two episodes I had been treating aggressively medically for Syndrome X [classic angina with totally smooth coronary lumens by angio at age 66 (elected no IVUS due to expense & questionable value) but heavy plaque both carotid bulbs and internal branches on Carotid IMT] by driving NMR lipoproteins to <10% MESA (rousva or simva + ezetimibi + niacin) values, Lovaza 1 gm on empiric grounds, low nl BP on titrated perindopril and carvedilol, working to reduce HbA1c (typically 5.8-6.1, despite Actos & GlP1 analogue tx) was age 70 at time of first episode. She presented to my office with dramatic elevations of trop I & CK nearly 2 days after MI occurance [during anesthesia for implanted pump removal surgery, held overnight, sent home, but then came in office because of persistent dyspnea and concern that what patient and husband were told did not make sense, was not reassuring]. By symptoms and echo, she did appear to dramatically improve LV function (EF 20s up to mid-60s within a week). While, on my recommendation and with my help, she has remained on complex treatment with generally excellence responses clinically, yet she had another event c/w Takotsubo at age 73, despite above continued aggressive therapy, verified by EKG + echo and troponin rise in office. This time advised no angio given her two previous normal angiograms 4 years apart, both with angiographically perfectly normal lumens (I nit-pick angiogram images for subtle evidence of arterial disease). With the further additions of ranolazine and L-arginine, she has not had further, clinically obvious/recognized episodes, though she does still have occasional problems with angina consistent chest discomfort and fatigue. We have also worked on multiple human issues, stressors, but not with any evident solutions. Neither I, the patient or her husband are terribly happy with this status but we don’t know what else to do.
My name is Steve and I am a 54 year old man who is physically active. I was diagnosed through an EP study four years ago with VT and I have had a total of eight surgeries, six of them installing and removing ICD's for various reasons. I finally had the last ICD removed and I had a year without any problems but then last October while climbing Half Dome in Yosemite I had a problem and barely made it back to the truck after 12 hours and 17 miles of hiking. Two days later I was still short of breath and my chest felt like a gorilla was standing on it so I went to Stanford. They did an EKG and Echo and then rushed me in to get an angiogram convinced that I had a heart attack two days earlier and was about to have another that might do me in. The angiogram showed that my cardiac arteries were in really good shape and that I didn’t have any blockage, but my heart was only pumping at one half of normal capacity. My ejection fraction was only 30% and two days prior on the hike it was lower. Instead what I had is a very rare condition called TakoTsubo. They were all stumped about the cause and it looks like my heart pretty much returned to normal after six months They told me that I was very lucky to still be here. I wonder if this extremely rare condition for a man my age has anything to do with the holes they punched in my ventricle installing and removing the ICD leads all of those times. I know that none of the doctors would tell me if they were thinking it. Anyway I still have PVC’s and weird arrhythmias and my Mitral valve still has a moderate regurgitation, but I am reluctantly still considering an ICD but only if I actually pass out and survive one time, then I will do it. I would rather take my chances that I won’t die of a VT and live to make a better decision than to just have them implant one on the hope that it may save me. They still don't know if I will ever have another TakoTsubo or not and the ICD probably wouldn’t save me from that. Please let me know if you have any thoughts. Thanks, Steve.
I had a takotsubo heart attack 8/1/2011. Heart cath. was clear, mild troponin elevation, and ST segment deviations on EKG. EF was 10%. Hospitalized for 4 days mostly to adjust my meds. My pressure normally runs 100/50 so couldn't take the aldactone with the coreg.
Almost 3 months later, I have had two episodes where chest pain was severe enough to wake me up. It only lasted a couple of minutes. I made an appointment with Cardiologist who diagnosed it as GERD. I don't have GERD. He prescribed Prilosec and Zocor (LDL=140 and HDL=84) increased Coreg 3.125mg from BID to TID and ordered a stress test to appease me. (EF was 40% a few weeks ago)
I have been under some stress, but I must admit that more things seem to stress me than usual. Could be menopause. I am 57 y.o. female.
My question-Is angina possible if you don't have any clogs? Personally I feel I should just take an antianxiety med for few months to get me through the hormonal stress I feel and stop the other meds. I am not even going to have the new ones filled. I am still plagued with SOB, possibly caused by continued low EF? I will continue with the Coreg BID until prescription runs out.
Thank you for your help. Joni
9 months ago I had a takotsubo episode after hearing of the death of my mother. According to MRI, ECHO cardiogram, CT scan and pathology it was severe reducing heart capacity to 39%. I have now recovered and am back to pre takotsubo life!!
My question is however is there any evidence that depression can follow these episodes. I have come to terms with my mothers death, I have just become a grandmother for the 2nd time such a delight, and one of my sons has become engaged. All ths is to say I have a normal and very happy family. But I am finding it more difficult every day to keep on top of things without crying or experiencing deep sadness. I have never suffered from depression so dont really know.
I am 54yrs old. Have had hypertension and on avapro HCT. But have reduced BP by reducing salt intake. BP now average 130/80.
Not much literature around re takotsubo so just starting here. I hope you can shed some light on things
Regards Jenny