II. Definition
- Abrupt onset Left Ventricular Systolic Dysfunction as a response to severe emotional or physiologic stress
III. Epidemiology
- Prevalence: 0.02% of hospitalized patients
- Ages 50 to 70 most commonly affected
- Primarily in women (95% of cases)
- Accounts for 1-2% of presumed STEMI cases
IV. History
- Initially described in Japan (1990)
- Takotsuba is Japanese for a ceramic octopus trap (which resembles the heart on Echocardiogram)
V. Pathophysiology
- Postulated cause as Catecholamine surge that results in heart Muscle injury and a drop in contractility
- Transient with often a full recovery without significant residual Cardiomyopathy by 2 weeks
VI. Risk Factors
- Major stressors (85%-89% report a stressful event in the preceding 12 hours)
- Stress examples
- Emotional stressors (e.g. fear, grief, anger)
- Physical stressors (e.g. Cerebrovascular Accident)
- General Surgery
- Chemotherapy
- Exogenous Catecholamines such as beta Agonists (e.g. Albuterol, Phenylephrine)
VII. Symptoms
VIII. Signs
- May present with Cardiogenic Shock or lethal Arrhythmia (e.g. VT/VF, PEA)
IX. Labs
- Serum Troponin
- Frequently increased
X. Diagnostics
-
Electrocardiogram
- May mimic ST Elevation Myocardial Infarction
- Deep T Wave Inversions and ST Depression
- May demonstrate contiguous lead ST Elevation with reciprocal changes
- Frequently affects the anterior distribution and to a lesser extent inferior distribution
-
Echocardiogram
- Acute, severe Systolic Dysfunction (with ejection fraction dropping from normal to <25-35%)
- Echocardiogram demonstrates reduced contractility not explained by single vessel disease
- May demonstrate apical ballooning of the left ventricle
- Heart assumes elongated shape (Japanese octopus trap)
- Akinetic apex
- Angiogram
- No occlusive vascular disease identified to explain the event
XI. Management
- Supportive care
- Start by treating as Acute Coronary Syndrome and exclude STEMI
- Manage Arrhythmias as needed
- Manage Cardiogenic Shock and Acute Pulmonary Edema
- See Cardiogenic Shock for emergent management
- Beta Blockers and ACE Inhibitors are commonly used for Takotsuba
- Consider Diuretics
- Anticoagulation may be considered (if decreased left ventricle wall motion)
- Consider Endotracheal Intubation
- Consider Intra-aortic balloon pump
XII. Prognosis
- Initial aggressive management is critical for good prognosis
- Ejection Fraction returns to normal (at least >50%) in nearly all cases (100% in the Sharkey study)
- Typically normalizes after first month
- Mortality 2% during hospitalization
- Recurrence in 5-6%
XIII. References
- Hochman and Patel in Herbert (2015) EM:Rap 15(1): 4-6
- Brieler (2017) Am Fam Physician 96(10):640-6 [PubMed]
- Sharkey (2010) J Am Coll Cardiol 55(4): 333-41 [PubMed]