II. Definition

  1. Abrupt onset Left Ventricular Systolic Dysfunction as a response to severe emotional or physiologic stress

III. Epidemiology

  1. Prevalence: 0.02% of hospitalized patients
  2. Ages 50 to 70 most commonly affected
  3. Primarily in women (95% of cases)
  4. Accounts for 1-2% of presumed STEMI cases

IV. History

  1. Initially described in Japan (1990)
  2. Takotsuba is Japanese for a ceramic octopus trap (which resembles the heart on Echocardiogram)

V. Pathophysiology

  1. Postulated cause as Catecholamine surge that results in heart Muscle injury and a drop in contractility
  2. Transient with often a full recovery without significant residual Cardiomyopathy by 2 weeks

VI. Risk Factors

  1. Major stressors (85%-89% report a stressful event in the preceding 12 hours)
  2. Stress examples
    1. Emotional stressors (e.g. fear, grief, anger)
    2. Physical stressors (e.g. Cerebrovascular Accident)
    3. General Surgery
    4. Chemotherapy
    5. Exogenous Catecholamines such as beta Agonists (e.g. Albuterol, Phenylephrine)

VIII. Signs

  1. May present with Cardiogenic Shock or lethal Arrhythmia (e.g. VT/VF, PEA)

IX. Labs

  1. Serum Troponin
    1. Frequently increased

X. Diagnostics

  1. Electrocardiogram
    1. May mimic ST Elevation Myocardial Infarction
    2. Deep T Wave Inversions and ST Depression
    3. May demonstrate contiguous lead ST Elevation with reciprocal changes
      1. Frequently affects the anterior distribution and to a lesser extent inferior distribution
  2. Echocardiogram
    1. Acute, severe Systolic Dysfunction (with ejection fraction dropping from normal to <25-35%)
    2. Echocardiogram demonstrates reduced contractility not explained by single vessel disease
    3. May demonstrate apical ballooning of the left ventricle
    4. Heart assumes elongated shape (Japanese octopus trap)
    5. Akinetic apex
  3. Angiogram
    1. No occlusive vascular disease identified to explain the event

XI. Management

  1. Supportive care
  2. Start by treating as Acute Coronary Syndrome and exclude STEMI
  3. Manage Arrhythmias as needed
  4. Manage Cardiogenic Shock and Acute Pulmonary Edema
    1. See Cardiogenic Shock for emergent management
    2. Beta Blockers and ACE Inhibitors are commonly used for Takotsuba
    3. Consider Diuretics
    4. Anticoagulation may be considered (if decreased left ventricle wall motion)
    5. Consider Endotracheal Intubation
    6. Consider Intra-aortic balloon pump

XII. Prognosis

  1. Initial aggressive management is critical for good prognosis
  2. Ejection Fraction returns to normal (at least >50%) in nearly all cases (100% in the Sharkey study)
    1. Typically normalizes after first month
  3. Mortality 2% during hospitalization
  4. Recurrence in 5-6%

XIII. References

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