Takotsubo cardiomyopathy (TC) is a condition charactised by transient regional abnormal cardiac wall motion, not defined to single coronary arterial territory. It has been described predominantly in postmenopausal women, often following exposure to sudden, unexpected emotional or physical stress.
The initial presentation may be life-threatening (and can resemble presentation of ST-elevation myocardial infarction), with a small number dying of arrhythmia (generally torsades de pointes due to prolonged QT interval) or of cardiogenic shock. Following the acute presentation, prognosis is generally very good, with complete resolution occurring in a number of weeks to months.
There is a transient left ventricular dysfunction with no evidence of obstructive epicardial coronary disease.
While there is no definite consensus on the diagnostic criteria for Takotsubo cardiomyopathy, a set of diagnostic criteria was proposed in 2004 by researchers at the Mayo Clinic, which has been modified recently 1:
- transient hypokinesis, akinesis, or dyskinesis in the left ventricular mid segments with or without apical involvement; regional wall motion abnormalities that extend beyond a single epicardial vascular distribution; and frequently, but not always, a stressful trigger
- absence of obstructive coronary disease or angiographic evidence of acute plaque rupture
- new ECG abnormalities (ST-segment elevation and/or T-wave inversion) or modest elevation in cardiac troponin
- absence of pheochromocytoma and/or myocarditis
Patients with Takotsubo cardiomyopathy can have high levels of serum catecholamines and plasma brain natriuretic peptide (BNP). The secretion pattern of BNP in takotsubo patients can be quite similar to those with a myocardial infarction.
On cardiac MRI, four distinct patterns of dyskinesia and ballooning are recognised: apical (most common), biventricular, mid-ventricular, and basal.
There is typically an absence of late enhancement on delayed contrast sequences, which differentiates Takotsubo cardiomyopathy from anterior STEMI.
There can be high T2 intensity signal (directly relating to water content in the myocardial wall); the oedema is typically located in the apical mid ventricular planes and spares the basal plane, and matches the wall-motion abnormalities seen on cine MRI.
- MR perfusion: usually normal
History and etymology
The word tako-tsubo in Japanese refers to a pot used to catch octopi (see Figure 1) 2. It is thought to have been first described by Keigo Dote et al. in 1991 5.
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