Takotsubo cardiomyopathy (TCM) is a condition in which there is rapid weakening of the left ventricular muscles as a result of acute physical or emotional stress. This condition is also called stress cardiomyopathy, apical ballooning syndrome, or broken heart syndrome. This condition persists for a short period (for a few minutes to a few hours) and in most cases, the patient recovers quickly without residual disability.
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People with stress cardiomyopathy complain of sudden chest pain and breathing difficulties. This condition may recur in a few cases, following exposure to stressors, and it may develop complications. People seek emergency treatment for this syndrome which is often mistaken to be a heart attack, due to the similarity of the symptoms.
Outline of prognosis
Generally, the prognosis of TCM is favorable as long as the acute phase of the syndrome is managed properly. In the literature, the in-hospital death rate of such cases is reported to be 1.1%.
The prognosis depends upon the type of stress that precipitates the condition. The risk of a fatal outcome is negligible in TCM caused by emotional stress as compared with that due to physical stress.
The long-term prognosis is good as the chances of recurrence are very low, only 2% to 5%. The recurrence may involve the previously unaffected segment of the left ventricle.
The long-term prognosis of this condition is not yet established, but preliminary reports seem to suggest some similarity between the broken heart syndrome and acute myocardial infarction but a better prognosis, since it is related to non-cardiovascular and occurs at a higher age.
It is also found that some patients suffer long-term cardiac symptoms following the acute phase of the syndrome. These include pulmonary edema, exertional breathlessness, angina, trembling or palpitation associated with a anxiety state, and elevated sympathetic tone.
If recurrence happens soon after the initial episode, it may result in severe or fatal complications such as formation of a thrombus in the left ventricle, serious disturbances in ventricular rhythm, cardiogenic shock, or mechanical complications. Electrocardiography may reveal traces of these occurrences, such as prolongation of the QT interval, conduction defects or repolarization defects. However, the risk of recurrence is relatively low, as well as the mortality rate, about 1–2%.
Prognostic factors and recurrence
The etiology of TCM is not clear and there is inadequate data on the prognostic factors. The clinical characteristics of the syndrome include dyspnea, elevated cardiac biomarkers, electrocardiographic recordings of abnormal left ventricular wall motion, ST segment depression, and T-wave inversion.
The recurrence of TCM is not the only adverse prognostic factor. Mortality is rare, but is due to other major health issues such as cardiogenic shock, myocardial infarction, and rare problems such as pneumonia, mechanical ventilation, and inotropic agents. These issues complicate the condition and may increase the probability of recurrence or lead to a fatal outcome.
Physical stress is the most serious precipitating factor in TCM. Increased high-sensitivity C-reactive protein (hs-CRP) levels and decreased initial left ventricular ejection fraction are independent risk factors for cardiogenic shock or death in TCM patients.
In the pathogenesis of the condition, elevated levels of catecholamines in the blood play a major role. Certain medical interventions, such as repeated exposure to beta-2-adrenergic receptor agonist inhalation, may also stimulate the occurrence of the syndrome.
Some patients continuously exposed to beta-2-adrenergic agonists showed signs of TCM via clinical and electrocardiographic results. Beta-2-agonists may also cause myocyte injury, cardiac dysfunction, as well as apical myocardial dysfunction and ballooning, all of which are generally found in TCM. Further, beta-2-adrenergic agonists and other blockers can worsen apical contractile dysfunction in TCM.
Sudden worsening of several conditions such as hypoglycemia, gastrointestinal bleeding, pneumothorax and asthma are also considered to be potential inducers.
Following an episode of TCM, several post-treatment measures are advised to promote a quicker recovery and to avoid recurrences. Novel developments in medical care and the adoption of a healthy lifestyle may aid the healing process and also support the patient’s health in the long run.
Prolonged use of β-blockers or similar drugs may be considered to suppress the hyper-responsiveness of the heart to the actions of stress hormones. Regular cardiac checkups along with echocardiography are recommended.
Patients should be directed to appropriate therapists to improve their ability to control physical or emotional stresses, to learn to handle problems more effectively, and to improve their overall health. Relaxation therapy and physical activities help in relieving stress and this is of great importance in avoiding recurrence.
Reviewed by Liji Thomas, MD.