Makindo Medical Notes.com

Related Subjects: |Dilated Cardiomyopathy |Hypertrophic cardiomyopathy (HCM - HOCM) |Peripartum cardiomyopathy |Restrictive Cardiomyopathy |Takotsubo Cardiomyopathy

Often triggered by severe emotional or physical stress, hence the term "Broken Heart Syndrome." Patients typically present with chest pain, shortness of breath, and other symptoms similar to acute coronary syndrome (ACS). Unlike typical MI, it is reversible, with most patients recovering normal heart function within days to weeks

About

• This is a retrospective diagnosis - manage acutely as Acute coronary syndrome
• A stress-related reversible cardiomyopathy - "apical ballooning of LV" is seen
• Can mimic ACS. First described in 1990 in Japan
• Provoked by emotional/physical stress "Broken heart syndrome"
• Classically Asian or Caucasian post-menopausal women (90% are female)

Aetiology

• Changes rapidly resolve within hours including wall motion abnormalities
• Very unclear. Microinfarction. Excess catecholamines
• Reported after cocaine, methamphetamine and exercise stress testing
• There is no evidence for coronary obstruction

Clinical

• Emotional stress with associated chest pain
• Cardiogenic shock, Heart failure, pulmonary oedema
• Dysrhythmias left ventricular thrombus formation
• Left ventricular free wall rupture, and death may be seen

Differential

• Exclude paroxysmal symptoms e.g. due to phaeochromocytoma

Investigations

• ECG: may find ST-segment elevation, T-wave inversion, or QT prolongation, suggestive of STEMI
• Echo: Left ventricular apical akinesis. There is a rounded, hypokinetic apex with a narrow, hyper contracted base. ballooning of the left ventricle's apex, while the base remains relatively normal, creating the characteristic "takotsubo" shape.
• Troponin: Mildly Raised troponin but not as high as with typically STEMI
• BNP: is often elevated
• Elevated catecholamine levels (higher than with STEMI)
• Normal coronary angiogram with no evidence of plaque or obstructive lesion causing symptoms
• Cardiac MRI : absence of delayed gadolinium hyperenhancement

Management

• Acutely treat as per acute coronary syndrome algorithm. Give aspirin, beta-blockers, and ACE inhibitors. Manage heart failure, arrhythmias, and thromboembolism.
• The cardiac dysfunction is transient, and the left ventricle returns to normal and contractile function is restored within days to weeks. The LV dysfunction can lead to LV outflow obstruction which may be helped with beta-blockade.
• This is often a retrospective diagnosis and once diagnosed management is supportive. Prognosis is generally good, with most patients recovering fully within a few weeks. However, there is a risk of recurrence (up to 10%), and in rare cases, it can lead to complications such as cardiogenic shock.

References

• Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review
• The clinical features of takotsubo cardiomyopathy