Takotsubo cardiomyopathy: Pathophysiology, diagnosis and treatment

Table 1 Diagnostic criteria of the Mayo Clinic

Suspicion of AMI based on precordial pain and ST elevation observed on the acute-phase ECG

Transient hypokinesia or akinesia of the middle and apical regions of the LV and functional hyperkinesia of the basal region, observed on ventriculography or echocardiography

Normal coronary arteries confirmed by arteriography (luminal narrowing of less than 50% in all the coronary arteries) in the first 24 h after the onset of symptoms

Absence of recent significant head injury, intracranial hemorrhage, suspicion of pheochromocytoma, myocarditis, or hypertrophic cardio myopathy

AMI: Acute myocardial infarction; ECG: Electrocardiogram; LV: Left ventricular.

Table 2 Diagnostic criteria of Kawai et al[16]

Exclusion criteria

Significant organic stenosis or spasm of a coronary artery. In particular, AMI due to a lesion of the anterior descending artery of the left coronary artery, which irrigates a large territory including the apex of the LV (urgent coronary angiography is desirable in order to view the image in the acute phase; during the chronic phase, coronary angiography is necessary to confirm the presence or absence of significant stenotic lesions or abnormal lesions that could explain the ventricular contraction)

Cerebrovascular disturbances

Pheochromocytoma

Viral or idiopathic myocarditis

(Note: Coronary angiography is required for the exclusion of coronary artery lesions. Takotsubo-like myocardial dysfunction can occur in conditions such as cerebrovascular disorders or pheochromocytoma)

Diagnostic references

Symptoms: Precordial pain and dyspnea similar to the findings in the acute coronary syndrome. TCM can also occur without symptoms

Triggers: Emotional or physical stress, although it can also occur without any obvious trigger

Age and gender: There is a recognized tendency to a higher frequency in elderly individuals, principally women

Ventricular morphology: Apical ballooning with rapid recovery on ventriculography and echocardiography

ECG: ST elevation may be observed immediately after the event. T waves progressively become negative in various leads and the QT interval progressively lengthens. These changes gradually improve, but the T waves may remain negative for months. Pathological Q waves and alterations of the QRS voltage may be observed in the acute phase

Cardiac biomarkers: There is only a slight rise in the cardiac enzymes and troponin

Nuclear medicine scan of the heart: Abnormalities may be detected on myocardial gamma scan in some cases

Prognosis: Recovery is rapid in most cases, but some patients develop acute pulmonary edema and other sequel, even death

AMI: Acute myocardial infarction; ECG: Electrocardiogram; LV: Left ventricular; TCM: Takotsubo cardiomyopathy.