Takotsubo syndrome: Advances in the understanding and management of an enigmatic stress cardiomyopathy

Table 1 Epidemiological and clinical features of takotsubo cardiomyopathy

	Tsuchihashi et al[15]	Núñez et al[14]	Kurowski et al[13]	Eshtehardi et al[16]	Parodi et al[11]	Ahmed et al[17]	Templin et al[18]
Country	Japan	Spain	Germany	Swiss	Italy	United States	Europe and United States
Year of publication	2001	2015	2007	2009	2007	2013	2015
Subjects, n	88	202	35	41	36	620 (systematic review)	1750 (international registry)
Age (yr)	67 ± 13	70 ± 12.5	72 ± 9	65 ± 11	75 ± 7	67	66.8 ± 13
In percentage (%)
Reported incidence1	---	1.2	1.2	1.7	2	---	---
Women	86	90	94	85	1006	91	89.8
Hypertension	48	67	74	56	50	---	65
Diabetes	12	15	23	5	5.5	---	14
Hyperlipidemia	24	41	34	39	39	---	31
Current smoking	---	15	20	27	19	---	20
Apical type	1003	---	60	---	---	---	81.7
Emotional/psychological trigger	20	50	43	46	---	41	27.7
Physical (acute diseases, exercise, surgery and medical procedures) trigger	53	20	43	17	---	45	36
No identified triggering factor	26	27	14	37	28	14	28.5
Chest pain	67	80	---	76	1002	54	76
Dyspnea	7	45	---	24	---	26	47
Syncope	---	9	---	---	---	---	7.7
ST segment elevation	90	62	69	39	1002	39	43.7
T wave inversion	97	94.4	---	46	---	31	415
In hospital mortality	1	2.44	9	0	---	4	4.1
Long term mortality from all causes	---	---	8.6 (at 12 mo)	2 (23 ± 10 mo)	3 (at 6 mo)	---	5.6 (per patient-year)
Recurrences	2.7	0	6	5	---	---	1.8 (per patient-year)

¹Incidence is based on patients with acute coronary syndrome;

²This case series included only patients with chest pain and ST segment elevation;

³Included only the typical form (apical ballooning);

⁴All from noncardiac causes;

⁵On admission;

⁶Only included women.

Table 2 Clinical comparison between takotsubo cardiomyopathy and STEMI

	TTC	STEMI
Predominant gender	Women	Men
Myocardial segments involved	Extent beyond one coronary artery	Corresponding to culprit vessel
Peak of troponin	Lower	Higher
Left ventricle dysfunction recovery	Complete and at short term	Variable
Long term mortality	Lower	Higher

TTC: Takotsubo cardiomyopathy; STEMI: ST-segment elevation myocardial infarction.

Table 3 Diagnosis criteria for takotsubo cardiomyopathy

Patients must satisfy all the following
ECG	New abnormalities: ST-segment elevation and or T waves inversion
Blood test	Modest peak of troponin
Imaging	Transient wall motion abnormalities (with or without apical involvement) that extend beyond a single epicardial coronary artery
Angiography	Normal or near normal epicardial coronary arteries and no evidence of plaque rupture
Excluding other diseases	Pheochromocytoma, myocarditis

Based on Mayo Clinic Criteria (2008). ECG: Electrocardiographic.

Table 4 Electrocardiographic findings in takotsubo cardiomyopathy

T waves inversion	ST-segment	QRS complex	Q waves
Are the most frequent finding along ECG evolution	Makes priority rule out obstructive coronary artery disease	aVR lead is especially sensible to changes in voltage because it "faces" the apex	Permanent pathological Q waves are exceptional
Appear mainly in precordial leads (V2-V6)	More frequent on precordial leads, except V1
Negative T waves are deep, symmetrical and widespread	Reciprocal depression is less frequent than in STEMI
Progressive QT-interval prolongation	Suspicious combinations:
	ST-depression in aVR plus no elevation in V1 (91% sensitivity, 96% specificity)[87]
	The sum of elevation in V4-V6/V1-V3 ≥ 1 (77% sensitivity, 80% specificity)[65]
No negative T wave in V1 plus positive T wave in aVR must raise suspicion (95% sensitivity, 97% specificity)[62]	Level of ST segment elevation lesser than in anterior STEMI

ECG: Electrocardiogram; STEMI: ST-segment elevation myocardial infarction.