Category: Critical Care
Posted: 2/21/2018 by Ashley Menne, MD
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-Nonischemic cardiomyopathy, classically seen in post-menopausal women preceded by an emotional or physical stressor
-Named for characteristic appearance on echocardiography and ventriculography with apical ballooning and contraction of the basilar segments of the LV – looks like a Japanese octopus trap or “takotsubo" (pot with narrow neck and round bottom)
-Clinical presentation usually similar to ACS with chest pain, dyspnea, syncope, and EKG changes not easily distinguished from ischemia (ST elevations – 43.7%, ST depressions, TW inversions, repol abnormalities) and elevation in cardiac biomarkers (though peak is typically much lower than in true ACS)
** Diagnosis of exclusion – only after normal (or near-normal) coronary angiography **
-Care is supportive and prognosis is excellent with full and early recovery in almost all patients (majority have normalization of LVEF within 1 week)
-Supportive care may include inotropes, vasopressors, IABP, and/or VA ECMO in profound cardiogenic shock
** LVOT Obstruction **
-occurs in 10-25% of patients with Takotsubo’s cardiomyopathy
-LV mid and apical hypokinesis with associated hypercontractility of basal segments of the LV predisposes to LV outflow tract obstruction
-Important to recognize as it is managed differently:
-may be worsened by hypovolemia, inotropes, and/or systemic vasodilatation
-mainstay of treatment is avoidance of the above triggers/exacerbating factors while increasing afterload
*phenylephrine is agent of choice +/- beta blockade
Take Home Points:
***Diagnosis of exclusion!!! Presentation very similar to ACS and ACS MUST be ruled out
* Treatment is supportive and similar to usual care for cardiogenic shock. Can be severe and require mechanical circulatory support!
*10-25% have LVOT obstruction. Manage with phenylephrine +/- beta blockade
Weiner MM, Asher DI, Augoustides G, et al. Takotsubo Cardiomyopathy?: A Clinical Update for the Cardiovascular Anesthesiologist. J Cardiothorac Vasc Anesth. 2017;31(1):334-344. doi:10.1053/j.jvca.2016.06.004.
