Takotsubo cardiomyopathy: Healing a broken heart

Takotsubo cardiomyopathy
Takotsubo cardiomyopathy

Not all medical problems are easy to diagnose, and it can be especially tricky when similar symptoms occur in different diseases. It is important to consider all possible diagnoses, even when a patient has classic signs and symptoms of a very common diagnosis, such as a heart attack. Consider the following case study of a patient with chest pain and other symptoms typical of a heart attack.

Case study

Judy, a 67-year-old female, presents to the emergency department with chest pain that is unrelieved by rest. She states that the pain began the day before and has significantly worsened over time. She describes it as a heavy pain in the center of her chest. Judy rates her pain as a 15 on a scale from 1 to 10, with 10 being the worst pain. She also complains of weakness, shortness of breath, and nausea.

Judy also reports being under increased stress, because her father had passed away three days ago. She began having chest pain the evening of his funeral.

Judy has no personal history of heart disease, lung disease, or diabetes. She also denies tobacco, drug, and alcohol use. Judy says that she was not worried about the chest pain at first, because she exercises daily, eats a healthy diet, and does not smoke, but that she became more concerned as it worsened.

Evaluation in the emergency room includes cardiac monitoring, which shows sinus tachycardia with a rate of 110 beats per minute. Judy’s vital signs are stable with her blood pressure at 135/85 mmHg, unlabored respirations of 25 breaths per minute, and normal temperature of 98.8 °F. Her oxygen saturation is 98% on room air. She is given a sublingual nitroglycerin tablet and started on two liters of oxygen per nasal cannula.

A 12 lead electrocardiogram (ECG) is abnormal with a slight ST segment elevation. This can be a sign of cardiac ischemia, a restricted blood supply to the heart muscle. Blood troponin tests, a type of cardiac biomarker, show a slight elevation, which points to heart muscle damage.

The cardiologist orders an echocardiogram, which reveals hypokinesis (decreased movement) of the apical wall of the heart. Judy’s ejection fraction, which measures how well the heart is pumping blood, is abnormal at 35%. (Normal ejection fraction ranges from about 55 % to 70%).

The cardiologist also performs a coronary angiography to assess Judy’s coronary arteries for blockages. The cardiac angiography finds that her coronary arteries are not blocked or occluded. This helps rule out a heart attack (myocardial infarction).

The cardiologist considers the absence of coronary artery disease (CAD), her medical history, the results of all of her tests, and her recent history of extreme stress. Her final diagnosis is takotsubo cardiomyopathy, an uncommon temporary form of cardiomyopathy. It is also known as stress-induced cardiomyopathy and broken heart syndrome.

Judy is admitted to the hospital and prescribed a low-dose angiotension-converting enzyme (ACE) inhibitor and a beta-blocker to reduce the workload on the heart. Judy’s troponin tests return to normal on the second day of her hospital stay. After three days, her condition improves significantly and she has no permanent cardiac damage.

On discharge, Judy is instructed to continue taking the beta-blocker, to reduce stress in her life, and to follow up with the cardiologist in four weeks.

Pathophysiology of takotsubo cardiomyopathy

Takotsubo cardiomyopathy is characterized by reversible, left ventricular dysfunction in the absence of CAD. It is also known as stress-induced cardiomyopathy. Approximately 1-2% of patients (10% of women) admitted to the hospital with a suspected myocardial infarction are eventually diagnosed with takotsubo cardiomyopathy.

Takotsubo cardiomyopathy is triggered by a response to a physical or psychosocial stressor. Associated stressors include death of loved one, domestic abuse, natural disasters (such as earthquakes or tornado), severe pain, receiving a diagnosis of cancer, or even a surprise party. (See Stressors associated with broken heart syndrome [takotsubo cardiomyopathy]).

Stressors associated with broken heart syndrome (takotsubo cardiomyopathy)

Stressors include:

  • death of a loved one
  • domestic abuse or violence
  • unexpected surprise
  • car accident
  • natural disasters, such as an earthquake or tornado
  • severe pain
  • gambling or financial difficulties
  • work related stress
  • public speaking
  • receiving a diagnosis of cancer or other bad news
  • serious illness, surgery, or medical procedure
  • intense fear

The exact cause of takotsubo cardiomyopathy is unknown, but patients with this syndrome have elevated levels of stress hormones, or catecholamines, in their blood during the time of the incident. Normally, when a person is under stress, the sympathetic nervous system releases catecholamines, such as adrenaline, to help the body deal with the stressful event. Elevated levels of stress hormones can sometimes have a toxic effect on the cardiac tissue. It can “stun” the heart, causing decreased contractility and wall movement, especially at the apex, or bottom, of the heart.

This temporary loss of regional left ventricular contraction can lead to a decreased ejection fraction, in which the percentage of blood pumped from the left ventricle decreases with every heartbeat. When the ejection fraction is decreased, the heart does not pump effectively, putting the patient at risk for heart failure or even cardiogenic shock.

Risk factors

Ninety percent of patients diagnosed with takotsubo cardiomyopathy are postmenopausal women age 60 to 80. It remains unclear why more women have takotsubo cardiomyopathy than men do. One theory suggests that women may be more sensitive to the effects of catecholamines than men, especially after menopause.

Patients with takotsubo cardiomyopathy typically have very few risk factors associated with coronary artery disease (CAD), such as diabetes, smoking, high cholesterol, and high blood pressure.

Symptoms

Patients with takotsubo cardiomyopathy often have decreased contractility of the heart, so the signs and symptoms can mimic a myocardial infarction. Symptoms include:

  • chest pain
  • shortness of breath
  • excessive sweating,
  • nausea and vomiting
  • weakness and fatigue
  • irregular heartbeat

In severe cases, a patient can have symptoms of heart failure with fluid overload and pulmonary edema.

Differential diagnosis of takotsubo cardiomyopathy versus myocardial infarction

The symptoms of takotsubo cardiomyopathy can mimic those of a myocardial infarction, which can make diagnosis difficult. On admission, many patients have ECG changes (ECG) with an elevated ST segment or T wave inversion similar to a patient having a myocardial infarction. In addition, the patient will frequently have slightly elevated levels of cardiac biomarkers, such as troponin, which points to an acute myocardial infarction.

ECG changes and cardiac biomarker elevations due to takotsubo cardiomyopathy are generally temporary and will return to normal. In our case study, Judy did have slight elevation of her cardiac biomarkers and her ECG showed ST segment elevation, yet all returned to normal as her condition resolved.

It is important to note that a normal ECG is unusual and occurs in only 2% of patients. An echocardiogram may show hypokinesis (as in Judy’s case) or akinesis (no movement) of the walls of the left ventricle. The most common finding on the echocardiogram is ballooning or bulging out of the apex of the left ventricle. Patient will often have a reduced ejection fraction, which may lead to heart failure.

Coronary angiography or heart catheterization is an important test in making a differential diagnosis. A patient with myocardial infarction will frequently have blockages in the coronary arteries. A patient with Takotsubo cardiomyopathy will not have any blockages of the coronary arteries.

Treatment options

Currently, there are no standard guidelines for the treatment of patients with Takotsubo cardiomyopathy. Many physicians order the patient a beta-blocker and an ACE inhibitor. These drugs reduce the effects of catecholamines and lower the workload on the heart while the heart recovers.

Other drugs used for treatment may include a diuretic, which helps remove extra fluid from the body and reduce stress on the heart. Anticoagulants can also be ordered to reduce the risk of a blood clot. This is more likely to occur due to impaired contraction of the heart resulting in pooling of the blood in the heart.

The mortality rate for takotsubo cardiomyopathy is low, generally 3-5%. Patients are generally monitored in the hospital for two to three days and discharged after their symptoms resolve. Patients will be instructed to reduce or manage stress in their life. Most cases of takotsubo cardiomyopathy will completely resolve within one to four weeks. Physicians generally recommend an echocardiogram after four to six weeks to confirm this and that the patient’s ejection fraction has returned to normal.

Some physicians recommend that patients continue to take a beta-blocker to help reduce the effects of catecholamines and other stress hormones, but this is controversial. Recurrences are not prevented by beta blockers or ace inhibitors. In addition, there is no evidence that beta blockers are beneficial after the left ventricle has recovered.

The chance of a recurrence of Takotsubo cardiomyopathy is 5-10%; however, patients should be instructed to call 911 right away for immediate evaluation and treatment if they have similar symptoms in the future.

Nursing implications

Nurses should be aware of this uncommon disorder in postmenopausal women. These women often have no risk factors or history of CAD. Takotsubo cardiomyopathy should be considered as a possible diagnosis in all patients with chest pain, especially with the onset of symptoms after a stressful situation.

The initial nursing care for these patients involves monitoring cardiac and hemodynamic status, providing supportive measures, and assessing for signs of heart failure or cardiogenic shock.

Because stress appears to be a trigger for Takotsubo cardiomyopathy, it is recommended that patients learn healthy coping strategies to manage their stress. There are many resources available to assist a patient in dealing with stress. Resources include self-help books, counseling, support groups, and relaxation exercises. Nurses should help patients assess their stressors and explore which method works best to address them.

A diagnosis of Takotsubo cardiomyopathy can be frightening for a patient and family. Nurses can help reassure then and relieve stress by providing information about Takotsubo cardiomyopathy, including the low rate of recurrence and its reversibility. Patients should also be encouraged to follow-up with their physician to verify the return of normal cardiac function.

Selected references

Andrade A, Stainback R. Takotsubo cardiomyopathy. Texas Heart Institute J. 2014;41(3):299-303.

Barto, D. MI mimickers: Takotsubo cardiomyopathy. Nursing 2013 Crit Care. 2013;8(5) 6-7.

Cleveland Clinic. Stress & Heart Disease. 2014. Retrieved on June 5, 2014, from http://my.clevelandclinic.org/heart/prevention/emotional-health/stress-relaxation/stress-management-your-heart.aspx.

Pore N, Burley M. When a broken heart is real: Takotsubo cardiomyopathy. Nurse Pract. 2012;37(10):48-52.

Siu-Hin W, Liang J. Takotsubo cardiomyopathy: etiology, diagnosis, and optimal management. Research Reports in Clinical Cardiology. 2014;5:297-303.

Annette Lynn Ferguson, RN, MS, CNE is an Assistant Professor at Ohio University Southern in Ironton, Ohio.

 

 

9 COMMENTS

  1. I was diagnosed with Takosubo Cardiomyopathy in May of 2018, three days after my mom passed. I was 53 years old at the time. It was funny because I had been her caregiver through hospice. I was grieving after she passed, the first day I started to loose my appetite, then the second day I felt like I had the flu, the third day I woke up incredibly dizzy and called a friend to take me to the ER. They thought that I had some sort of strange pneumonia… but after doing an echocardiogram they discovered it was my heart. I spent a week in ICU, and was discharged. It is almost two years later and I still have issues and am still on medication. I have noticed that if I skip a day of meds my symptoms start to reappear. So I see my cardiologist regularly and am hoping that eventually things get better.

  2. My symptoms and back story have been very similar to those of the ladies above. My “incident” seems to have occurred as the result of long term stress rather than an acute and specific trigger cause. I am now on day 18 since the incident and extremely curtailed; very physically weak and only able to walk very slowly for maybe 10 minutes tops, compared to my pre-incident ability to walk fast for miles! I am still extraordinarily fatigued by conversation/phonecalls and even reading/emails etc. It would be interesting to see comments by patients who are further down the line to see how recovery progresses.

  3. I was diagnosed with Takotsubo cardiomyopathy on 21 May 2019 and released with a beta blocker and ACE inhibitor. The angiogram showed normal arteries but the ballooning of the LV consistent with Takotsubo; this was confirmed later by an echocardiogram. The trigger was severe pain from diverticular disease, which has been troubling me from some time. My normal routine is curtailed by fatigue and some chest discomfort. I am in the process of being transferred from one regional NHS service to my local NHS jurisdiction and, in the meantime, am concerned about the continuing stress caused by my diverticular symptoms. Controlling stress is as long as a piece of string; I wonder if stressors of various nature over time can predispose one to a Takotsubo attack.

  4. I was diagnosed 2 weeks ago. I was scheduled to fly to New Orleans for work. The stress from my job had been enormous for the past 1 year. I’m a Quality Director for a major Health Plan. Two days prior to the flight I had severe chest pain and shortness of breath. I took aspirin and continued to have heart palpitations. They began to resolve, although I was fatigued.

    I decided to go to New Orleans and boarded my flight. On board I began to have severe palpitations and embarked before we took flight. I rushed to the ER and was admitted for 3 days and diagnosed with Takotsubo-cardiomyopathy after blood test, angiogram, chest xray, and echocardiogram. My trigger is work related stressors.

    I am fortunate that my employer is working with me to help eliminate some contributing factors. However, I remain fatigued and if I do not take time to walk away I do get palpitations still. As such, I am transitioning to a nonmanagement position in the very near future, or possible career change.

  5. I had surgery last Friday the 25th January involving a femoral angiogram and angioplasty. During the operation my heart rhythm altered and my heart rate slowed alarmingly. My consultant, taking advice from the cardiac team, (I was fortunate to be in the National Heart hospital in London) continued with the operation. On awaking in the recovery area I suffered severe chest pains going through to my back and was immediately moved to the cardiac laboratory where the appropriate tests and heart angiogram were carried out. These showed no blockage in my heart and the diagnosis given to me was Takotsubo syndrome. My heart recovered from 10% to 60% within a few hours and tests the following day showed that my heart was functioning normally. It is true to say that I was under intense stress prior to my operation. It has left me with overwhelming tiredness but hopefully this will improve. I was prescribed beta blockers, ace inhibitors and stronger blood thinning medication. I suppose I exhibit as a classic case as I am a 61 year old woman. Prior to this episode I was totally unaware of ‘broken heart’ syndrome and must attempt to reduce my stress levels!

  6. I am a 53 yr old female that recently was diagnosed with Takosubo Cardiomyopathy after receiving news that my cousin committed suicide on Christmas day. My symptoms started the evening I received the news and were worse the next morning when I decided I needed to go to the ER. I had chest pressure, radiation to my R arm, severe shortness of breath and diaphoresis. My Ekg was abnormal, my troponin was elevated and my echocardiogram showed anterior wall abnormalities. My cardiac catheterization was clean. I was discharged home after one night in the hospital with follow up in 2 weeks with cardiology. I have been on minimal activity until my repeat echocardiogram in 4 weeks. My discharge medication included starting on Lipitor 40mg every day and baby aspirin. It has been 2 weeks and I continue to have shortness of breath with some chest pressure with increased exertion. My cardiologist tells me I will recover 100% within 3 mo with rest and stress management.

  7. I recently was diagnosed with Takotsubo Cardiomyopathy after seeing a car accident during which a young woman lost control of her vehicle as she was passing us during inclement weather. My ECG showed ST changes. My blood showed an increase in Troponin levels. My cardiac ultrasound showed a change in the shape of my left ventricle. Later that week the cardiac catheterization was negative for any blockages of the cardiac arteries. A few days after discharge I experienced several hours of an irregular heartbeat which I plan to tell my family doctor about. The young pregnant woman was not injured in the accident.

  8. This article was very helpful. Thank you. My twin sister who turned 62 in January was in the hospital recently with elevated blood pressure and test finding fluid on her lungs. She was diagnosed with this after an arteriograhm confirmed this diagnosis. She is now home and has returned back to her stressful home and school situation after two days from being discharged. I am very concerned about her.

  9. I was recently taken off a cruise ship and diagnosed with Takosubo Cardiomyopathy. I am a 62 yr old female and my husband was recently diagnosed with CMML, which elevated stress levels. The article has been so helpful and informative since I am currently still trying to return from Scotland where the event happened.

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