Apical Ballooning Syndrome a.k.a. Tako-Tsubo Cardiomyopathy a.k.a. Stress-induced Cardiomyopathy a.k.a. Broken Heart Syndrome

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Apical Ballooning Syndrome a.k.a.Tako-Tsubo
Cardiomyopathy a.k.a.Stress-induced
Cardiomyopathy a.k.a.Broken Heart Syndrome
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Epidemiology

• Incidence is unknown although some have estimated
  1-2 of all patients presenting with ACS
• Mean age is 58-75 and rarely has been reported in
  patients less than 50 years of age
• Ninety percent of the cases have occurred in women

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Clinical Presentation

• Essentially present as ACS patients
• 50 with angina-like chest pain at rest
• Dyspnea
• 66 have a preceding physical or emotional
  stressor (reports have described various
  stressful events such as a surprise party, public
  speaking, and the death of loved one)
• Rarely present with syncope or cardiac arrest

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Pathophysiology

• Catecholamine induced?
• Very high levels of circulating catecholamines
• Contraction band necrosis on endomyocardial
  biopsy
• Coronary spasm
• Myocarditis

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Findings on workup

• EKG Typically STE in precordial leads although
  reports have been described where no STE were
  observed.
• Rarer findings include nonspecific T wave
  abnormalities or a bundle branch block
• Biomarkers Elevated Troponin and CK-MB
• Levels are not as high as expected given degree
  of cardiac dysfunction.
• Cardiac catheterization Normal or insignificant
  disease

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Left ventriculogram
Prasad, A. et al. American Heart Journal. 2008
155 408-417
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Echocardiogram

• Hypokinesis or akinesis of mid and apical
  segments of the LV
• Motion abnormality involves more than one
  coronary artery distribution
• Function at the base is normal
• RV may show similar findings in 30 of patients
  (seen in sicker patients)

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Cardiac MRI

• Documents degree of wall motion abnormalities
• No delayed hyperenhancement
• MI and myocarditis show hyperenhancement

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Proposed Mayo Clinic criteria for Diagnosis

• Transient hypokinesis, akinesis, or dyskinesis of
  the left ventricular mid segments with or
  without apical involvement the regional wall
  motion abnormalities extend beyond a single
  epicardial vascular distribution a stressful
  trigger is often, but not always present. ?
• Absence of obstructive coronary disease or
  angiographic evidence of acute plaque rupture.
• New electrocardiographic abnormalities (either
  ST- segment elevation and/or T-wave inversion) or
  modest elevation in cardiac troponin.
• Absence of Pheochromocytoma or Myocarditis

Prasad, A. et al. American Heart Journal. 2008
155 408-417
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Treatment

• In short, nobody really knows optimal therapy.
• Patients will initially be treated as ACS
  (anticoagulation, asa, b-blocker, tele, etc.)
• Beta-blockers and ACEI are reasonable at
  discharge (no asa necessary if cath revealed no
  CAD)
• Some argue for several weeks of warfarin therapy
  if LV dysfunction is severe
• CHF can be seen in 20 of patients which
  responds well to diuretics

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Outcomes

• In hospital mortality is exceedingly low
• Typically complete recovery is seen within 4-8
  weeks.
• ACEI can be discontinued at that time