Sdr di TakoTsubo

Question 1

general findings

Answer 1

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, refers to acute, stress-induced, reversible dysfunction of the left ventricle (non è altro che uno stordimento cardiaco). It is an uncommon but clinically significant cause of chest pain that can mimic acute coronary syndrome (ACS). Typically triggered by an extreme emotional stressor or severe illness, it is typically characterized by ballooning of the left ventricular wall, which can lead to chest pain and heart failure. While most cases fully resolve within a couple of weeks, patients can become critically ill, particularly if the disease causes left ventricular outflow tract obstruction (LVOT obstruction). As symptoms overlap with those seen in acute coronary syndrome, this condition should be excluded.

Question 2

definizione

Answer 2

Acute, stress-induced, reversible dysfunction of the left ventricle that can mimic acute coronary syndrome

Question 3

epidemiologia

Answer 3

• 90% of affected individuals are postmenopausal women.

- More common in patients with preexisting mental illness

Question 4

Eziologia

Answer 4

Triggers

-Intense emotional stress
The stress is usually negative (i.e., “broken heart syndrome”)
Less common: strong, positive emotions (i.e., “happy heart syndrome”)
-Severe illness (soprattuto neurologiche come emorragia sub aracnoidea, epilessia oppure sepsi e feocromocitoma)
-Drugs
Pathophysiology: Emotional/physical stress → activation of the sympathetic nervous system → massive catecholamine discharge → cardiotoxicity, multivessel spasms, and dysfunction → myocardial stunning (A state of abnormal regional LV wall motion that persists for hours to weeks following transient ischemia)

Question 5

Clinica (ricorda, mima una ACS)

Answer 5

Most common symptoms

• Retrosternal chest pain with typical features of angina
• Dyspnea

Additional symptoms

• Syncope
• Arrhythmias
• Signs of heart failure and/or cardiogenic shock (e.g., hypotension, pulmonary edema)

Question 6

Diagnosi

Answer 6

Laboratory studies
↑ Troponin T/I
↑ Creatine kinase-MB
↑ BNP

ECG
ECG is abnormal in > 95% of patients with takotsubo cardiomyopathy and usually shows ischemic changes.

-ST elevations (most common finding), typically in the precordial leads
(ST depressions are uncommon (< 10% of cases).
-Diffuse T-wave inversions (anche in displasia aritmogenica)
-Prolonged QT interval

Imaging
Echocardiography (TTE)
Indications: all patients suspected of having takotsubo cardiomyopathy
Supportive findings
-↓ LVEF!
-Global LV dyskinesis involving the apex (most common)
-Regional wall motion abnormalities
-Apical left ventricular ballooning (not always present)
More rarely, midventricular ballooning (10–20% of cases) or basal ballooning (< 5% of cases) may be present [1]
LVOT obstruction may be present (up to 25% of cases)

Coronary angiography (with ventriculography)
Indications: to exclude ACS
Findings
Most cases: normal coronary arteries or nonobstructive coronary artery disease
∼ 15% of cases: obstructive coronary artery disease may also be present

Cardiac MRI
Indications
To exclude differential diagnoses (e.g., myocarditis) and confirm the diagnosis of takotsubo cardiomyopathy in stable patients
Allows for better imaging of the right ventricle
Suggestive findings
Similar to findings in TTE
-Transmural edema along the areas of wall motion abnormalities
-Myocardial scarring
-LVOT obstruction
-Valve disease
-Pericardial effusion
-LV thrombus
Coronary CT angiography: consider as an alternative for stable patients with contraindications to cMRI to exclude high-grade coronary stenosis

Question 7

Managment (in generale , in acuto viene trattata come una disfunzione ventricolare sistolica)

Answer 7

1. Hemodynamically stable patients
   - Heart failure management
   - Treat as systolic heart failure (o come una ACS con disfunzione ventricolare)
   - ACE inhibitors (e.g., lisinopril )
   - Low-dose beta blockers (e.g., metoprolol tartrate

2.Hemodynamically unstable patients
No LVOT obstruction

• Inotropic support: Dobutamine and dopamine can be used; however, both can cause tachycardia and worsening of takotsubo cardiomyopathy, and so other agents, e.g., levosimendan, may be preferable. Patients receiving inotropic support should be monitored closely for the development of LVOT.
• Vasopressor support: if inotropes are insufficient

Advanced therapies: consider in refractory cases

• Intra-aortic balloon pump (IABP)
• Left ventricular assist device
• ECMO

LVOT obstruction (occurs in up to 25% of cases)

LVOT obstruction further impairs LV systolic function and can be very difficult to treat. Inotropic support should be avoided, as this can precipitate cardiogenic shock in patients with LVOT obstruction.

• IV fluids (come nel caso di un infarto del ventricolo destro): may improve LV systolic function
• Beta blocker: Use of a short-acting, low-dose beta blocker (if tolerated) may be helpful to relieve LVOT obstruction but should be used with caution in patients with hypotension.

-Vasopressor support: in cases of shock
Advanced therapies: consider in refractory cases
Left ventricular assist device
ECMO

The following therapies should be avoided:
Inotropes
Vasodilators
Nitroglycerin (per lo stesso motivo per cui è controindicata in infarto cardiaco destro, cosi come la morfina)
Diuretics
IABP

Avoid inotropes, as they can worsen LVOT obstruction and precipitate cardiogenic shock.

Question 8

Terapia cronica

Answer 8

Chronic therapy

-Consider chronic beta blocker therapy (e.g., metoprolol ).
-Consider a chronic ACE inhibitor or ARB (e.g., lisinopril , losartan )
These drugs are thought to facilitate left ventricular recovery in takotsubo cardiomyopathy. Some studies have shown an association with reduced mortality.