Takotsubo cardiomyopathy


A depicts the left ventricular dilation that occurs in Takotsubo cardiomyopathy compared to a normal heart in B.
  • AKA transient apical ballooning syndrome or stress-induced cardiomyopathy
  • Bulging out of LV apex with preserved function of the base looks like an octopus pot or "tako tsubo" in Japanese
    • Recent recognition of additional subtypes: reverse Takotsubo (basal ballooning), mid-ventricular type, localized type
  • 85% of cases caused by stressful event before symptoms (death of loved one, fear, argument, asthma, surgery, stroke, etc.)[1]
    • Proposed mechanisms include vasospasm, microvascular dysfunction, and abnormal myocyte response to catecholamine surge
    • As high as 28% in ICU patients due to severe physical stress[2]

Clinical Features

Differential Diagnosis

ST Elevation



LV apical ballooning during systole
  • Troponin may elevated or normal, but not usually as high as with traditional STEMI
  • ECG
    • May mimic STEMI
    • Frequently affects the anterior distribution and to a lesser extent inferior distribution
  • Echocardiography
    • Systolic Dysfunction (with ejection fraction dropping from normal to <25-35%)
    • Reduced contractility not explained by single vessel disease
    • Apical Ballooning on US
Apical Ballooning[3]
  • Ventriculography
    • Shows LV ballooning
  • Angiogram
    • No significant coronary blockage to explain LV dysfunction

Clinical Differences Between AMI and [4]

AMI Takutsubo
ECG Specific vascular distribution Multiple regions of change
Echo Specific vascular distribution Multiple regions of wall motion abnormalities
Troponin Significant elevation Mild to no elevation
NT proBNP Mild elevation Significant elevation
RV Uncommon in left heart AMI ~1/3 have biventricular ballooning
Hypotension Cardiogenic shock Multi-factorial: LVOT obstruction, peripheral vasodilation, LV and/or RV decreased inotropy
PCI Stenosis No coronary obstruction


  • Treat as STEMI until ruled out
  • Anticoagulation may be required until wall motion abnormalities resolve
  • Monitor QTc intervals and arrhythmias
    • Stop all QT prolonging drugs
    • Replete magnesium
  • Management of differs from usual cardiogenic shock[5]
    • IVF
    • With LVOT obstruction, avoid volume depletion and vasodilator therapy such as nitroglycerine (similar to hypertrophic cardiomyopathy management)
    • Inotropic medications may worsen hypotension whereas pure vasoconstriction with phenylephrine can improve MAPs
    • Consider beta blockers and ACE inhibitors, which reduce recurrence
    • Intra-aortic balloon pump or ECMO in refractory cases


  • Ejection Fraction returns to normal (at least >50%) in nearly all cases
  • Some patients experience recurrence


  • Admit for post catheterization care

See Also

External Links


  1. Sharkey, S., Lesser, J., & Maron, B. (2011). Takotsubo (stress) cardiomyopathy. American Heart Association.
  2. Park JH, Kang SJ, Song JK, et al. Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU. Chest 2005;128:296-302.
  3. http://www.thepocusatlas.com/left-ventricle-1
  4. TakotsuboMasoud H. Takotsubo Cardiomyopathy in Intensive Care Unit: Prevention, Diagnosis and Management. International Cardiovascular Forum Journal. 2016; 5:33-35.
  5. Masoud H. Takotsubo Cardiomyopathy in Intensive Care Unit: Prevention, Diagnosis and Management. International Cardiovascular Forum Journal. 2016; 5:33-35.