Takotsubo Syndrome: Optimizing Care with a Multidisciplinary Approach

Figures & data

Box 1 Mayo Clinic Criteria for TTS

1. Transient hypokinesis, akinesis, or dyskinesis of the LV midsegments with or without apical involvement; the regional WMAs extend beyond a single epicardial vascular distribution; a stressful trigger is often but not always present.

2. Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture.

3. New ECG abnormalities (either ST-segment elevation and/or T-wave inversion) or modest elevation in cardiac troponin.

4. Absence of pheochromocytoma and myocarditis.

Notes: Reprinted from Am Heart J. 155(3), Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J. 2008;155(3):408–417, Copyright (2008), with permission from Elsevier.⁴²

Abbreviations: ACS, acute coronary syndrome; ECG, electrocardiography; LV, left ventricular, TTS, Takotsubo syndrome; WMA, wall motion abnormality.

Box 2 Heart Failure Association Diagnostic Criteria for TTS

1. Transient regional WMAs of the LV or RV myocardium that are frequently, but not always, preceded by a stressful trigger (emotional or physical).

2. The regional WMAs usually extend beyond a single epicardial vascular distribution and often result in circumferential dysfunction of the ventricular segments involved.

3. Absence of atherosclerotic coronary artery diseases including acute plaque rupture, thrombus formation, and coronary dissection or other pathological conditions, that explain the pattern of temporary LV dysfunction observed (eg, hypertrophic cardiomyopathy, viral myocarditis).

4. New and reversible ECG abnormalities (ST-segment elevation, ST depression, LBBB, T-wave inversion, and/or long QTc) occur during the acute phase (3 months).

5. Serum BNP or NT-proBNP levels are significantly elevated during the acute phase.

6. Cardiac troponin measured by a conventional assay is positive but at a relatively small elevation (ie, disparity between the troponin level and the amount of dysfunctional myocardium present).

7. Recovery of ventricular systolic function on cardiac imaging at follow-up (3–6 months).

Notes: Reprinted from Lyon AR, Bossone E, Schneider B, et al. Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2016;18(1):8–27. © 2015 The Authors European Journal of Heart Failure © 2015 European Society of Cardiology. ⁴⁶

Abbreviations: ECG, electrocardiography; LBBB, left bundle branch block; LV, left ventricle; RV, right ventricle; TTS, Takotsubo syndrome; WMA, wall motion abnormality.

Box 3 International Takotsubo Diagnostic Criteria (InterTAK Diagnostic Criteria)

1. Patients show transient LV dysfunction (hypokinesia, akinesia, or dyskinesia) presenting as apical ballooning or midventricular, basal, or focal WMAs. RV involvement can be present. Aside from these regional wall-motion patterns, transitions between all types can exist. The regional WMA usually extends beyond a single epicardial vascular distribution; however, rare cases can exist wherein the regional WMA is present in the subtended myocardial territory of a single coronary artery (focal TTS).

2. An emotional, physical, or combined stress can precede the TTS event but is not obligatory.

3. Neurological disorders as well as pheochromocytoma may serve as triggers of TTS.

4. New ECG abnormalities are present (ST-segment elevation, ST-segment depression, T-wave inversion, and QTc prolongation); however, rare cases exist without any ECG changes.

5. The levels of cardiac biomarkers (troponin and creatine kinase) are moderately elevated in most cases; significant elevation of brain natriuretic peptide is common.

6. Significant coronary artery disease is not a contradiction in TTS.

7. Patients have no evidence of infectious myocarditis.

8. Postmenopausal women are predominantly affected.

Note: Reprinted from Ghadri JR, Wittstein IS, Prasad A, et al. International Expert Consensus Document on Takotsubo Syndrome (Part I): clinical Characteristics, Diagnostic Criteria, and Pathophysiology. Eur Heart J. 2018;39(22):2032–2046. Creative Commons license and disclaimer available from http://creativecommons.org/licenses/by-nc/4.0/.²⁷

Abbreviations: ECG, electrocardiography; TTS, Takotsubo syndrome; WMAs, wall motion abnormalities.

Table 1 Important Signs in TTS Patients Indicating a Need for Consultation with Specialists

Specialist Consulted	Acute Phase	Chronic Phase
Neurologist	Acute stroke symptoms; Seizure	Memory deficits
Psychiatrist	Preexisting psychiatric illness; Taking psychiatric medication	No apparent physical and emotional stress before onset; Psychiatric symptoms
Oncologist	Past history of chemotherapy	Positive for screening test of cancer
Other specialists	COVID-19	Remarkable past history

Notes: Remarkable past history includes COPD, asthma, a pulmonary circulatory disorder, hyper- or hypothyroidism, alcohol abuse, drug abuse, surgery, chronic connective tissue disease, chronic liver disease, chronic kidney disease, sexual intercourse,⁹⁸ and pregnancy.

Abbreviation: COVID-19, coronavirus disease 2019.

Figure 1 TTS following autoimmune limbic encephalitis. (A and B) Left ventriculographic findings. The diastole (A) and systole (B) images are shown. (C and D) MRI findings. The initial MRI (C) revealed abnormal hyperintense areas (arrows) in the bilateral medial temporal lobes on the fluid-attenuated inversion recovery image (left). Diffusion-weighted imaging (middle) and an apparent diffusion coefficient map (right) both revealed abnormal hyperintensity in these areas. The abnormalities were all resolved in follow-up MRI (D).

Notes: Reproduced from Kakinuma Y, Kimura T, Sakae Y, Kubota S, Ono K, Kinno R. Takotsubo syndrome associated with autoimmune limbic encephalitis: a case report. BMC Cardiovasc Disord. 2021;21(1):86. Creative Commons license and disclaimer available from: http://creativecommons.org/licenses/by/4.0/legalcode.⁶⁵.

Abbreviation: MRI, magnetic resonance imaging.

Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J. 2008;155(3):408–417. doi:10.1016/j.ahj.2007.11.008

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Lyon AR, Bossone E, Schneider B, et al. Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2016;18(1):8–27. doi:10.1002/ejhf.424

 PubMed Web of Science ®Google Scholar

Ghadri JR, Wittstein IS, Prasad A, et al. International Expert Consensus Document on Takotsubo Syndrome (Part I): clinical Characteristics, Diagnostic Criteria, and Pathophysiology. Eur Heart J. 2018;39(22):2032–2046. doi:10.1093/eurheartj/ehy076

 PubMed Web of Science ®Google Scholar

Mathew B, Villarreal D. Two unusual cases of Takotsubo cardiomyopathy presenting with sudden cardiac death. Am J Med Sci. 2009;337(6):473–475. doi:10.1097/MAJ.0b013e3181956f49

 Web of Science ®Google Scholar

Kakinuma Y, Kimura T, Sakae Y, Kubota S, Ono K, Kinno R. Takotsubo syndrome associated with autoimmune limbic encephalitis: a case report. BMC Cardiovasc Disord. 2021;21(1):86. doi:10.1186/s12872-020-01789-3

 Web of Science ®Google Scholar