Wednesday, December 03, 2014

Takotsubo cardiomyopathy update

Here is one of many reviews on this subject.

Notable concerning this particular review:

It focuses only on apical ballooning, failing to mention the recent reports of stress associated transient basal and mid ventricular ballooning. Thus Takotsubo, a reference to the shape of a Japanese octopus trap, would not apply to all cases of the disorder leading to a recent shift to the term “stress cardiomyopathy.” The designation “inverted Takotsubo cardiomyopathy” has been used to describe some of these variants. That said, the most accepted diagnostic criteria, as cited in the review, focus on apical ballooning.

An emotional of physical stress can be cited in about two thirds of cases. Such a trigger, however, is not essential for the diagnosis.

Although acute structural neurologic processes and pheochromocytoma can cause a similar cardiomyopathy they are considered exclusions in the diagnostic criteria.

Although catecholamine toxicity is a favored mechanism, there may be others at play.

The authors state, concerning treatment:

Hemodynamically stable patients are often treated with diuretics, angiotensin-converting enzyme (ACE) inhibitors and β-blockers. To reduce the risk of thromboembolism, patients with loss of motion of the LV apex should be treated with anticoagulant therapy until the contractility of the apex is improved unless there is a definite contraindication.
There is no consensus regarding long-term management of TCM, although it is reasonable to treat patients with β-blockers and ACE inhibitors during the ventricular recovery period. However, no data support the continuous use of these drugs for the prevention of TCM recurrence or improvement of survival rate. After LV function normalizes, physicians may consider discontinuation of these drugs.

Here is some background from my previous posts on this topic:

TCM in the general spectrum of brain-body medicine.

TCM can be a mimic of anterior STEMI.

TCM can be distinguished from STEMI by comparing the magnitude of troponin elevation with the degree of LV systolic dysfunction.

TCM may be precipitated by inhaled beta agonists.

Physical stress may be a more frequent trigger than emotional stress.

Mini-review from 2013.

Electrocardiographic differentiation from acute LAD occlusion.

TCM as one of the causes of troponin elevation in critical illness.

Mechanisms. This post emphasizes acute catecholamine toxicity and the associated pathologic change (contraction band necrosis). This post is a little dated and additional mechanisms have since been suggested, though the catecholamine view still holds considerable sway.

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