Takotsubo Cardiomyopathy: Current Treatment

Abstract

Management of takotsubo syndrome (TTS) is currently empirical and supportive, via extrapolation of therapeutic principles worked out for other cardiovascular pathologies. Although it has been emphasized that such non-specific therapies for TTS are consequent to its still elusive pathophysiology, one wonders whether it does not necessarily follow that the absence of knowledge of TTS’ pathophysiological underpinnings should prevent us for searching, designing, or even finding, therapies efficacious for its management. Additionally, it is conceivable that therapy for TTS may be in response to pathophysiological/pathoanatomic/pathohistological consequences (e.g., “myocardial stunning/reperfusion injury”), common to both TTS and coronary artery disease, or other cardiovascular disorders). The present review outlines the whole range of management principles of TTS during its acute phase and at follow-up, including considerations pertaining to the recurrence of TTS, and commences with the idea that occasionally management of TTS should consist of mere observation along the “first do no harm” principle, while self-healing is under way. Finally, some new therapeutic hypotheses (i.e., large doses of insulin infusions in association with the employment of intravenous short- and ultrashort-acting β-blockers) are being entertained, based on previous extensive animal work and limited application in patients with neurogenic cardiomyopathy and TTS.

Pretreatment with Betablockers, a Potential Predictor of Adverse Cardiovascular Events in Takotsubo Syndrome

“…Betablockers are used as an evidence-based treatment for heart failure with reduced ejection fraction (HFrEF), ACS, anginal symptoms, and prevention of sudden cardiac death [ 7 , 8 , 9 , 10 ]. However, based on the analysis of retrospective studies, the use of betablockers in the short- and long-term management of TTS patients remains controversial [ 11 ]. There is some evidence for beneficial effects of short acting betablockers in the presence of hemodynamic relevant left ventricular outflow tract obstruction (LVOT) [ 12 ].…”

Anesthesia/surgery‐triggered takotsubo syndrome: A dearth of specific knowledge on its pathophysiology and therapy

“…3-5 (6) Regarding the choice of β-blockers, esmolol (short-acting), and landiolol (ultrashort-acting) β-blockers are recommended, since these two drugs have a half-life of just a few minutes, and if their use is met with side effects or any undesirable consequences, their dose can be reduced or they can be discontinued without impunity. [3][4][5][6]…”

“…1 of their paper, which are typical of ECG hyperacute ischemic changes, inducing the merging of the QRS and ST-segment, a pattern resembling ventricular tachycardia (VT), which is not VT. 2 (4) The authors did not report the presence of left ventricular (LV) outflow tract obstruction, but even in its absence, intra-aortic balloon pump (IABP) is currently discouraged in the management of patients with TTS, while extracorporeal membrane oxygenation (ECMO) and/or LV assist devices are recommended. [3][4][5] (5) There are some emerging insights that catecholamines and vasopressor medications should be avoided in patients with TTS, or at risk of developing TTS, particularly when hypotension is associated with adequate organ perfusion due to peripheral vasodilation and reduced peripheral vascular resistance, 3 and instead we should aim for fluid volume expansion, use of β-blockers, and if needed employment of mechanical circulatory support (not IABP) and ECMO. 3-5 (6) Regarding the choice of β-blockers, esmolol (short-acting), and landiolol (ultrashort-acting) β-blockers are recommended, since these two drugs have a half-life of just a few minutes, and if their use is met with side effects or any undesirable consequences, their dose can be reduced or they can be discontinued without impunity.…”

Fentanyl for the prevention and management of Takotsubo syndrome

“…In such a state, it is paramount that we ensure that the patients are optimally “volumized,” and such assessment should be evaluated by minute to minute invasive monitoring by the anesthesiologists or intensivists. Resorting to the implementation of left ventricular assist devices and/or extracorporeal membrane oxygenation is advisable, and it should be employed before the patients’ state becomes unmanageable 5 . Administration of inotropic and vasoactive catecholamines (e.g., epinephrine, norepinephrine, dopamine, dobutamine) or catecholamine‐like (e.g., isoproterenol, metaraminol, phenylephrine) drugs often becomes inevitable, and what we need herein is to take advantage of information available in the patients’ electronic records, including the anesthesia records, as to which of such drugs result in hemodynamic improvement without triggering TTS.…”

“…Accordingly, various preventive/therapeutic schemata for periprocedural/perioperative management of TTS have been proposed, and have been recently summarized. [2][3][4][5] This author has advocated the avoidance of catecholamine-based inotropic and vasoactive drug employment in the perioperative period, as much as it is possible, considering the daunting states we are facing, when our patients become hypotensive, and slip into heart failure or cardiogenic shock, with total body organ hypoperfusion. 5 In such a state, it is paramount that we ensure that the patients are optimally "volumized," and such assessment should be evaluated by minute to minute invasive monitoring by the anesthesiologists or intensivists.…”