Takotsubo cardiomyopathy: diagnosis in an emergency department

Abstract

Takotsubo cardiomyopathy (TC) is a reversible cardiomyopathy characterized by transient wall-motion abnormalities of the left ventricle (LV) in the absence of significant obstructive coronary disease. In emergency departments the diagnosis remains a challenge because clinical and electrocardiographic presentation of Takotsubo is quite similar to ST-segment elevation myocardial infarction. We conducted a retrospective descriptive study on 1654 patients admitted to our emergency department from 2006 to 2009 who had a left heart catheterization for a suspected acute coronary syndrome and among them we evaluated characteristics on admission of 14 patients with a clinical picture suggestive for a TC. All patients were postmenopausal female. Ten patients (71%) had preceding stressful events and four patients (29%) did not have identifiable stressors. Thirteen patients (93%) presented chest pain and one (7%) syncope. ST-segment elevation was present in six patients (43%). One patient (7%) presented an episode of ventricular fibrillation. All patients presented increased cardiac Troponin T. Initial LV ejection fraction, evaluated by transthoracic echocardiography was 44±10%. Follow-up LV ejection fraction was 61±10%. Six patients (43%) had characteristic apical ballooning and eight patients (57%) had hypokinesia or akinesia of the apical or/and midventricular region of the LV without ballooning. Coronary angiography was normal in nine patients (64%) and five (36%) had stenosis <50%. None had complete obstruction of a coronary. Takotsubo syndrome should be considered as a possible diagnosis in patients admitted in an emergency department with a suspected diagnosis of acute coronary syndrome. Emergency physicians should recognize salient aspects of the medical history at presentation in order to organize appropriate investigations and avoid inappropriate therapies.