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Takotsubo syndrome: A current review of presentation, diagnosis, and management

  • Monica Li
    Affiliations
    J. Willis Hurst Internal Medicine Residency Training Program, Emory University School of Medicine, Atlanta, GA, United States of America
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  • Christopher N. Nguyen
    Affiliations
    Northside Hospital Gwinnett Internal Medicine Residency Program, Lawrenceville, GA, United States of America
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  • Olga Toleva
    Affiliations
    Andreas Gruentzig Cardiovascular Center, Emory University School of Medicine, Atlanta, GA, United States of America

    Emory Women's Heart Center and Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
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  • Puja K. Mehta
    Correspondence
    Corresponding author at: 1462 Clifton Rd, Suite 505, Atlanta, GA 30322, United States of America.
    Affiliations
    Emory Women's Heart Center and Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
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      Highlights

      • Takotsubo syndrome is an acute cardiomyopathy characterized by a transient decrease in left ventricular function, which primarily affects post-menopausal women after a stressful trigger for reasons that have not been fully elucidated.
      • Takotsubo syndrome presents similarly to acute coronary syndrome, and while new guidelines emphasize that the two are not exclusive (as previously thought), it is important to distinguish them.
      • Diagnostic criteria and scoring tools created within the last several years, in addition to a variety of imaging modalities, can be helpful in diagnosing this entity.
      • Acute treatment is centered on management of heart failure, improving hemodynamics, and monitoring for arrhythmias.
      • Takotsubo syndrome is not benign and in-hospital mortality is comparable to that of acute myocardial infarction.
      • Although the majority of these patients are expected to have recovery of left ventricular function within weeks, there are patients who have persistent chest pain and recurrent events.
      • Further research on the sex differences in autonomic stress reactivity, vascular dysfunction, and underlying inflammation is needed to improve our understanding of this condition.

      Abstract

      Takotsubo syndrome is a syndrome of acute heart failure due to left ventricular systolic dysfunction that is associated with increased cardiovascular morbidity and mortality. It occurs in both sexes and at all ages, but predominates in post-menopausal women for reasons that are unclear. In a patient who presents with cardiac symptoms, electrocardiographic changes, and/or biomarker elevation indicating myocardial stress (i.e. troponin elevation), this condition should be considered in the differential diagnosis. Cardiac imaging is critical for a timely diagnosis of this condition and has management implications. This syndrome can occur with or without underlying coronary artery disease, and while there are various characteristic myocardial patterns described on imaging, the most common one is left ventricular dysfunction due to apical stunning with basal hyperkinesis. In the acute phase, Takotsubo syndrome can lead to life-threatening sequelae, including cardiogenic shock, pulmonary edema, thromboembolism, and arrhythmias. Multiple pathophysiologic mechanisms are implicated, including an acute increase in left ventricular afterload in the setting of sympathetic activation with a catecholamine storm, multi-vessel coronary vasospasm, coronary endothelial microvascular dysfunction, and inflammation. In this review, we discuss the current knowledge surrounding presentation, diagnosis, and treatment of this under-diagnosed condition.

      Keywords

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