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Transient Stress Cardiomyopathy

Transient Stress Cardiomyopathy is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Transient stress cardiomyopathy (TSC) is a unique cause of reversible left ventricle (LV) dysfunction with a presentation indistinguishable from the acute coronary syndromes (ACSs), particularly ST-segment elevation myocardial infarction (MI) (1).
  • Typically, the patient is a postmenopausal woman who presents with acute chest pain or dyspnea after an identifiable “trigger” (i.e., an acute emotional or physiologic stressor).
  • First reported by authors from Japan, TSC was known initially as the takotsubo syndrome because the typical LV morphology (i.e., apical ballooning) resembled that of a Japanese octopus trap or takotsubo.
  • Presenting clinical features include the following:
    • Chest symptoms and/or dyspnea
    • ECG changes, including ST-segment elevations or diffuse T-wave inversions
    • Mild elevation in cardiac biomarkers (creatine kinase [CK], troponin)
    • Transient wall motion abnormalities that may involve the base, midportion, and/or lateral walls of the LV.
    • The apex of the right ventricle (RV) may be affected in up to 25% of cases (2)[B].
  • Clinical features may vary on a case-by-case basis, and formal diagnostic criteria have not been established.
  • Authors from the Mayo Clinic have proposed that 3 of the 4 following criteria establish the diagnosis (1)[A]:
    • Transient akinesis or dyskinesis of the LV apical and midventricular segments with regional wall motion abnormalities extending beyond a single epicardial vascular distribution
    • Absence of obstructive coronary artery disease (CAD) or angiographic evidence of acute plaque rupture
    • New ECG abnormalities, either ST-segment elevation or T-wave inversion
    • Absence of
      • Recent significant head trauma
      • Intracranial bleeding
      • Pheochromocytoma
      • Obstructive epicardial CAD
      • Myocarditis
      • Hypertrophic cardiomyopathy
  • Synonym(s): takotsubo cardiomyopathy; apical ballooning syndrome; stress cardiomyopathy; broken heart syndrome; ampulla cardiomyopathy

Epidemiology

Incidence
  • TSC accounts for a small percentage (1–3%) of ACS.
  • In a recent prospective evaluation of patients admitted to the ICU, as many as 28% had apical ballooning, often in association with sepsis.
  • Predominant sex: 82–100% of cases occur in women.
  • Predominant age: Mean age of patients is 62 to 75 years.

Prevalence
2.2% of patients presenting to a referral hospital with ST-segment MIs were found to have TSC.

Etiology and Pathophysiology

  • The exact pathophysiology is not known.
  • A perturbation in the brain–heart axis, originating in the insular cortex, may be the inciting event (3).
  • Subsequent overwhelming activation of the sympathetic nervous system initiates a cascade of events, including the following:
    • Catecholamine-induced LV dysfunction: “biased agonism” of epinephrine for β2-adrenergic receptors, located predominantly at the cardiac apex
    • Endothelial dysfunction and vasospasm
    • Cellular metabolic injury
      • Myocardial norepinephrine release
      • Calcium overload
      • Contraction band necrosis

Genetics
No genetic associations have been described to date.

Risk Factors

  • Female sex
  • Postmenopausal state
  • Emotional stress (i.e., argument, death of family member)
  • Physiologic stress (i.e., acute medical illness)
  • Chronic neurologic or psychiatric disease (3)

Commonly Associated Conditions

Death from TSC is rare, and most cases resolve rapidly, within 2 to 3 days. Reported complications include:

  • Left-sided heart failure
  • Pulmonary edema
  • Cardiogenic shock and hemodynamic compromise
  • Dynamic LV outflow tract gradient complicated by hypotension
  • Mitral regurgitation
  • Ventricular arrhythmias
  • LV thrombus formation
  • LV free wall rupture
  • Death (rare, 0–8%)

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Citation

Stephens, Mark B., et al., editors. "Transient Stress Cardiomyopathy." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117474/all/Transient_Stress_Cardiomyopathy.
Transient Stress Cardiomyopathy. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117474/all/Transient_Stress_Cardiomyopathy. Accessed April 24, 2019.
Transient Stress Cardiomyopathy. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117474/all/Transient_Stress_Cardiomyopathy
Transient Stress Cardiomyopathy [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 24]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117474/all/Transient_Stress_Cardiomyopathy.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Transient Stress Cardiomyopathy ID - 117474 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117474/all/Transient_Stress_Cardiomyopathy PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -