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Is it an Octopi or Octopuses Trap?

Drs. Zachary Landau and Benjamin Bayly present to us two patients with elevated troponin and similar patterns on bedside echo. Can you figure out what is going on here? Scroll to the bottom for an explanation!  

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A middle aged female with lighthededness after an argument 

An elderly male with dyspnea after an argument 

​Takotsubo is a syndrome of regional myocardial dysfunction thought to be caused by excessive catecholaminergic stress, typically due to an acute physical or psychological event. There is an 80% female predominance with greater than 90% of cases occurring above the age of 50. (1) Echocardiography classically demonstrates a dilated, “ballooning” akinetic or hypokinetic LV apex. At initial presentation, the clinical picture (symptoms, EKG, echo, cardiac enzymes) can be indistinguishable from acute coronary occlusion involving the apex and anterolateral walls. Therefore, suspected Takotsubo should be treated as ACS until proven otherwise. (2) If cardiac cath demonstrates widely patent coronary arteries and the regional hypokinesis resolves, the diagnosis of stress cardiomyopathy is likely present. Yet “broken heart syndrome” is not as benign as we once thought…

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  • In-hospital mortality from Takotsubo is the same as acute ST-segment-elevation MI—between 5% and 12%. (3,7)

  • Approximately 20% of patients will demonstrate hypotension and 10% will experience cardiogenic shock. (1)

  • 10% of Takotsubo patients develop dynamic left ventricular outflow obstruction. This occurs when the base of the heart becomes hyperdynamic, allowing the anterior MV leaflet to be sucked into the LVOT, potentially precipitating an obstructive shock state. (4,5)

  • 1 in 8 patients will have recurrence of Takotsubo syndrome within 5 years of the index event. (1)

  • LV thrombus occurs in approximately 5% of cases, up to 17% of which will go on to have a CVA as a consequence. (6,7)

  • Takotsubo is associated with persistent myocardial dysfunction and many patients remain symptomatic even after ejection fraction has normalized. (8)

  • Treatment of Takotsubo (once ACS has been excluded) focuses on mitigation of precipitating physiologic stressors, identification of treatable complications (LVOT obstruction, mural thrombus, etc.), and, when possible, avoidance of harmful therapies such as inotropes.

References

(1) Singh T, Khan H, Gamble DT, Scally C, Newby DE, Dawson D. Takotsubo Syndrome: Pathophysiology, Emerging Concepts, and Clinical Implications [published correction appears in Circulation. 2022 May 17;145(20):e1053. doi: 10.1161/CIR.0000000000001075]. Circulation. 2022;145(13):1002-1019. doi:10.1161/CIRCULATIONAHA.121.055854

(2) Medina de Chazal H, Del Buono MG, Keyser-Marcus L, Ma L, Moeller FG, Berrocal D, Abbate A. Stress Cardiomyopathy Diagnosis and Treatment: JACC State-of-the-Art Review. J Am Coll Cardiol. 2018 Oct 16;72(16):1955-1971. doi: 10.1016/j.jacc.2018.07.072. PMID: 30309474; PMCID: PMC7058348.

(3) Ghadri JR, Wittstein IS, Prasad A, Sharkey S, Dote K, Akashi YJ, Cammann VL, Crea F, Galiuto L, Desmet W, Yoshida T, Manfredini R, Eitel I, Kosuge M, Nef HM, Deshmukh A, Lerman A, Bossone E, Citro R, Ueyama T, Corrado D, Kurisu S, Ruschitzka F, Winchester D, Lyon AR, Omerovic E, Bax JJ, Meimoun P, Tarantini G, Rihal C, Y-Hassan S, Migliore F, Horowitz JD, Shimokawa H, Lüscher TF, Templin C. International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management. Eur Heart J. 2018 Jun 7;39(22):2047-2062. doi: 10.1093/eurheartj/ehy077. PMID: 29850820; PMCID: PMC5991205.

(4) El Mahmoud R, Mansencal N, Pilliére R, et al. Prevalence and characteristics of left ventricular outflow tract obstruction in Tako-Tsubo syndrome. Am Heart J. 2008;156(3):543-548. doi:10.1016/j.ahj.2008.05.002

(5) Di Vece D, Silverio A, Bellino M, et al. Dynamic Left Intraventricular Obstruction Phenotype in Takotsubo Syndrome. J Clin Med. 2021;10(15):3235. Published 2021 Jul 22. doi:10.3390/jcm10153235

(6) Santoro F, Stiermaier T, Tarantino N, De Gennaro L, Moeller C, Guastafierro F, Marchetti MF, Montisci R, Carapelle E, Graf T, Caldarola P, Thiele H, Di Biase M, Brunetti ND, Eitel I. Left Ventricular Thrombi in Takotsubo Syndrome: Incidence, Predictors, and Management: Results From the GEIST (German Italian Stress Cardiomyopathy) Registry. J Am Heart Assoc. 2017 Dec 4;6(12):e006990. doi: 10.1161/JAHA.117.006990. PMID: 29203578; PMCID: PMC5779019.

(7) Beckmann T, Afify H, Mattumpuram J. An incidental danger: Left ventricular thrombus in takotsubo syndrome. Glob Cardiol Sci Pract. 2023 Aug 1;2023(3):e202322. doi: 10.21542/gcsp.2023.22. PMID: 37575291; PMCID: PMC10422875.

(8) Scally C, Rudd A, Mezincescu A, et al. Persistent Long-Term Structural, Functional, and Metabolic Changes After Stress-Induced (Takotsubo) Cardiomyopathy. Circulation. 2018;137(10):1039-1048. doi:10.1161/CIRCULATIONAHA.117.031841

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