Curriculum in Cardiology
Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): A mimic of acute myocardial infarction

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Apical ballooning syndrome (ABS) is a unique reversible cardiomyopathy that is frequently precipitated by a stressful event and has a clinical presentation that is indistinguishable from a myocardial infarction. We review the best evidence regarding the pathophysiology, clinical features, investigation, and management of ABS. The incidence of ABS is estimated to be 1% to 2% of patients presenting with an acute myocardial infarction. The pathophysiology remains unknown, but catecholamine mediated myocardial stunning is the most favored explanation. Chest pain and dyspnea are the typical presenting symptoms. Transient ST elevation may be present on the electrocardiogram, and a small rise in cardiac troponin T is invariable. Typically, there is hypokinesis or akinesis of the mid and apical segments of the left ventricle with sparing of the basal systolic function without obstructive coronary lesions. Supportive treatment leads to spontaneous rapid recovery in nearly all patients. The prognosis is excellent, and a recurrence occurs in <10% of patients. Apical ballooning syndrome should be included in the differential diagnosis of patients with an apparent acute coronary syndrome with left ventricular regional wall motion abnormality and absence of obstructive coronary artery disease, especially in the setting of a stressful trigger.

Section snippets

Incidence

The precise incidence of ABS is unknown due to its novel nature, varied presentation, and evolving diagnostic criteria. Nevertheless, several studies have estimated that approximately 1% to 2% of all patients presenting with an initial primary diagnosis of either an acute coronary syndrome or myocardial infarction have ABS.14, 29, 30, 31, 32According to American Heart Association statistics, there are 732 000 hospital discharges with a primary diagnosis of an acute myocardial infarction in the

Age and sex

Apical ballooning syndrome is a unique cardiomyopathy in that it usually occurs in postmenopausal women. Recent review of the published case series reveals that approximately 90% of all reported cases have been in women. The mean age has ranged from 58 to 75 years, with <3% of the patients being <50 years.15, 34 The reason for the female predominance is unknown but raises the intriguing question as to whether withdrawal from estrogens contributes to the pathogenesis. It has been suggested that

Clinical presentation

The clinical presentation in most patients is indistinguishable from an acute coronary syndrome; 50% to 60% present with chest pain at rest, which has an angina-like quality. Dyspnea may also be the initial presenting symptom, but syncope or out-of-hospital cardiac arrest is rare.15, 34 Intensive care unit patients are likely to present with pulmonary edema, ischemic changes on the electrocardiogram, or elevated cardiac biomarkers. In general, hemodynamic compromise is unusual, but mild to

Electrocardiogram and cardiac biomarkers

The most common abnormality on the electrocardiogram (ECG) is ST-segment elevation, mimicking an ST-elevation myocardial infarction (STEMI).13 However, there is significant variability in the frequency (46%-100%) of this finding in the published literature.15 At least 2 reasons may account for the variability in the reported frequency of ST-segment elevation. First, the elevation is transient, and hence, the time from symptom onset to presentation may determine whether it is detected. Second,

Coronary angiogram and cardiac imaging

Most patients with ABS either have angiographically normal coronary arteries or mild atherosclerosis.15, 34 Obstructive coronary artery disease may rarely coexist by virtue of its prevalence in the population at risk.

The characteristic regional wall motion abnormalities involve hypokinesis or akinesis of the mid and apical segments of the left ventricle (Figure 3). There is sparing of the basal systolic function. Importantly, the wall motion abnormality typically extends beyond the distribution

Diagnosis

The diagnosis should be considered in the differential diagnosis of any patient with acute myocardial infarction. However, the classic situation is a postmenopausal woman presenting with chest pain or dyspnea that is temporally related to emotional or physical stress, with positive cardiac biomarkers or an abnormal electrocardiogram. Apical ballooning syndrome should also be considered in the differential diagnosis of inpatients, including those in the intensive care unit, who develop an acute

Management

Since the presentation mimics an acute coronary syndrome, initial management should be directed towards the treatment of myocardial ischemia with continuous ECG monitoring, administration of aspirin, intravenous heparin, and β-blockers. The optimal management of ABS has not been established, but supportive therapy invariably leads to spontaneous recovery. Once the diagnosis has been made, aspirin can be discontinued unless there is coexisting coronary atherosclerosis. The efficacy of β-blocker

Prognosis

The systolic dysfunction and the regional wall motion abnormalities are transient and resolve completely within a matter of days to a few weeks. In our experience14 and in other large series,13, 16, 25 complete recovery is seen in virtually all patients by 4 to 8 weeks. This is such a uniform finding that an alternative diagnosis should be considered in patients in whom the cardiomyopathy does not resolve. Patients with ABS generally have a good prognosis in the absence of significant

Pathophysiology

The pathophysiology of ABS is not well understood. Several mechanisms for the reversible cardiomyopathy have been proposed, including catecholamine-induced myocardial stunning, ischemia-mediated stunning due to multivessel epicardial or microvascular spasm, and myocarditis (Figure 5). Myocarditis is extremely unlikely to be the mechanism since studies reporting endomyocardial biopsy data have consistently shown the absence of myocarditis.17, 24, 58, 59 Furthermore, cardiac magnetic resonance

Controversies

There is debate over the most suitable nomenclature for ABS.71, 72 Tako-Tsubo cardiomyopathy12 and ABS13 were the original names proposed by the Japanese. Most non-Japanese-speaking physicians are not familiar with the meaning of Tako-Tsubo. Apical ballooning syndrome has become popular because it is descriptive of the appearance of the left ventricle. However, ABS does not account for the less common variants. Some have favored using stress cardiomyopathy or neurogenic stunning.71 These

Conclusions

Apical ballooning syndrome is a distinctive reversible cardiomyopathy that mimics an acute coronary syndrome. It should be included in the differential diagnosis of patients with an apparent acute coronary syndrome with regional wall motion abnormality and absence of obstructive coronary artery disease.

One of the hallmarks of ABS is that it is almost exclusively seen in postmenopausal women. This is unique to the medical field and warrants further investigation regarding the potential

References (82)

  • R. Pilliere et al.

    Prevalence of Tako-Tsubo syndrome in a large urban agglomeration

    Am J Cardiol

    (2006)
  • G. Parodi et al.

    Incidence, clinical findings, and outcome of women with left ventricular apical ballooning syndrome

    Am J Cardiol

    (2007)
  • S. Azzarelli et al.

    Clinical features of transient left ventricular apical ballooning

    Am J Cardiol

    (2006)
  • A. Elesber et al.

    Four-year recurrence rate and prognosis of the apical ballooning syndrome

    J Am Coll Cardiol

    (2007)
  • K. Matsuoka et al.

    Evaluation of the arrhythmogenecity of stress-induced “Takotsubo cardiomyopathy” from the time course of the 12-lead surface electrocardiogram

    Am J Cardiol

    (2003)
  • A. Elesber et al.

    Transient cardiac apical ballooning syndrome: prevalence and clinical implications of right ventricular involvement

    J Am Coll Cardiol

    (2006)
  • R.T. Hurst et al.

    Transient midventricular ballooning syndrome: a new variant

    J Am Coll Cardiol

    (2006)
  • S.O. Van de Walle et al.

    Transient stress-induced cardiomyopathy with an “inverted Takotsubo” contractile pattern

    Mayo Clin Proceed

    (2006)
  • J.H. Park et al.

    Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU

    Chest

    (2005)
  • G. Parodi et al.

    Tuscany Registry of Tako-Tsubo Cardiomyopathy. Left ventricular apical ballooning syndrome as a novel cause of acute mitral regurgitation

    J Am Coll Cardiol

    (2007)
  • Y. Ohba et al.

    Takotsubo cardiomyopathy with left ventricular outflow tract obstruction

    Int J Cardiol

    (2006)
  • S. Kurisu et al.

    Tako-Tsubo–like left ventricular dysfunction with ST segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction

    Am Heart J

    (2002)
  • A. Elesber et al.

    Myocardial perfusion in apical ballooning syndrome. Correlate of myocardial injury

    Am Heart J

    (2006)
  • K.A. Bybee et al.

    Acute impairment of regional myocardial glucose metabolism in the transient left ventricular apical ballooning (Tako-Tsubo) syndrome

    J Nucl Cardiol

    (2006)
  • S. Kurisu et al.

    Myocardial perfusion and fatty acid metabolism in patients with Tako-Tsubo–like left ventricular dysfunction

    J Am Coll Cardiol

    (2003)
  • S.W. Sharkey et al.

    Stress cardiomyopathy

    J Am Coll Cardiol

    (2007)
  • G. Parodi

    Transient left ventricular apical ballooning—the need for a common terminology

    Int J Cardiol

    (2007)
  • B. Ibanez et al.

    Tako-tsubo syndrome: a Bayesian approach to interpreting its pathogenesis

    Mayo Clin Proceed

    (2006)
  • S. Arora et al.

    Transient left ventricular apical ballooning after cocaine use: is catecholamine cardiotoxicity the pathologic link?

    Mayo Clin Proc

    (2006)
  • J.M. Rivera et al.

    “Broken heart syndrome” after separation (from OxyContin)

    Mayo Clin Proc

    (2006)
  • T. Dorfman et al.

    Takotsubo cardiomyopathy induced by treadmill exercise testing: an insight into the pathophysiology of transient left ventricular apical (or midventricular) ballooning in the absence of obstructive coronary artery

    J Am Coll Cardiol

    (2007)
  • S.N. Willich et al.

    Sudden cardiac death. Support for a role of triggering in causation

    Circulation

    (1993)
  • D.R. Witte et al.

    Cardiovascular mortality in Dutch men during 1996 European football championship: longitudinal population study

    BMJ

    (2000)
  • M. Baumhakel et al.

    Soccer world championship: a challenge for the cardiologist

    Eur Heart J

    (2007)
  • P.A. Grayburn et al.

    Cardiac events in patients undergoing noncardiac surgery: shifting the paradigm from noninvasive risk stratification to therapy

    Ann Intern Med

    (2003)
  • M. Ruiz Bailen et al.

    Reversible myocardial dysfunction, a possible complication in critically ill patients without heart disease

    J Crit Care

    (2003)
  • T. Kono et al.

    Left ventricular wall motion abnormalities in patients with subarachnoid hemorrhage: neurogenic stunned myocardium

    J Am Coll Cardiol

    (1994)
  • S.A. Mayer et al.

    Cardiac injury associated with neurogenic pulmonary edema following subarachnoid hemorrhage

    Neurology

    (1994)
  • H. Sato et al.

    Tako-Tsubo–like left ventricular dysfunction due to multivessel coronary spasm

  • K.A. Bybee et al.

    Transient left ventricular apical ballooning syndrome: a mimic of ST-segment elevation myocardial infarction

    Ann Intern Med

    (2004)
  • S.W. Sharkey et al.

    Acute and reversible cardiomyopathy provoked by stress in women from the United States

    Circulation

    (2005)
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