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