What happens to broken hearts?
TAKOTSUBO
CARDIOMYOPATHY
TRISTAH ROMERO, BSN, RN
MSN NURSING STUDENT
ALVERNO COLLEGE
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Hover over any words which are BLUE and
underlined for further description/definition.
Objectives
By the end of the tutorial the user will be able to:



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Identify potential signs and symptoms of Takotsubo
Cardiomyopathy.
Indentify factors which contribute to the diagnosis of Takotsubo
Cardiomyopathy.
Distinguish differences between Takotsubo Cardiomyopathy and
other cardiac conditions.
Identify potential treatment/ management options for Takotsubo
Cardiomyopathy.
Review of basic concepts
Blood Flow
Chart
Heart Failure
Cardiomyopathy
Sympathetic
Nervous System
Hover over any of the images for a
description and click on it. It will link
you to a variety of sites for a refresher
of basic concepts IF needed.
Anatomy/ Structure &
Blood Flow
Cardiac Cycle
Images from Microsoft clip art & Google images
Review of basic concepts quiz
Where does blood go to immediately after leaving
the left ventricle?
Left atrium
No, that is not correct, the
blood actually came from
the left atrium to the left
ventricle.
Right ventricle
Aorta
No, that is not correct,
You are correct! This
oxygen rich blood goes
try again.
through the aorta and then out
to the body.
Review of basic concepts quiz
If the blood from the left ventricle is unable to move
through the aorta and out to the body, what will
happen?
Nothing
No, that is not correct, the
blood has to go
somewhere and if it is not
moving forward it will likely
back up and/or pool.
Blood will back up
into the lungs
Cause peripheral
edema
Yes, you are correct,
although some blood may
push out to the body, it is
likely inadequate and blood
will back up into the lungs.
No, that is not correct,
peripheral edema would be
caused by failure of the
right ventricle.
Review of basic concepts quiz
Which one of these three are more likely to turn on
the sympathetic nervous system?
Eating
Stress
Sleeping
That is not correct,
Remember the
sympathetic nervous
That is correct! Stress is
one of the many things
which could turn on the
sympathetic nervous
system.
That is not correct,
please try again.
system is “fight or flight”.
Review of basic concepts quiz
True or False, cardiomyopathy affects the hearts
ability to pump blood?
True
You are correct!
False
That is not correct. There
are many types of
cardiomyopathy but all
types affect the heart’s
ability to pump blood.
Defining Cardiomyopathy
There are many variations of cardiomyopathy. A
general definition is:
“Cardiomyopathy is a weakening of the heart muscle
or a change in the heart muscle. It often occurs when
the heart cannot pump as well as it should, or with
other heart function problems.”
- University of Maryland Medical Center, 2011
What is Takotsubo Cardiomyopathy?
Takotsubo [tah-ku-su-bu] cardiomyopathy was first
identified in Japan in the 1990’s.
In Japanese takotsubo translates into octopus pot. The shape
of the heart (during systole) resembles this pot used to trap
octopus.
Takotsubo has been called many names: broken heart
syndrome, stress cardiomyopathy, transient apical
ballooning.
Mayo Clinic (2011)
Characteristics of Takotsubo Cardiomyopathy
1.
ECG abnormalities: ST segment changes or T wave inversion.
2.
Temporary wall motion abnormality; akinesis, hypokinesis or
dyskinesis (many times of the left ventricle) contradictory to
coronary composition.
3.
Absence of obstructive coronary disease or plaque rupture.
4.
Absence of other disease/ conditions that would explain the clinical
presentation (specifically including pheochromocytoma or
myocarditis).
5.
Often a physically or emotionally stressful event just prior to onset
of symptoms.
This list is not all inclusive nor intended to serve as a diagnostic tool
Akashi, Nakazawa, Sakakibara, Miyake, Koike & Sasaka (2003)
Litvinov, Kotowycz & Wassmann (2009)
Takotsubo Cardiomyopathy
Presents similar to Acute Coronary Syndrome (ACS).
There are many names for Takotsubo Cardiomyopathy.
There are several diagnostic characteristics.
BUT…
The combination of the clinical presentation, labs,
diagnostics and the exclusion other potential causes is
what assists in the diagnosis of Takotsubo
Cardiomyopathy.
Akashi, Goldstein, Barbaro & Ueyama (2008)
Litvinov, Kotowycz & Wassmann (2009)
Defining Acute Coronary Syndrome
“The term acute coronary syndrome (ACS) is applied
to patients in whom there is suspicion of myocardial
ischemia”
- Up to date, 2011
“Acute coronary syndrome is a term used for any
condition brought on by sudden, reduced blood flow
to the heart.”
- Mayo Clinic, 2010
Population affected with Takotsubo Cardiomyopathy
 First discovered in the Japanese population.
 Studies also found Caucasians from Belgium, people in North
America, and Europe.
 One case study focused on an Italian woman.
 More commonly seen in post menopausal women.
 Has been seen in a small number of men and premenopausal
women too!
 Many times there are no risk factors or signs of coronary
disease.
Lisi, et al. (2007)
Litvinov, Kotowycz & Wassmann (2009)
Causes
The most consistent statement found regarding the
cause(s) of Takotsubo Cardiomyopathy is that it is still
unclear.
There have been many attempts to identify the cause(s) of
Takotsubo Cardiomyopathy.

One of the more promising leads is the possibility of
damage from high levels of catecholamines.
Akashi, Goldstein, Barbaro & Ueyama (2008)
Now wait a minute…
Does this sound familiar?

Examples of catecholamines are norepinephrine (NE) and epinephrine
 They are located in the Locus Ceruleus and the adrenal medulla
 They can cause an increase in:
 heart rate, cardiac contractility as well as vascular smooth muscle
contraction

Catecholamines (among many other hormones and
neurotransmitters) are important and used to:



Alert the body that there is something wrong AND
Help improve cardiovascular and metabolic function
BUT too much of something isn’t good either … ex:
SNS
Porth & Matfin, 2009
Findings on catecholamines
Some studies have found:

Left ventricular dysfunction when testing animals with the use of
catecholamines.

Patients with elevated catecholamine levels. Levels more than 5+
times the normal level.

Patients diagnosed with Takotsubo Cardiomyopathy had elevated
levels of catecholamines which were 2-3 times higher then that of
patients with myocardial infarctions (who may have already had
elevated levels of catecholamines above the normal level).
Akashi, Goldstein, Barbaro & Ueyama (2008)
Causes continued
Other proposed causes include:
o
Microvascular spasm
o
o
Stunned myocardium
o
o
Which can cause ischemia in the absence of an occlusion.
Due to elevated catecholamines which can decrease the viability of
myocytes and/ or injure the myocytes.
Temporary occlusion by atherosclerotic plaque
o
Caused by a combination of a thrombosis and narrowing of the artery that
is transient.
Virani, Khan, Mendoza, Ferreira, & de Marchena (2007)
Case Study
A 65 year old women came into the emergency room with complaints of
chest pain and shortness of breath. She was pale and diaphoretic
(sweating). Her B/P was 100/50, heart rate 120, respirations were 32.
An ECG and initial blood work was obtained. Her initial ECG showed
ST elevation. The cardiac markers from her initial blood work indicated
a slightly elevated troponin level.
Patient’s past medical history included rotator cuff repair and past
pregnancies. There was no history of any cardiac conditions. The
patient denied any tobacco or alcohol use.
Quiz
What symptoms are related to the activation of the
sympathetic nervous system?
Tachycardia
Pallor
Sweating
You are correct,
is there anything
else?
You are correct,
is there anything
else?
You are correct,
is there anything
else?
Case study continued
Upon further questioning the patient reported recently
having financial difficulties, she began to sob. She stated
she is about to lose her house, she doesn’t know how she
will pay for these medical bills and her husband had died
in a car accident just 2 weeks prior.
Further evaluation was needed
Case study continued
Finally an echocardiogram was performed and found
apical ballooning of her left ventricle. This 65 year
old women was rushed into the cardiac catheterization
lab. The cath lab found akinesis of the apical,
diaphragmatic and anterolateral portions of her left
ventricle and hyperkinesis of the basal segment.
There were no signs of occlusion or cardiac vessel
disease.
Click on the images above to view photos
Images from Microsoft clip art
Quiz
Which sign(s)/ symptom(s) from this case study potentially
could indicate Takotsubo Cardiomyopathy?
Emotional stress
You are correct, many
times there is a
significant emotionally or
physically stressful event
prior to the onset of
symptoms … is there
anything else?
Cath lab results of
apical ballooning
You are correct, with
Takotsubo Cardiomyopathy
the apical ballooning is a
more common sign along
with no signs of coronary
artery disease. Is there
anything else?
Chest pain
You are correct, this is one
of the many possible
characteristics, although
chest pain could represent
MANY other conditions: it is
the COMBINATION of
symptoms that draws a
clearer diagnosis of
Takotsubo Cardiomyopathy…
is there anything else?
Treatments/ Management
In general, management varies and is based on the
patient’s present symptoms.
There is no specific treatment regimen.
Treatment similar to that of an Acute Coronary Syndrome (ACS)

Partly because presentation is similar to that of ACS and ACS can not be
ruled out until laboratory and diagnostics are completed, combined with
signs/ symptoms the patient presents with… which then may lead to the
diagnosis of Takotsubo Cardiomyopathy.
Derrick (2009)
Litvinov, Kotowycz & Wassmann (2009)
Scharkey, Lesser, Zenovich, Maron, Lindberg, Longe & Maron (2005)
Do’s & Don'ts
Some studies have used the following treatment(s):
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Alpha and beta adrenoreceptor blockers
Diuretics for fluid overload and/or pulmonary edema
Anticoagulants for the treatment or prevention of a thrombus (controversial)
If shock occurs, to support circulation, intraaortic balloon pumping have been used
Treatments that had been avoided in prior studies:

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Vasopressors and Beta agonist
BUT why?
Derrick (2009)
Litvinov, Kotowycz & Wassmann (2009)
Scharkey, Lesser, Zenovich, Maron, Lindberg, Longe & Maron (2005)
Significance of disease
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Occurs in approximately 1-3% of suspected acute coronary syndrome
patients
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Approximately 80-90% of patient’s studied with Takotsubo
Cardiomyopathy were women

Mortality rate approximately 1%

Recovery within an estimated 4-6 weeks
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Reoccurrence has been found to be low

Complications seen in 19% of patients:

heart failure, pulmonary edema, cardiogenic shock, mitral regurgitation,
thrombus, ventricular arrhythmias, left ventricular outflow tract obstruction
Akashi, Goldstein, Barbaro & Ueyama (2008)
Derrick (2009)
Outcome/Prognosis
Prognosis is good IF the patient can overcome the initial
episode/symptoms of Takotsubo Cardiomyopathy.
Complete recovery usually occurs within several weeks of the
initial occurrence.
Recent studies indicate no signs of residual effects.
Derrick (2009)
Scharkey, Lesser, Zenovich, Maron, Lindberg, Longe & Maron (2005)
Summary
Takotsubo Cardiomyopathy presents similarly to acute coronary
syndrome (ACS), treatment path is usually similar to ACS.
It is the combination of diagnostics, labs and signs and symptoms
that can assist in leading to the diagnosis of Takotsubo
Cardiomyopathy.
It is important to recognize the signs and symptoms and act
promptly to support and provide the needed care.
The patient prognosis is good, if symptoms are managed
appropriately.
Tomich (2011)
Further research needed?
Yes, of course there is….
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
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Clearly defined cause(s) of Takotsubo Cardiomyopathy
Studies with larger number of participants
Long term outcomes
Prevalence among women versus men


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Related to hormones?
Related to anatomy?
Relationship to menopausal women

Role of estrogen in protecting the heart
And much more… let your thoughts be endless!
Virani, Khan, Mendoza, Ferreira & de Marchena (2007)
References
Akashi, Y. J., Goldstein, D. S., Barbaro, G., & Ueyama, T. (2008). Takotsubo
Cardiomyopathy: A new form of acute, reversible heart failure. Circulation. doi:
10/1161CIRCULATIONAHA.108767012
Akashi, Y. J., Nakazawa, K., Sakakibara, M., Miyake, F., Koike, H., & Sasaka, K. (2003).
The clinical features of takotsubo cardiomyopathy. QJM, 96(8), 563-573. doi:
10.1093/qjmed/hcg096
Bowne, P. S., (2004-2010). Cardiac cycle. Retrieved from
http://faculty.alverno.edu/bowneps/cardiaccycle/cardiaccycle1map.htm
Bowne, P. S., (2004). Path of Blood Flow Tutorial. Retrieved from
http://faculty.alverno.edu/bowneps/pathofbloodflow/pathmap.htm
Bowne, P. S., (2004-2010). Heart failure/ defects. Retrieved from
http://faculty.alverno.edu/bowneps/pathofbloodflow/pathproblem.htm
References continued
Bowne, P. S., (2004-2010). Sympathetic nervous system. Retrieved from
http://faculty.alverno.edu/bowneps/snsreview/snsintro.htm
Cherry, E. M., & Fenton, F. H. (n.d.) Heart structure, function and arrhythmias. Retrieved
from http://thevirtualheart.org/3dpdf/Heart_3d.pdf
Derrick, D. (2009). The “broken heart syndrome”: Understanding takotsubo
cardiomyopathy. American Association of Critical-Care Nurses, 29, 49-57. doi:
10.4037/ccn2009451
Lisi, M., et al. (2007). Takotsubo cardiomyopathy in a caucasian Italian woman: Case report.
Cardiovascular Ultrasound, 5(18). doi: 10.1186/1476-7120-5-18
Litvinov, I. V., Kotowycz, M. A., & Wassmann, S. (2009). Iatrogenic epinephrine-induced
reverse Takotsubo cardiomyopathy: direct evidence supporting the role of
catecholamines in the pathyophysiology of the “broken heart syndrome”. Clinical
Research in Cardiology, 98(7), 457-462. doi: 10.1007/soo392-009-0028-y
References continued
Mayo Clinic. (2011). Acute coronary syndrome. Retrieved from
http://www.mayoclinic.com/health/acute-coronary-syndrome/DS01061
Mayo Clinic. (2011). Broken heart syndrome. Retrieved from
http://www.mayoclinic.com/health/broken-heart-syndrome/DS01135
Porth, C., & Matfin, G. (2009). Pathophysiology Concepts of Altered Health States.
Philadelphia, PA: Lippincott Williams & Wilkins
Scharkey, W. S., Lesser, J. R., Zenovich, A. G., Maron, M. S., Lindberg, J., Longe, T. F., &
Maron, B. J. (2005). Acute reversible cardiomyopathy provoked by stress in women from
the united states. Circulation. doi. 10.1161/01.CIR.0000153801.51470.EB
Tomich, E. B. (2011). Takotsubo Cardiomyopathy. Retrieved from
http://emedicine.medscape.com/article/1513631-overview#showall
University of Maryland Medical Center. (2011). Cardiomyopathy- Overview. Retrieved from
http://www.umm.edu/ency/article/001105.htm
References continued
Up to date. (2011). Criteria for the diagnosis of acute myocardial infarction. Retrieved from
https://ive.aurora.org/contents/,DanaInfo=www.uptodate.com+criteria-for-thediagnosis-of-acute-myocardialinfarction?source=search_result&search=acute+coronary+syndrome&selectedTitle=11%
7E150
Virani, S. S., Khan, A. N., Mendoza, C. E., Ferreira, A. C., & de Marchena, E. (2007).
Takotsubo cardiomyopathy, or broken-heart syndrome. Texas Heart Institute Journal,
34(1), 76–79.
Wittstein, I. S., et al. (2005). Neurohumoral features of myocardial stunning due to sudden
emotional stress. The New England Journal of Medicine, 352(6), 539-548. doi:
10.1056/NEJMoa043046
Wikipedia. (2008). Takotsubo cardiomyopathy images. Retrieved from
http://en.wikipedia.org/wiki/Takotsubo_cardiomyopathy
ECG of patient with Takotsubo Cardiomyopathy
“ECG showing sinus tachycardia and non-specific ST and T
wave changes from a patient with confirmed Takotsubo
Cardiomyopathy”
– Wikipedia, 2008
Image from Wikipedia- used with permission
Left ventriculogram of a patient with
Takotsubo Cardiomyopathy
__
“Left ventriculogram during systole displaying the
characteristic apical ballooning with apical motionlessness
in a patient with Takotsubo Cardiomyopathy”
- Wikipedia, 2008
(A) “Schematic representation of takotsubo
cardiomyopathy”
(B) “compared to the situation in a normal person.”
- Wikepedia, 2008
Image from Wikipedia- used with permission