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Cardiac
Diagnosis
Heart Failure and Cardiomyopathies
Takotsubo Cardiomyopathy
Takotsubo Cardiomyopathy
Sanjeev A. Francis, MD, FACC
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KEY FACTS

  • Terminology

    • Imaging

      • Clinical Issues

        TERMINOLOGY

        • Synonyms

          • Stress-induced cardiomyopathy
          • Apical ballooning syndrome

        • Definitions

          • Reversible dysfunction of left ventricle (LV) in absence of significant coronary artery stenosis
            • Classically described following periods of severe emotional or physical stress
              • In recent prospective multicenter study, stressful trigger was identified in ~ 70% of patients
            • Often accompanied by acute chest pain, ischemic ST segment abnormalities, and elevation of cardiac biomarkers

        IMAGING

        • General Features

          • Imaging Recommendations

            • Nuclear Medicine Findings

              • CT Findings

                • MR Findings

                  • Echocardiographic Findings

                    • Angiographic Findings

                      • Image-Guided Biopsy

                        DIFFERENTIAL DIAGNOSIS

                          PATHOLOGY

                          • General Features

                            • Microscopic Features

                              CLINICAL ISSUES

                              • Presentation

                                • Demographics

                                  • Natural History & Prognosis

                                    • Treatment

                                      DIAGNOSTIC CHECKLIST

                                      • Consider

                                        • Image Interpretation Pearls

                                          Selected References

                                          1. Citro R et al: Long-term outcome in patients with Takotsubo syndrome presenting with severely reduced left ventricular ejection fraction. Eur J Heart Fail. ePub, 2019
                                          2. Templin C et al: Altered limbic and autonomic processing supports brain-heart axis in Takotsubo syndrome. Eur Heart J. ePub, 2019
                                          3. Scally C et al: Persistent long-term structural, functional, and metabolic changes after stress-induced (Takotsubo) cardiomyopathy. Circulation. 137(10):1039-48, 2018
                                          4. Abbas A et al: Cardiac magnetic resonance assessment of takotsubo cardiomyopathy. Clin Radiol. 71(1):e110-9, 2016
                                          5. Plácido R et al: The role of cardiovascular magnetic resonance in takotsubo syndrome. J Cardiovasc Magn Reson. 18(1):68, 2016
                                          6. Rajiah P et al: Update on the role of cardiac magnetic resonance in acquired nonischemic cardiomyopathies. J Thorac Imaging. 31(6):348-66, 2016
                                          7. Garg P et al: Important role of myocardial tissue characterization by cardiac MRI in diagnosing Takotsubo syndrome. Nat Rev Cardiol. 12(11):669, 2015
                                          8. Kohan AA et al: Usefulness of MRI in takotsubo cardiomyopathy: a review of the literature. Cardiovasc Diagn Ther. 4(2):138-46, 2014
                                          9. Nakamori S et al: Prevalence and signal characteristics of late gadolinium enhancement on contrast-enhanced magnetic resonance imaging in patients with takotsubo cardiomyopathy. Circ J. 76(4):914-21, 2012
                                          10. Eitel I et al: Clinical characteristics and cardiovascular magnetic resonance findings in stress (takotsubo) cardiomyopathy. JAMA. 306(3):277-86, 2011
                                          11. King A: Cardiomyopathies: CMR sheds new light on the clinical profile of stress cardiomyopathy. Nat Rev Cardiol. 8(9):480, 2011
                                          12. Naruse Y et al: The clinical impact of late gadolinium enhancement in Takotsubo cardiomyopathy: serial analysis of cardiovascular magnetic resonance images. J Cardiovasc Magn Reson. 13:67, 2011
                                          13. Bellera MN et al: Magnetic resonance reveals long-term sequelae of apical ballooning syndrome. Int J Cardiol. 139(1):25-31, 2010
                                          14. Hurst RT et al: Takotsubo cardiomyopathy: a unique cardiomyopathy with variable ventricular morphology. JACC Cardiovasc Imaging. 3(6):641-9, 2010
                                          15. Sharkey SW et al: Natural history and expansive clinical profile of stress (tako-tsubo) cardiomyopathy. J Am Coll Cardiol. 55(4):333-41, 2010
                                          16. Celik T et al: Stress-induced (Takotsubo) cardiomyopathy: a transient disorder. Int J Cardiol. 131(2):265-6, 2009
                                          17. Kurisu S et al: Prevalence of incidental coronary artery disease in tako-tsubo cardiomyopathy. Coron Artery Dis. 20(3):214-8, 2009
                                          18. Rolf A et al: Immunohistological basis of the late gadolinium enhancement phenomenon in tako-tsubo cardiomyopathy. Eur Heart J. 30(13):1635-42, 2009
                                          19. Dorfman TA et al: An unusual manifestation of Takotsubo cardiomyopathy. Clin Cardiol. 31(5):194-200, 2008
                                          20. Arora S: Autonomic imbalance in patients with takotsubo cardiomyopathy: cause or association? QJM. 100(9):593-4; author reply 594-6, 2007
                                          21. Cocco G et al: Stress-induced cardiomyopathy: a review. Eur J Intern Med. 18(5):369-79, 2007
                                          22. Haghi D et al: Guidelines for diagnosis of takotsubo (ampulla) cardiomyopathy. Circ J. 71(10):1664; author reply 1665, 2007
                                          23. Kawai S: Typical and atypical forms of takotsubo (ampulla) cardiomyopathy. Circ J. 71(10):1665, 2007
                                          24. Kimura K et al: Images in cardiovascular medicine. Rapid formation of left ventricular giant thrombus with Takotsubo cardiomyopathy. Circulation. 115(23):e620-1, 2007
                                          25. Matsuzaki M: Stress 'Takotsubo' cardiomyopathy: questions still remain. Nat Clin Pract Cardiovasc Med. 4(11):577, 2007
                                          26. Nanda S et al: Takotsubo cardiomyopathy--a new variant and widening disease spectrum. Int J Cardiol. 120(2):e34-6, 2007
                                          27. Pilgrim TM et al: Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: A systematic review. Int J Cardiol. 2007
                                          28. Gianni M et al: Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J. 27(13):1523-9, 2006
                                          29. Iqbal MB et al: Stress, emotion and the heart: tako-tsubo cardiomyopathy. Postgrad Med J. 82(974):e29, 2006
                                          30. Bybee KA et al: Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med. 141(11):858-65, 2004
                                          31. Ito T et al: Development of pulmonary neuroendocrine cells of fetal hamster in explant culture. Lab Invest. 77(5):449-57, 1997
                                          Related Anatomy
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                                          Related Differential Diagnoses
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                                          References
                                          Tables

                                          Tables

                                          KEY FACTS

                                          • Terminology

                                            • Imaging

                                              • Clinical Issues

                                                TERMINOLOGY

                                                • Synonyms

                                                  • Stress-induced cardiomyopathy
                                                  • Apical ballooning syndrome

                                                • Definitions

                                                  • Reversible dysfunction of left ventricle (LV) in absence of significant coronary artery stenosis
                                                    • Classically described following periods of severe emotional or physical stress
                                                      • In recent prospective multicenter study, stressful trigger was identified in ~ 70% of patients
                                                    • Often accompanied by acute chest pain, ischemic ST segment abnormalities, and elevation of cardiac biomarkers

                                                IMAGING

                                                • General Features

                                                  • Imaging Recommendations

                                                    • Nuclear Medicine Findings

                                                      • CT Findings

                                                        • MR Findings

                                                          • Echocardiographic Findings

                                                            • Angiographic Findings

                                                              • Image-Guided Biopsy

                                                                DIFFERENTIAL DIAGNOSIS

                                                                  PATHOLOGY

                                                                  • General Features

                                                                    • Microscopic Features

                                                                      CLINICAL ISSUES

                                                                      • Presentation

                                                                        • Demographics

                                                                          • Natural History & Prognosis

                                                                            • Treatment

                                                                              DIAGNOSTIC CHECKLIST

                                                                              • Consider

                                                                                • Image Interpretation Pearls

                                                                                  Selected References

                                                                                  1. Citro R et al: Long-term outcome in patients with Takotsubo syndrome presenting with severely reduced left ventricular ejection fraction. Eur J Heart Fail. ePub, 2019
                                                                                  2. Templin C et al: Altered limbic and autonomic processing supports brain-heart axis in Takotsubo syndrome. Eur Heart J. ePub, 2019
                                                                                  3. Scally C et al: Persistent long-term structural, functional, and metabolic changes after stress-induced (Takotsubo) cardiomyopathy. Circulation. 137(10):1039-48, 2018
                                                                                  4. Abbas A et al: Cardiac magnetic resonance assessment of takotsubo cardiomyopathy. Clin Radiol. 71(1):e110-9, 2016
                                                                                  5. Plácido R et al: The role of cardiovascular magnetic resonance in takotsubo syndrome. J Cardiovasc Magn Reson. 18(1):68, 2016
                                                                                  6. Rajiah P et al: Update on the role of cardiac magnetic resonance in acquired nonischemic cardiomyopathies. J Thorac Imaging. 31(6):348-66, 2016
                                                                                  7. Garg P et al: Important role of myocardial tissue characterization by cardiac MRI in diagnosing Takotsubo syndrome. Nat Rev Cardiol. 12(11):669, 2015
                                                                                  8. Kohan AA et al: Usefulness of MRI in takotsubo cardiomyopathy: a review of the literature. Cardiovasc Diagn Ther. 4(2):138-46, 2014
                                                                                  9. Nakamori S et al: Prevalence and signal characteristics of late gadolinium enhancement on contrast-enhanced magnetic resonance imaging in patients with takotsubo cardiomyopathy. Circ J. 76(4):914-21, 2012
                                                                                  10. Eitel I et al: Clinical characteristics and cardiovascular magnetic resonance findings in stress (takotsubo) cardiomyopathy. JAMA. 306(3):277-86, 2011
                                                                                  11. King A: Cardiomyopathies: CMR sheds new light on the clinical profile of stress cardiomyopathy. Nat Rev Cardiol. 8(9):480, 2011
                                                                                  12. Naruse Y et al: The clinical impact of late gadolinium enhancement in Takotsubo cardiomyopathy: serial analysis of cardiovascular magnetic resonance images. J Cardiovasc Magn Reson. 13:67, 2011
                                                                                  13. Bellera MN et al: Magnetic resonance reveals long-term sequelae of apical ballooning syndrome. Int J Cardiol. 139(1):25-31, 2010
                                                                                  14. Hurst RT et al: Takotsubo cardiomyopathy: a unique cardiomyopathy with variable ventricular morphology. JACC Cardiovasc Imaging. 3(6):641-9, 2010
                                                                                  15. Sharkey SW et al: Natural history and expansive clinical profile of stress (tako-tsubo) cardiomyopathy. J Am Coll Cardiol. 55(4):333-41, 2010
                                                                                  16. Celik T et al: Stress-induced (Takotsubo) cardiomyopathy: a transient disorder. Int J Cardiol. 131(2):265-6, 2009
                                                                                  17. Kurisu S et al: Prevalence of incidental coronary artery disease in tako-tsubo cardiomyopathy. Coron Artery Dis. 20(3):214-8, 2009
                                                                                  18. Rolf A et al: Immunohistological basis of the late gadolinium enhancement phenomenon in tako-tsubo cardiomyopathy. Eur Heart J. 30(13):1635-42, 2009
                                                                                  19. Dorfman TA et al: An unusual manifestation of Takotsubo cardiomyopathy. Clin Cardiol. 31(5):194-200, 2008
                                                                                  20. Arora S: Autonomic imbalance in patients with takotsubo cardiomyopathy: cause or association? QJM. 100(9):593-4; author reply 594-6, 2007
                                                                                  21. Cocco G et al: Stress-induced cardiomyopathy: a review. Eur J Intern Med. 18(5):369-79, 2007
                                                                                  22. Haghi D et al: Guidelines for diagnosis of takotsubo (ampulla) cardiomyopathy. Circ J. 71(10):1664; author reply 1665, 2007
                                                                                  23. Kawai S: Typical and atypical forms of takotsubo (ampulla) cardiomyopathy. Circ J. 71(10):1665, 2007
                                                                                  24. Kimura K et al: Images in cardiovascular medicine. Rapid formation of left ventricular giant thrombus with Takotsubo cardiomyopathy. Circulation. 115(23):e620-1, 2007
                                                                                  25. Matsuzaki M: Stress 'Takotsubo' cardiomyopathy: questions still remain. Nat Clin Pract Cardiovasc Med. 4(11):577, 2007
                                                                                  26. Nanda S et al: Takotsubo cardiomyopathy--a new variant and widening disease spectrum. Int J Cardiol. 120(2):e34-6, 2007
                                                                                  27. Pilgrim TM et al: Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: A systematic review. Int J Cardiol. 2007
                                                                                  28. Gianni M et al: Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J. 27(13):1523-9, 2006
                                                                                  29. Iqbal MB et al: Stress, emotion and the heart: tako-tsubo cardiomyopathy. Postgrad Med J. 82(974):e29, 2006
                                                                                  30. Bybee KA et al: Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med. 141(11):858-65, 2004
                                                                                  31. Ito T et al: Development of pulmonary neuroendocrine cells of fetal hamster in explant culture. Lab Invest. 77(5):449-57, 1997