We describe two cases of Takotsubo syndrome and discuss the issues relating to diagnosis and patient communication that they raise.
Takotsubo syndrome (TS) is increasingly recognised by the medical community following its first description in five Japanese patients, mostly male, in 1990 by Sato et al.1 Dote, his colleague, named the syndrome Takotsubo in 1991 due to its characteristic left ventricle (LV) shape in systole (narrow neck and wide base) and similarity to the Japanese octopus trap (takotsubo).2 The syndrome is also termed apical ballooning syndrome, broken heart syndrome and stress cardiomyopathy, among other names.
Case one: a woman born in 1947
In January 2018 she was aged 70 and had been diagnosed with hypertension in 1996, but had no other cardiovascular condition. Her granddaughter had a serious medical condition and she accompanied her granddaughter to a hospital outpatient appointment. She was worried about her granddaughter, but did not feel that she was excessively stressed. However, during the appointment she developed chest pains. As the pain persisted, she visited her GP two days later and an electrocardiogram (ECG) reported “left-axis deviation and ischaemic ST-T changes in the lateral leads”. An emergency ambulance was summoned, and the ECG performed by the paramedic reported “meets ST-elevation MI (STEMI) criteria”. She was, therefore, transferred directly to the cardiology catheter laboratory, where a senior cardiologist felt unsure that this was the pattern of a true anterior STEMI, but he proceeded to perform an angiogram. As the angiogram was normal, they went on to request an echocardiogram, which showed the classical appearance of Takotsubo cardiomyopathy. She made a full recovery and her repeat echocardiogram in April 2018 was normal. She remains well at this time and an ECG performed in June 2019 simply shows sinus bradycardia, which is a result of her post-discharge medication, bisoprolol 5 mg.
Case two: a woman born in 1946
In February 2008 she witnessed the sudden collapse and death of her husband at home, she was aged 61 at that time. She developed “heavy central chest pain radiating down the left arm” at 02.00 am the next morning. She was seen at home by the out-of-hours GP service, diagnosed as “stressed” and she was advised to see her own GP in the morning. When seen at that appointment she was tachycardic with a blood pressure of 90/64 mmHg and an ECG showed T-wave inversion of the lateral leads. She was admitted to hospital and subsequently developed a right hemiparesis. On the echocardiogram she showed “severe left ventricular impairment with apical ballooning syndrome (takotsubo)”. She subsequently made a full recovery and now has normal findings on both ECG and echocardiography. Since that time, she has been readmitted with further chest pain. All investigations were normal. While discharging her, a consultant hospital physician remarked that “like your previous illness this was all just anxiety”, which upset her as she felt she was being accused of hypochondria and time-wasting.
Currently the consensus of expert opinion on TS, reflects the limited clinical reports for patients from cohort and case-control series and highlights the need to improve our knowledge surrounding the communication hiccoughs that can occur from our growing understanding of the syndrome.3,4
The first woman patient (case one) satisfies the age demographic of the majority of TS patients. There was also the presence of an emotional factor potentially precipitating TS, the illness of a close person. A study utilising the International Takotsubo registry, a collaboration of 26 European and American centres by Templin et al., compared 1,750 TS patients with age- and sex-matched patients with an acute coronary syndrome (ACS). Physical triggers (36%) were more common than emotional triggers (27.7%). Emotional triggers were more commonly observed in women and physical triggers more prevalent among men. Both groups showed similar rates of ST-segment elevation. Whereas only 8.3% of patients with TS had ST-segment depression, compared with 31.1% of those with an ACS. In the first case the patient meets the criteria for ST-segment elevation.
The clinical course of TS showed significant recovery of systolic left ventricular function over time but 21.8% of patients had serious in-hospital complications, equal to or higher than a patient with an ACS. The end points included in-hospital death, complications of ventricular tachycardia (3%), ventricular thrombus (1.3%), ventricular rupture (0.2%). None of these complications occurred in either of the cases.5,6
Despite both patients not having the potential serious in-hospital complications from TS, it is important for clinicians to be aware of these outcomes in order to correctly identify TS patients and communicate to patients about their diagnosis. The second patient stated that dismissing the diagnosis as a result of her own anxiety left her feeling upset. This serves to question how we can improve communication between healthcare professionals and patients with TS. By recognising the serious outcomes, including in-hospital death, and becoming aware that this condition is not caused by the anxiety, and, therefore, not preventable by the patient by reducing anxiety, we can reassure patients in their diagnosis. Particularly in a condition that occurs predominantly in post-menopausal women, it is important for patients not to be labelled as overly anxious and dramatic and to distinguish their trigger for TS from anxiety if this is not the case.7,8
Conflicts of interest
Patient consent for the publication of the two cases cited was obtained.
Please also see the article by Díaz-Navarro on pages 30–4 of this issue (https://bjcardio.co.uk/2021/03/takotsubo-syndrome-the-broken-heart-syndrome/), and the case report by Sekar et al. on pages 35–6 (https://bjcardio.co.uk/2021/01/lockdown-cardiomyopathy-from-a-covid-19-pandemic-to-a-loneliness-pandemic/).
1. Sato H, Tateishi H, Uchida T et al. Takotsubo type cardiomyopathy due to multivessel spasm. In: Kodama K, Haze K, Hon M (eds). Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure. Tokyo: Kagaku Hyoronsha, 1990; pp. 56–64 (in Japanese).
2. Dote K, Sato H, Tateishi H et al. Myocardial stunning due to simultaneous multivessel coronary spasm: a review of 5 cases. J Cardiol 1991;21:203–14 (in Japanese).
3. Ghadri J, Kato K, Cammann V et al. Long-term prognosis of patients with Takotsubo syndrome. J Am Coll Cardiol 2018;72:874–82. https://doi.org/10.1016/j.jacc.2018.06.016
4. Rivera A, Ruiz-Bailen M, Aguilar LR. Takotsubo cardiomyopathy – a clinical review. Med Sci Monit 2010;17:RA135–RA147. https://doi.org/10.12659/MSM.881800
5. Templin C, Ghadri JR, Diekmann J et al. Clinical features and outcomes of Takotsubo (stress) cardiomyopathy. N Engl J Med 2015;373:929–38. https://doi.org/10.1056/NEJMoa1406761
6. Akashi YJ, Goldstein DS, Barbaro G et al. Takotsubo cardiomyopathy: a new form of acute, reversible heart failure. Circulation 2008;118:2754–62. https://doi.org/10.1161/CIRCULATIONAHA.108.767012
7. Deshmukh A, Kumar G, Pant S, Rihal C, Murugiah K, Mehta JL. Prevalence of Takotsubo cardiomyopathy in the United States. Am Heart J 2012;164:66.e1–71.e1. https://doi.org/10.1016/j.ahj.2012.03.020
8. Whiteley J, DiBonaventura Md, Wagner JS, Alvir J, Shah S. The impact of menopausal symptoms on quality of life, productivity, and economic outcomes. J Womens Health (Larchmt) 2013;22:983–90. https://doi.org/10.1089/jwh.2012.3719