Transient Stress Cardiomyopathy (TSC)
BASICS
- Definition: A reversible cause of left ventricular (LV) dysfunction mimicking ST-elevation myocardial infarction (STEMI), often triggered by emotional or physical stress.
- Also known as:
- Takotsubo cardiomyopathy
- Apical ballooning syndrome
- Broken heart syndrome
- Ampulla cardiomyopathy
- Initial Presentation: Acute chest pain, dyspnea, syncope, ST-segment elevation, mild troponin elevation, and transient wall motion abnormalities.
EPIDEMIOLOGY
| Parameter | Details |
|---|---|
| Incidence | 1–3% of all STEMI-suspected cases |
| Female patients | 82–100% of cases; postmenopausal women |
| ICU patients | 28% incidence with sepsis |
| Mean age | 62–75 years |
| Prevalence | 2.2% among STEMI presentations at referral centers |
ETIOLOGY & PATHOPHYSIOLOGY
- Key Mechanism: Catecholamine-induced cardiotoxicity with sympathetic overactivation.
- Triggers:
- Emotional: grief, shock, arguments, public speaking
- Physical: acute illness, trauma, seizures
- Mechanisms:
- β2-adrenergic “biased agonism” at cardiac apex
- Coronary microvascular spasm
- Myocardial calcium overload → contraction band necrosis
- Endothelial dysfunction
- No known genetic associations
- Brain–Heart Axis: Insular cortex activation → sympathetic surge
RISK FACTORS
- Female sex (especially postmenopausal)
- Acute emotional or physiological stress
- Chronic psychiatric or neurologic conditions
ASSOCIATED COMPLICATIONS
| Cardiovascular | Others |
|---|---|
| Acute LV failure, pulmonary edema | Cardiogenic shock |
| Mitral regurgitation | Dynamic LV outflow obstruction |
| Ventricular arrhythmias | LV thrombus or rupture |
| Death (rare, up to 8%) |
CLINICAL PRESENTATION
- History:
- Sudden chest pain, dyspnea, palpitations, or syncope
- Preceding emotional or physical stress in ~66%
- Seasonal pattern: summer and winter more common
- Physical Exam:
- Variable: may include hypotension, S3 gallop, murmur, JVD, rales
DIFFERENTIAL DIAGNOSIS
- Acute STEMI
- Pulmonary embolism
- Myocarditis
- Pheochromocytoma
- Hypertrophic cardiomyopathy
- Subarachnoid hemorrhage or stroke
DIAGNOSTIC CRITERIA (Mayo Clinic)
- Transient wall motion abnormalities (beyond single-vessel distribution)
- Absence of significant CAD or plaque rupture
- New ECG abnormalities (ST elevation or T-wave inversion)
- Absence of alternate causes (e.g., myocarditis, HCM)
DIAGNOSTIC TOOLS
InterTAK Diagnostic Score
| Factor | Description |
|---|---|
| Score ≥70 | Suggests TSC; echo preferred |
| Score ≤70 | Angiography + ventriculography required |
| Parameters | Sex, emotional/physical trigger, QTc, etc. |
Laboratory & Imaging
| Test | Findings |
|---|---|
| ECG | ST elevation, T-wave inversion, QTc prolongation |
| Cardiac biomarkers | Mildly elevated troponin, CK, BNP |
| Chest X-ray | Cardiomegaly, pulmonary edema |
| Echo | Classic apical ballooning; other variants |
| MRI | Confirms regional dysfunction, no fibrosis |
| Coronary angiography | Excludes CAD; gold standard |
| Hemodynamic cath | ↑LVEDP, ↓CI, ↑PCWP in shock |
WALL MOTION VARIANTS
- Classic: Apical ballooning, hyperdynamic base
- Reverse: Basal akinesis, apical sparing
- Midventricular: Isolated mid-wall akinesis
- Focal: Limited to one segment
- Right ventricular involvement: Variable
TREATMENT
General Approach
- Treat as ACS until excluded
- Urgent cardiology consult
- Oxygen, IV access, ECG, monitor vitals
First-Line Medications
| Drug/Class | Use Case & Notes |
|---|---|
| β-blockers | Theoretical benefit, use cautiously if QTc >500 |
| ACEi/ARBs | Shown to improve survival (e.g., lisinopril, valsartan) |
| Loop diuretics | Pulmonary edema (e.g., furosemide 20–40 mg BID) |
Second-Line / Supportive
| Scenario | Intervention |
|---|---|
| LV thrombus risk | Anticoagulation (UFH or enoxaparin) |
| Cardiogenic shock | Vasopressors (phenylephrine, norepinephrine) |
| LVOTO present | Avoid inotropes; consider β-blockade |
| Severe cases | Intra-aortic balloon pump |
PSYCHIATRIC SUPPORT
- Strong link with psychiatric illness
- Psychiatric consult underutilized (only 32% treated during admission)
- Consider SSRIs or psychotherapy in high-risk individuals
ADMISSION & ONGOING CARE
| Phase | Action |
|---|---|
| Admission | ECG, labs, CXR, echo; monitor for CHF or arrhythmia |
| Follow-up | Cardiology visit; echo to confirm LV recovery |
| Discharge | Once ACS is ruled out and LV function stabilized |
PROGNOSIS
| Outcome | Details |
|---|---|
| Recovery | Usually within 2–3 days to 1 month |
| Recurrence | Low (0–8%) |
| Mortality | Similar to ACS in ICU patients |
| Prognostic caveat | Historically viewed as benign, now reconsidered |
ICD-10 CODE
- I51.81: Takotsubo syndrome
CLINICAL PEARLS
- TSC mimics STEMI; always rule out ACS.
- Echocardiography and clinical context guide diagnosis.
- β-blockers and ACE inhibitors are mainstays in heart failure-like presentations.
- Emotional or physical stress history is crucial.
- Cardiology referral and psychiatric support should not be overlooked.