Takotsubo cardiomyopathy (TCM), also known as apical ballooning syndrome or acute stress-induced cardiomyopathy, is a condition in which the heart suddenly dysfunctions. The tip of the left ventricle becomes enlarged and weakened due to sudden intense physical or emotional stress. It is a temporary condition typically followed by complete recovery of the affected individual within a few weeks.

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Broken heart syndrome is not a genetic disease. Although it may develop among people of any age group, it is most commonly seen in postmenopausal women who are over 50 years of age.

Symptoms

Most patients report symptoms such as angina, shortness of breath, and sudden chest pain, which occur within a few minutes or hours of experiencing unexpected and severe emotional or physical stress. These symptoms occur in patients without any previous record of cardiac disease

Chest pain

People with broken heart syndrome may experience symptoms remarkably similar to those of a heart attack, such as chest pain. However, these patients do not have a blockage in the coronary arteries, but the apex of the left ventricle takes on a distinctive oval shape.

Difficulty in breathing

Breathing may become labored in a patient with broken heart syndrome. This is mainly due to forceful contractions in the region of the chest; sometimes, performing vigorous exercises can result in extreme stress, leading to respiratory problems in TCM-affected patients.

Arrhythmia  

This symptom is associated with an irregular heartbeat. That is, the heart beats too slowly or too fast, or without a regular sequence. Too slow and too fast a beat are clinically termed bradycardia and tachycardia, respectively. In this condition, the heart is not able to pump enough blood to the body parts, which results in ischemia of the brain and other organs. Arrhythmia may be fatal if not treated immediately.

Other common symptoms include nausea, sweating, dizziness, palpitations, disorientation, dyspnea, low blood pressure, and exaggerated sympathetic activation. More infrequently, cardiogenic shock and pulmonary edema may be present.

Clinical signs

The clinical signs of TCM are related to findings on electrocardiography (ECG), magnetic resonance imaging (MRI), echocardiography, and angiography. The individual may have ST-segment elevation, increased level of cardiac biomarkers such as troponin and creatinine, and other signs.

ST-segment elevation

In people with TCM, the ECG findings include the elevation of the ST-segment, generally in the range of a few millimeter. Furthermore, abnormal T-waves and Q-waves may also be present, and the interval between these waves may be extended. Some changes may evolve later, such as disappearance of the ST-segment elevation and the development of inverted T-waves.

About 80% of patients have ST-segment elevation. Similarly, 64% of patients have T-wave inversion, while 32% show pathological Q-waves.

Other signs

High levels of plasma brain natriuretic peptide (BNP) and serum catecholamines are observed, in addition to elevated levels of serotonin and other metabolic factors present in neurons.

Levels of troponin and creatine

Patients with stress-induced cardiomyopathy have increased levels of serum cardiac troponin, while the levels of creatine kinase are generally normal or only mildly increased. Hemodynamic instability may occur as a result of the increase in creatine kinase.

In acute coronary syndrome (ACS), cardiac biomarkers are elevated 10 times above the average rise seen in TCM. Furthermore, the mean value of creatine kinase-MB (CK-MB) of a patient with TCM (34 IU/L) is lower, compared with that seen in patients with ACS (326 IU/L).

Imaging of left ventricular ballooning

The image of an enlarged lower left ventricle is seen in TCM patients on angiography and echocardiography. This syndrome may also result in a retrograde blood leakage through the mitral valve during the contraction of the left ventricle, known as mitral regurgitation. Further, the absence of an intraventricular gradient and normal systolic pressure in the pulmonary artery may be observed in TCM.

Angiography

In patients with TCM coronary angiography fails to show any obstruction of coronary blood flow, by definition. During the acute phase of TCM, akinesis or dyskinesis of the apical region is observed, with an elongation in the apex and left mid-ventricular dysfunction. The mean ejection fraction in these patients ranges from 20 to 49%. Hyperkinesia of the base of the heart is also observed, which produces narrowing of this region with an apical ballooning appearance.