Takotsubo cardiomyopathy: an acute and reversible cardiomyopathy mimicking acute myocardial infarction.

Takotsubo cardiomyopathy is an acute, reversible form of left ventricular dysfunction precipitated by emotional or physical stress. The condition is important to recognise as it mimics acute myocardial infarction and acute coronary syndrome. Most patients are female and postmenopausal. Presenting symptoms include severe chest pain, acute dyspnoea, hypotension or even cardiogenic shock. The ECG changes are suggestive of an acute coronary syndrome with T-wave inversion with/without ST elevation, most often in the precordial leads. The syndrome is characterised by a sudden onset of transient extensive akinesia of the left ventricle, often involving all three major coronary artery territories, in the absence of significant coronary artery stenosis. The wall motion typically involves the apex of the left ventricle with hyperkinesis of the base of the heart. Variant forms have recently been described where the wall motion abnormality involves the mid-ventricular wall with hyperkinesis of the base and apex, or the base of the heart with hyperkinesis of the apex. Characteristically, there is only a limited release of cardiac enzymes disproportionate to the extent of regional wall motion abnormality. Transient right ventricular dysfunction may occur and is associated with more complications, longer hospitalisation and worse left ventricular systolic dysfunction. Serial echocardiography is useful to document improvement in cardiac function. The pathogenesis is unclear. Transient mid-cavity obstruction has been invoked with subsequent myocardial stunning in the akinetic segments. Treatment is supportive. The most effective long-term management remains to be defined. Although the prognosis is good with recovery of ventricular function at about three weeks, some patients have died. The syndrome may recur.