Apical ballooning syndrome or Takotsubo cardiomyopathy: a new challenge in acute cardiac care.

Apical ballooning syndrome (ABS) is a unique acute cardiac syndrome characterized by symptoms and electrocardiographic changes that mimic acute myocardial infarction. It occurs in patients without evidence of significant obstructive coronary artery disease and is associated with transient extensive wall motion abnormalities of the apical and mid portions of the left ventricle. The onset of ABS is preceded by a stressful event, either emotional or physical in around 65% of cases. The underlying pathophysiology for ABS remains unclear; however, several mechanisms have been proposed including multivessel epicardial spasm, microvascular spasm, catecholamine induced myocardial stunning and myocarditis. The treatment of ABS remains entirely empirical and should be individualized according to the patient's clinical picture at the time of presentation. It should be initially managed according to the guidelines for acute coronary syndrome. Once the diagnosis of ABS is made, supportive care usually leads to spontaneous recovery. The prognosis of patients with Takotsubo cardiomyopathy is generally favourable. The left ventricular systolic dysfunction usually resolves within a few weeks. In-hospital mortality is low, less than 2%, and recurrence rate is no more than 10%. The aim of this article is to clarify, for the clinicians dealing with acute cardiac care, when they should suspect ABS and how they should confirm the diagnosis and subsequently manage it.