Tako-Tsubo Syndrome
Tako-Tsubo Cardiomyopathy
also known as
Stress Cardiomyopathy
Transient (Catecholaminergic) Myocardial Stunning
Transient (neurogenic) Myocardial Stunning

Please read one column after the other.

Some comments on Tako-Tsubo Syndrome

Tako-tsubo Cardiomyopathy or Syndrome is also known as:

• neurogenic myocardial stunning,
• stress cardiomyopathy
• stress-induced cardiomyopathy,
• transient left ventricular apical ballooning,
• "ampulla" cardiomyopathy
• "broken heart syndrome".
  

"Tako-tsubo" is the japanese name for octopus traps that fishermen still use to catch octopus. In this syndrome, the heart (left ventricle) takes the shape of an octopus trap (tako-tsubo). How about that!

NOTE ( très mucho IMPORTANT and before we forget ! ): a diagnosis of tako-tsubo syndrome can only be made after excluding:

• coronary artery disease (especially proximal left main or left anterior coronary artery stenosis),
• acute coronary syndrome,
• acute myocardial infarction,
• myocarditis, pericarditis, aortic dissections and so forth...

The shape that the left ventricle takes (tako-tsubo shape) is due to a state of complete exhaustion of the heart muscle (myocardial stunning) in the mid-section and tip of the heart. The fascinating part is that it occurs in patients without significant blockage (stenosis) of their coronary arteries (now: that is surprising and remarkable!).

A profound tako-tsubo syndrome is quite dangerous if not recognized as it can lead to transient but severe (occasionally lethal) cardiogenic shock. Electrocardiogram can show non-specific ST-T abnormalities, ST elevation, and/or QT prolongation with large negative T waves. Sometimes those changes occur in succession. And here is another surprise: the cardiac bio markers of heart damage (troponin, creatine kinase) are only very slightly elevated, confirming that there is not much heart muscle damage, but severe suffering (stunning) instead.

And that leads to the good news, Folks!
If this syndrome is recognized, over 95% of patients pull through that fairly easily (with most of the time complete recovery of the electrocardiographic changes and recovery of the cardiac shape and function. This may take a few weeks).

Suggestion: patients should be send to cardiac rehabilitation and if possible to a stress reduction clinic if the syndrome is complicated by continued stress or by a syndrome similar to "post-traumatic stress syndrome".
The idea is to prevent recurrence (which is low but still exists) by indentifying and trying to eliminate or deflect stressors while educating patients how to counter and how to develop resilience to stress .

Rare video clip in a snowy mountain range of an unfortunate stressed, resentful and angry giraffe running after some scrumptious food. Conclusion from this study: Even maximally stressed giraffes don't get tako-tsubo syndrome......

But there is no need for those fancy experiments...... how about studying non-human primates stuck for life in zoos? I would not be surprised that some tako-tsubo cases could be found there....... future will tell....

Shape of the Left Ventricle in Tako-Tsubo Cardiomyopathy

Normal left ventricular contraction

Abnormal contraction of left ventricle taking the shape of a "Tako-Tsubo"

Actual Left ventriculogram in a patient with tako-tsubo syndrome.

Post-menopausal woman - Cardiac ultrasound in the E.R. - Day 1 of a tako-tsubo syndrome: the left ventricular tip (apex) is "paralyzed"

Same patient, 3 months after the tako-tsubo episode: there is full recovery. The tip of the left ventricle contracts normally again. Yesss!

Syndrome named by Sato et al.
Sato H, Tateishi H, Uchida T, Dote K, Ishihara M. Tako-tsubo-like left ventricular dysfunction due to multivessel coronary spasm. in: Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure. Kodama K, Haze K, Hori M, Eds. Kagakuhyoronsha Publishing Co., Tokyo, 1990: 56–64 (in Japanese).

Syndrome seen in Worcester Massachusetts for a long time (followed up prospectively for up to 11 years) but named differently. "Massive T wave inversion mainly in women, with prognosis independent of ECG changes".
LA Walder and DH Spodick. Global T wave inversion: long-term follow-up. J Am Coll Cardiol, 1993; 21:1652-1656. Division of Cardiology, St. Vincent Hospital, Worcester, Massachusetts

Multivessel coronary artery spasm is a possibility.
Dote K, Sato H, Tateishi H, Uchida T, Ishihara M. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases. [Article in Japanese] J Cardiol. 1991;21(2):203-14.

Neurogenic cause is quite likely.
Akashi YJ, Nakazawa K, Sakakibara M, Miyake F, Musha H, Sasaka K.. 123I-MIBG Myocardial Scintigraphy in Patients with “Takotsubo” Cardiomyopathy. J Nucl Med 2004; 45:1121–1127

First patient cohort described in the U.S.
Seth PS, Aurigemma GP, Krasnow JM, Tighe DA, Untereker WJ, Meyer TE. A Syndrome of Transient Left Ventricular Apical Wall Motion Abnormality in the Absence of Coronary Disease: A Perspective from the United States. Cardiology, 2003;100:61-66

ALERT: what some of us expected to see described has just been ...described...
While most cases of tako-tsubo syndrome involve the tip of the heart, this can also happen in different area of the left ventricle: it is also transient and reversible. Masatoshi Shimizu , Yukio Kato , Hiroyuki Masai , Takashi Shima , Yoichi Miwa. [Recurrent episodes of takotsubo-like transient left ventricular ballooning occurring in different regions: a case report] (in japanese) J Cardiol. 2006 Aug ;48:101-7

Attention: instead of the characteristic takotsubo shape that the heart takes, some patients have, instead, focal or even completely diffuse wall motion abnormalities and therefore the "tako-tsubo" morphological change is not seen... Future research will sort out whether those cases should also be grouped into tako-tsubo syndrome.

Nevertheless, transient catecholaminergic myocardial stunning could still be the basis for some of those clinical presentations in patients with little or no coronary stenosis

Summary:
Tako-tsubo syndrome can appear because of an extremely, out of the ordinary, stressful episode, especially if it is associated with anger, resentment , and/or despair, mainly in women (men tend to drop dead or have a real heart attack because of stress... true! Hey! STRESS IS BAD FOR ANYBODY!). It is therefore key to try to calm yourself down (if necessary with outside help from friends and health practitioners) so that you don't let your octopus out of its tako-tsubo. Once the nervous system is so terribly activated you risk the following (especially women) with or without a full blown tako-tsubo syndrome:

neurogenic:

• myocardial stunning,
• heart failure,
• cardiogenic shock,
• chest pressure-pains (similar to angina),
• coronary spasm,
• shortness of breath,
• palpitations (arrhythmia, sometimes extremely serious)...

Treatment: Tako-tsubo syndrome is only treated with support measures.

Outcome: Excellent in 95% of cases. Recovery takes place over a few days with full recovery over a few weeks. Recurrence (another surprise) is extremely rare.

Root cause of tako-tsubo syndrome: Stress appears to be the underlying root cause in many cases. Because of this, some have investigated an excessive norepinephrine release over the heart muscle. Because this mechanism is not yet proven scientifically to satisfaction, we are a bit helpless for the treatment of this syndrome (we really only have standard support measures that we give to other patients with standard heart failure). There are some attempts to give a calcium channel blocker to prevent coronary spasm, but there is no solid literature on that. Besides, patients often have low blood pressure, prevent us from giving a vasodilator such as a calcium channel blocker. Like everything else: better prevent and recognize tako-tsubo syndrome rather than wait for the full syndrome.

Now: for a less serious view of this syndrome. The theory of everything given away by a giraffe...

Pathophysiology of Tako-Tsubo syndrome explained --- goofy "theory of everything", using all 6 character actors ... (Japanese researchers have come up with first papers and attempts to explain this syndrome... they should tie up all things under 6 character actors... here it is for the first time... I hope that this gets me 1/2 of their Nobel Prize...ahahahah!)

6 character actors

1. tako-tsubo (octopus trap)
2. the octopus itself
3. some serious stress, anger, resentment
4. the central and sympathetic nervous system
5. norepinephrine being released uncontrollably
6. the heart (the target of all this)

1. The Octopus is resting in its Tako-Tsubo - Do NOT irk it !

2. The Octopus is unhappy and on a prowl

3. The Octopus has found its target - the heart

4. Oh! No ! -- Big trouble ! -- The Octopus IS the CNS

5. The CNS is stressed and resentful

6. The CNS, through the sympathetic nervous system, discharges unconscionable and irrational amounts of catecholamines (mainly norepinephrine) on the heart and this creates chest pain, myocardial stunning and/or congestive heart failure... or even SHOCK

Now for another odd thing: the "inverted Tako-Tsubo syndrome"("squid syndrome")

This is much rarer than tako-tsubo syndrome ..... even more mind boggling syndrome... This syndrome can also be transient and reversible...
How about the inverted tako-tsubo syndrome that has been recently described in patients with severe intra cranial process or with pheochromocytoma crisis (references below)! In those rare cases, instead of the tip of the left ventricle becoming stunned and "paralyzed", the tip of the left ventricle is hyperdynamic ("hypercontracting") while it is the base of the heart that is stunned and "paralyzed". How about that!

Here is an example of inverted tako-tsubo syndrome in a patient with pheochromocytoma who was admitted to our hospital. (this type of contraction makes me think of a... squid taking off...)

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