Tako-Tsubo syndrome: an important differential diagnosis in patients with acute chest pain

Abstract

Background: The syndrome of Tako-Tsubo cardiomyopathy (TTC) is characterized by the occurrence of acute chest pain, electrocardiographic signs of ischemia, and transient balloon-like abnormalities in cardiac wall motion mostly involving the left ventricular apex. Significant obstructive coronary artery disease is absent. Owing to its clinical and imaging characteristics, TTC is frequently misdiagnosed as an acute coronary syndrome. Tako-Tsubo syndrome was first described in the 1990s in Japan, but meanwhile has been increasingly identified in other parts of the world also. TTC predominantly affects postmenopausal women, and may involve up to 2% of all patients with acute ST-segment elevation myocardial infarction (STEMI). Apart from single case reports, no systematic data from Austria are currently available.

Patients and methods: We analyzed prevalence, diagnostic characteristics and the clinical course of patients with TTC admitted to our cardiology department during a period of four years (May 2004 - December 2008). Diagnosis of TTC was established by the presence of the typical apical ballooning pattern of the left ventricle shown by ventriculography or echocardiography and by the absence of a significant coronary artery stenosis as demonstrated by coronary angiography. Among 448 patients with suspected acute STEMI and 963 patients with non-STEMI, 31 patients (2.2%) were diagnosed as having TTC.

Results: The majority of identified patients with TTC were postmenopausal women (90.3% women, mean age 75 +/- 10.2 years). At the time of acute hospital admission, the principal symptom was chest pain in 24 patients (77.4%), dyspnea in 10 (32.3%) and hypotension in one (3.2%). Preceding emotionally or physically stressful events were identified in 24 patients (77.4%: emotional 29%, physical 48.4%). Acute ST-segment elevation was present in 13 patients (42%) and ST/T wave abnormalities were found in 18 (58%). All patients demonstrated a distinct increase in levels of cardiac enzymes and biomarkers. Significant coronary artery stenosis was absent in all patients. After a clinical follow-up period of 172.4 +/- 342.8 days, three patients had died from non-cardiac causes, TTC had recurred in another patient 13 months after the index event, and the other 27 patients were free from cardiac symptoms and the electrocardiographic and echocardiographic abnormalities had resolved.

Conclusion: Patients with TTC display clinical symptoms and electrocardiographic findings that mimic acute myocardial infarction. A history of a preceding stressful event in elderly women, typical echocardiographic findings of TTC, and only a mild elevation of cardiac markers will be informative. Acute-coronary angiography should be performed in order to rule out acute coronary occlusion and to avoid inadequate treatment such as thrombolysis.