Takotsubo syndrome: between evidence, myths, and misunderstandings

Abstract

Takotsubo syndrome (TS) is an acute cardiac condition characterized by transient wall motion abnormalities mostly of the left ventricle. First described in 1990, TS has gained substantial attention during the past 15 years. However, the disease is still underdiagnosed. Prospective studies on TS are largely lacking, and the condition remains incompletely understood. In addition, significant misconceptions and misunderstandings are evident, contributing to potentially severe underestimation. Here, we review important aspects of TS with a focus on pitfalls, misinterpretations, and knowledge gaps considered important during diagnosis and management of the disease.

Keywords: Acute heart failure; Cardiogenic shock; Mechanical circulatory support; Pulmonary artery catheterization; Stress cardiomyopathy.

Fig. 1

Medline-listed publications on Takotsubo syndrome over time. PubMed entries per year, for the search term “Takotsubo.” Case report, letter, review, and clinical study refer to publication types as predefined by PubMed. Search was performed using an online search tool [135]

Fig. 2

Diagnostic management algorithm for suspected takotsubo syndrome (TS) and/or acute coronary syndrome (ACS). LGE late gadolinium enhancement, LVOTO left ventricular outflow tract obstruction, MINOCA myocardial infarction with nonobstructive coronary atherosclerosis, MR mitral regurgitation, MRI magnetic resonance imaging, S.p. status post, WMA wall motion abnormalities

Fig. 3

Takotsubo syndrome (TS) types. Schematic illustration of wall motion abnormalities, with dashed lines indicating stunned myocardium and green areas (hyper-)contractile myocardium. Right anterior oblique view as in standard ventriculography. a Apical TS, b apical TS with “nipple sign”, c midventricular TS, d basal TS, e focal TS

Fig. 4

Takotsubo syndrome heart failure and shock management algorithm. SCAI shock stages adapted from Baran et al. [136] and Jentzer et al. [137]. AHF Acute heart failure, BiV biventricular, CI cardiac index, CPO cardiac power output, ECPELLA VA-ECMO combined with Impella, ECPR extracorporeal cardiopulmonary resuscitation, LV left ventricle, LVEDP left ventricular end-diastolic pressure, LVOTO left ventricular outflow tract obstruction, MCS mechanical circulatory support, MR mitral regurgitation, PAPI pulmonary artery pulsatility index, PCWP pulmonary capillary wedge pressure, SCAI Society for Cardiovascular Angiography and Interventions, TS takotsubo syndrome, VA-ECMO veno-arterial extracorporeal membrane oxygenation