Takotsubo Syndrome in the Emergency Room - Diagnostic Challenges and Suggested Algorithm

Abstract

Takotsubo syndrome is an important condition to consider among patients with acute chest pain in the emergency room. It often mimics acute coronary syndrome since chest pain and ECG changes are key features in both conditions. The hallmark of takotsubo syndrome is transient left ventricular dysfunction (characterized by apical ballooning) followed by complete echocardiographic recovery in most cases. Although most patients exhibit a benign course, lethal complications may occur. The use of hand-held point-of-care focused cardiac ultrasound may be helpful for early identification of takotsubo syndrome and distinguishing it from acute coronary syndrome and other cardiovascular emergencies. Emergency room physicians should be familiar with typical and atypical presentations of takotsubo syndrome and its key electrocardiographic changes. The approach in the emergency room should be based on a combination the clinical presentation, ECG, and handheld echocardiography device findings, rather than a single electrocardiographic algorithm.

Keywords: acute coronary syndrome; echocardiography; point-of-care focused cardiac ultrasound; takotsubo syndrome.

Fig. 1.

Twelve-lead ECG of patient presented to the ER with chest pain. Twelve-lead ECG of a 70 -year-old female who admitted the ER with acute chest pain following an argument with her daughter. The pattern of ST elevation in the precordial and inferior leads without reciprocal ST depression raised the possibility of TTS. Immediate point-of-care cardiac ultrasound (POCUS) showed apical ballooning and basal hypercontractility (displayed later), consistent with TTS.

Fig. 2.

Apical four chamber view using handheld POCUS. Apical four-chamber view of the patient performed by ER physician showed typical apical ballooning and LVOTO secondary to basal hypercontractility.

Fig. 3.

Ventriculogram of the same patient during cardiac catheterization. Ventriculogram of the same patient who was suspected for TTS based on POCUS in the ER. Invasive coronary angiography was performed later and revealed patent coronary arteries without obstruction. Left ventriculogram showed typical apical ballooning, confirming the diagnosis of TTS.

Fig. 4.

Diagnostic algorithm. In stable patients, ECG within 10 minutes is recommended in patients with chest pain. When ST elevation is present, invasive coronary angiography should be performed to rule out obstructive disease. In patients without ST elevation, the interTAK score may help in patient triage. A score $>$70 should encourage POCUS and subsequent cardiac CT when the findings are consistent with TTS. If the probability for TTS is low (70), and in the cases that POCUS does not support TTS diagnosis, admitting to the cardiac care unit (CCU) for further evaluation is recommended. *Obstructive CAD may be present in TTS, however it should not be in a distribution that explains the observed wall motion abnormalities.