EMConference: Takotsubo's Cardiomyopathy

Case: 46M with PMH opiate use disorder on methadone, alcohol use disorder, and tobacco use disorder presents with 2 days of non-exertional chest pain radiating to his shoulder and jaw. In the days leading up to his presentation, he had had multiple legal and family stressors. Associated symptoms included diaphoresis, epigastric discomfort, nausea, and lightheadedness. Pain improved but did not completely resolve with ASA 324 mg PO and nitroglycerin given by medics. Vital signs and exam unremarkable.  


-high sensitivity troponin 14 -> 146 -> 135

-pro-BNP 7477 

POC U/S: reduced LVEF with apical hypokinesis and basal hyperkinesis  


Serial EKGs:


ED management and disposition: Cardiology consulted, heparin drip started, and admitted for further workup and cardiac catheterization.  


Diagnosis: stress-induced (takotsubo) cardiomyopathy  



  • There are two phenotypes of stress-induced cardiomyopathy. The first is more typical of this case, in which a patient experiences some sort of stressor, develops chest pain, and is found to have a cardiac process upon medical evaluation. The second is common of patients who have an underlying critical illness – such as sepsis, intracranial hemorrhage, or respiratory failure – and the cardiac process develops in response to that stress of critical illness.  

  • There is a suggestion that 1-2% of patients who present with STEMI/NSTEMI may actually have takotsubo cardiomyopathy, and that this is a more common disease process than originally thought  

  • Pathophysiology is poorly understood, but it is thought that a catecholamine surge disproportionately affects the apex of the heart due to a higher concentration of adrenergic receptors on that part of the myocardium, leading to apical stunning and reduced EF.  

  • Several different presentations possible:  

  • Chest pain, which may/may not have typical features such as dyspnea, nausea, radiation, and diaphoresis 

  • Lightheadedness/syncope due to arrhythmia  

  • Embolization due to mural thrombus formed 

  • Heart failure due to reduced EF  

  • Labs will show elevated troponins and BNP/pro-BNP. Troponin elevation out of proportion to regional wall motion abnormalities seen on echo may suggest takotsubo cardiomyopathy rather than ischemia  

  • EKGs follow a pattern:  

  • Day 1: anterior STEMI mimic. However, lack of q waves and reciprocal ST depressions may suggest takotsubo rather than LAD occlusion  

  • Days 1-2: ST elevations lower and are replaced by TWIs that are not localized to a single arterial distribution  

  • Days 2-3: TWIs become deeper, broader, and out of proportion to what is usually seen in cardiac ischemia  

  • Echo has a typical pattern: apical hypokinesis (ballooning) while the base of the heart is hyperdynamic. The apical hypokinesis is circumferential and less regional than would be expected in an LAD occlusion. Can also get basal hypokinesis with apical hyperkinesis (reverse takotsubo), left ventricular outflow obstruction, and global hypokinesis. Global hypokinesis is a poor prognostic indicator.  

  • An emergency physician can suspect but should never diagnosis takotsubo. This is a catheterization-negative diagnosis, and this patient should be treated as a STEMI/NSTEMI until proven otherwise. This is especially true given the similarities in cardiac biomarkers, EKG, and regional wall motion abnormalities seen on echo.  

  • In-hospital mortality is 2-5%, but most patient will do well and recover LV function in about 12 weeks  


Case outcome 

  • Cardiology echo showed LVEF 25-29% with hyperkinetic basal function and hypokinesis of all other segments 

  • Cardiac catheterization showed a normal left main, RCA, and LCx with 20% stenosis of the LAD  

  • The patient was started on goal-directed medical therapy with a statin, ACEiβ-blocker, and ASA due to a presumed diagnosis of takotsubo cardiomyopathy  

  • The patient was stabilized and discharged from the hospital with outpatient follow-up  


  1. Farkas, Josh. Takotsubo syndrome. The Internet Book of Critical Care. Accessed on September 28th, 2021. Available at https://emcrit.org/ibcc/takotsubo/ 

  1. Farkas, Josh. The Internet Book of Critical Care Podcast 82 – Takotsubo Cardiomyopathy. Published on June 1st, 2021. Accessed on September 28th, 2021. Available at https://emcrit.org/ibcc/takotsubo/ 

  1. Reeder GS, Prasad A. Clinical manifestations and diagnosis of stress (takotsubo) cardiomyopathy. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. (Accessed September 28th, 2021). No 

  1. Sadatian, SA. Takotsubo cardiomyopathy (broken heart syndrome) [Video]. YouTube. https://www.youtube.com/watch?v=MyG3IrATjQM. Published March 5th, 2019. Accessed on September 29th, 2021.