Episode 59: Takotsubo cardiomyopathy with Vincent Sorrell

We look at stress (Takotsubo) cardiomyopathy in the setting of critical illness, with Dr. Vincent Sorrell. Dr. Sorrell is a cardiologist at the University of Kentucky, where he helped develop the Advanced Cardiovascular Imaging Program, and is current Acting Chief of both the Division of Cardiovascular Medicine and the Gill Heart and Vascular Institute. Find us on Patreon here! Buy your merch here! Takeaway lessons * If considering ACS in any post-menopausal woman, you should also consider stress cardiomyopathy. Echo is the test of choice. * While hypokinesis classically occurs at the apex in TCM, almost any distribution can occur; 10% or more will have atypical distributions, particular outside the traditional demographics (older women), such as the critically ill. Of course, atypical anatomical distributions can also occur in ACS due to distinct anatomy. * Recurrence of TCM may occur with a different distribution. Recurrence occurs in up to 40% in the first four years. Withdrawal of beta blocker therapy may precipitate this, which may be a reason to select other therapies (e.g. ACE inhibition). * In general, TCM is a diagnosis of exclusion after ruling out ACS. The ECG pattern is non-specific, but STE in V1 or lead I is unusual in TCM. ACS usually causes more troponin elevation than TCM, and matches the degree of EF reduction. Persistent troponin elevation in a patient without intervention may suggest a missed ACS instead of TCM, but you should generally not wait that long. * The InterTAK score may give some guidance. Dr. Sorrell is working on echo criteria. * Cardiac CT may also be a helpful non-invasive tool. * Contraindications to stenting (e.g. bleeding) could also suggest utility in a non-invasive approach. * When addressing hemodynamics, always ask whether outflow tract obstruction is present or absent; this will be a critical decision-point. * Without obstruction, treat patients as usual. Vasopressors should not be viewed as potentially worsening the condition, and early beta blockers probably have no role. * Anticoagulate as soon as it’s safe, when there are large wall motion abnormalities; this is similar to WMA from other causes. Apical ballooning is probably somewhat riskier than other distributions due to the flow patterns. * The natural history of TCM involves recovery in most within 2 weeks, although the course during that period can vary widely. Almost all recover within a couple months. * Outpatient care focuses on ACE inhibition, diuresis if needed, anticoagulation when appropriate, with a gradually decreasing emphasis on beta blockers. Aspirin and statins are not usually needed if there is no concomitant ACS. * Hormone replacement may have a role. * RV involvement can occur atypically. It can help point to TCM, since this would be an unusual anatomic distribution for ACS.