Background

Takotsubo Cardiomyopathy (TTC), or broken heart syndrome, was first described in Japan in 1990. It is a stress-induced cardiomyopathy in which the heart resembles a Japanese “octopus pot”, or takotsubo. TTC is characterized by the weakening of the left ventricle, resulting in ballooning of the heart and left ventricular apical akinesis, causing symptoms that mimic acute coronary syndrome (ACS). Patients may present with myocardial infarction (MI) - like symptoms, show ST-segment elevation on electrocardiogram (ECG), and have elevation in ischemic cardiac enzymes. However, no coronary artery blockage will be seen. Onset usually follows a significant stressor, such as the death of a loved one, coining the term “broken heart syndrome”. It is hypothesized to be caused by the stunning of the myocardium via catecholamine release. Treatment involves ruling out ACS and MI, supportive care, and follow up with a cardiologist to ensure resolution of the syndrome. In the rare (<5%) case that a left ventricular thrombus forms, systemic anticoagulation is required.

Case Presentation

We present a case of a patient with a history significant for chronic kidney disease and hypertension presenting to the emergency department with one-day history of unchanged acute onset dyspnea and hypotension. She remarked that she was “incredibly stressed'' recently. Labs were significant for leukocytosis, increased troponins, and lactic acidosis. Her ECG showed T-wave inversions in the inferior and anterolateral leads. Echocardiography was significant for findings suggestive of TTC with an ejection fraction (EF) of 25- 30%. The patient was transferred to the intensive care unit for cardiogenic shock. Following supportive treatments, she was optimized based on her TTC, and was discharged with cardiology follow up. Currently, she is on goal-directed medical therapy, wears a life-vest, and continues to have left ventricular akinesis with an EF of 25-30%.

Discussion

Acute treatments are supportive, but vary based on level of left ventricular outflow tract obstruction. Traditional heart failure with reduced ejection fraction (HFrEF) treatments have limited efficacy for TTC-induced HFrEF. Some data indicates that TTC is often underdiagnosed, and the true rate may be closer to 5.7%. While most cases recover within 2 weeks, there is a significant recurrence rate of up to 4% per year. A consideration for prevention of recurrence is screening and addressing mental health comorbidities. It is important to note, that TTC is less commonly also referred to as “Happy Heart Syndrome,” so clinicians should be cognizant of TTC patients presenting with positive symptoms.