Tako-Tsubo Cardiomyopathy: A Recent Clinical Syndrome Mimicking an Acute Coronary Syndrome

Tako-Tsubo cardiomyopathy (TTC), first described in 1990 by Sato in Japan (Sato et al., 1990), has recently gained increasing consideration when reported in non-Japanese patients, including the United States and Europe (Hachamovitch et al., 1995; Sharkey et al., 2005; Desmet et al., 2003; Bybee et al., 2004; Dec, 2005; Kurowski et al., 2007) Typical presentation mimics acute coronary syndrome, with acute chest pain and/or dyspnoea, associated to electrocardiographic changes and moderate cardiac biomarkers release, but in which coronary angiography reveals no coronary arteries lesions. Echocardiography and left ventriculography show the characteristic abnormalities: a reversible left ventricle systolic dysfunction (Pilgrim et al., 2008; Prasad et al., 2008; Wittstein et al., 2005). These transient regional wall motion abnormalities, involving typically the left ventricle, usually extend beyond a single vessel territory (Sato et al., 1990; Dote et al., 1991). An expert consensus panel proposes a definition of TTC: “TTC is a recently described clinical entity characterised by acute but rapidly reversible left ventricle systolic dysfunction in the absence of atherosclerotic coronary artery disease, triggered by profound psychological stress. This distinctive form of ventricular stunning typically affects elderly women and preferentially involves the distal portion of the left ventricle chamber (apical ballooning), with the basal left ventricle hypercontractile. Although presentation often mimics ST-segment Elevation Myocardial Infarction, outcome is favourable with appropriate medical therapy” (Maron et al., 2006). The classical, first described, variant of TTC manifests as ballooning of the apical segment and compensatory hypercontraction of the middle-to-basal segments of the left ventricle during systole, similar to the Japanese octopus-trap pot, called Tako-Tsubo (Sato et al., 1990; Dote et al., 1991). Several variants of TTC have been reported recently, involving any part of the heart, but most commonly the left ventricle (Hahn et al., 2007; Kurowski et al., 2007; Pilliere et al., 2006; Reuss et al., 2007; Hurst et al., 2006). The incidence of TTC, also known as stress-induced cardiomyopathy, transient apical ballooning or broken heart syndrome, is estimated to be present in 1.7% to 2.2% of the patients with suspected acute coronary syndrome (Wittstein et al., 2005; Akashi et al., 2010;