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Takotsubo (Stress) Cardiomyopathy

Clinical Subject Page

Takotsubo Cardiomyopathy

Also called

Broken Heart Syndrome

ICD-10

I51.81

Specialty

Cardiology

Onset

Chronic

Reviewed

June 2026

On This Page

Overview

Takotsubo cardiomyopathy (also called stress-induced cardiomyopathy or broken heart syndrome) is an acute, reversible dysfunction of the left ventricle that is usually triggered by severe emotional or physical stress. It often mimics acute coronary syndrome (ACS) with chest pain and dyspnea but typically recovers within a few weeks.

Etiology & Risk Factors

Common triggers for Takotsubo Cardiomyopathy :

  • Emotional stress
    • Usually negative (“broken heart syndrome”)
    • Occasionally positive (“happy heart syndrome”)
  • Severe physical illness
    • Stroke
    • Subarachnoid hemorrhage
    • Seizures
    • Sepsis
    • Pheochromocytoma
      • Certain drugs

      In approximately one-third of patients, no trigger is identified.

      Risk factors

      • Postmenopausal women (≈90% of cases)
      • Preexisting mental illness

Pathophysiology

Stress leads to:

Emotional/physical stress
→ Sympathetic nervous system activation
→ Massive catecholamine release
→

  • Cardiotoxicity
  • Multivessel coronary spasm
  • Left ventricular dysfunction
    → Myocardial stunning

Myocardial stunning refers to temporary abnormal regional left ventricular wall motion that persists for hours to weeks after transient ischemia.

Clinical Presentation

Patients often present similarly to acute coronary syndrome, including:

  • Chest pain
  • Symptoms of heart failure

Severe disease may result in:

  • Left ventricular outflow tract (LVOT) obstruction
  • Cardiogenic shock

Because symptoms overlap with ACS, ACS must be excluded.

History Taking

Important questions include:

 

  • Recent emotional stress
  • Recent major physical illness
  • Neurological events
  • Drug exposure
  • Symptoms suggestive of heart failure
  • Previous psychiatric illness

Investigations

Because Takotsubo cardiomyopathy resembles ACS, patients require investigations to exclude acute coronary syndrome.

Patients should also be assessed for:

  • Left ventricular dysfunction
  • Presence of LVOT obstruction
  • Complications such as:
    • Arrhythmias
    • Heart failure
    • Left ventricular thrombus

Diagnosis

Diagnosis requires:

  • Recognition of the characteristic clinical presentation
  • Exclusion of acute coronary syndrome
  • Assessment for left ventricular dysfunction and LVOT obstruction
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Management

General principles

  • Treat supportively
  • Manage complications
  • Treat comorbidities
  • Consider empiric ACS treatment until ACS is ruled out
  • Admit all patients for at least 48 hours of continuous telemetry

     

    Hemodynamically unstable patients

    Without LVOT obstruction

    • Inotropes may be used cautiously
      • Dobutamine
      • Dopamine
      • Levosimendan
      • Milrinone
    • Vasopressors if needed
      • Phenylephrine
      • Vasopressin
    • Consider advanced support:
      • LV assist device
      • ECMO
      • Intra-aortic balloon pump (IABP)

Hemodynamically stable patients

Treat similarly to systolic heart failure:

  • ACE inhibitor (e.g., lisinopril)
  • Low-dose beta blocker (e.g., metoprolol)

    With LVOT obstruction

    Avoid:

    • Inotropes
    • Vasodilators
    • Nitroglycerin
    • Diuretics
    • IABP

    Treatment includes:

    • IV fluids
    • Short-acting low-dose beta blockers (if tolerated)
      • Esmolol
      • Metoprolol
      • Propranolol
    • Vasopressors
      • Phenylephrine
      • Vasopressin
    • ECMO or LV assist device if refractory

    Additional management

    • Continuous cardiac monitoring
    • Consider VTE prophylaxis (LV thrombus develops in ~10%)
    • Consider chronic ACE inhibitor/ARB
    • Consider chronic beta blocker
    • Treat the underlying trigger (e.g., depression)

Complications

Potential complications of Takotsubo Cardiomyopathy include:

  • Acute heart failure
  • Arrhythmias
  • Left ventricular outflow tract obstruction
  • Cardiogenic shock
  • Left ventricular thrombus
  • Mitral regurgitation associated with LVOT obstruction

Prognosis

Overall prognosis is favorable.

  • Recovery: usually within 1–2 weeks
  • Recurrence: 2–4% per year
  • In-hospital mortality: up to 5%, particularly in patients with cardiogenic shock or other complications

Key Points / Clinical Pearls

  • Reversible stress-induced cardiomyopathy.
  • Usually affects postmenopausal women.
  • Often follows major emotional or physical stress, although no trigger is identified in about one-third of cases.
  • Closely mimics acute coronary syndrome and should be evaluated accordingly.
  • Always assess for LVOT obstruction, as it changes management.
  • Avoid inotropes in patients with LVOT obstruction, as they can worsen obstruction and precipitate cardiogenic shock.
  • Most patients recover completely within days to weeks.