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Anand Chockalingam, M.D., Division of Cardiovascular Medicine, University of Missouri, Columbia, MO, USA
Stress cardiomyopathy (SC), also called Takotsubo cardiomyopathy, is increasingly diagnosed world over. ER physicians, Internists, Intensivists and anesthesiologists increasingly encounter SC patients presenting with angina, heart failure or arrhythmia. Initially, most patients were diagnosed in the catheterization lab when coronary angiograms were normal in STEMI settings. With increasing awareness among various providers and the wide proliferation of echocardiography, majority of this diagnosis is now made in critically ill hospitalized medical and surgical patients. The widely accepted Mayo criteria for diagnosis requires angiographic proof of normal coronaries. We have published a non-invasive echo based diagnostic algorithm that is applicable widely but especially suitable for the critically ill patients who are not candidates for catheterization or revascularization due to co-morbidities. Typical mental or physical stresses, ECG ischemia and subtle enzyme elevation raise the suspicion of ‘possible SC’. The first test can be an echocardiogram with careful assessment of LV wall motion. Disproportional significant LV dysfunction and regional abnormalities not conforming to a single coronary territory or characteristic apical ballooning raises this diagnosis to ‘probable SC’ at presentation. While unstable or critical coronary disease excludes SC, in a significant portion of the people with this diagnosis, we detect coincidental mild to moderate CAD during catheterization. If symptoms or ECG suggest STEMI, catheterization and revascularization should not be delayed. In many situations, especially in critically ill medical and surgical patients, catheterization is deferred for a few days for medical stabilization. The most specific diagnostic criterion and unique feature of SC is the spontaneous complete normalization of LV function and wall motion; this typically occurs within a few days requiring only supportive care. Thus, repeat echo after 3-5 days of presentation may demonstrate this recovery of LV function, facilitating the diagnosis of ‘definite SC’. Clinical suspicion and echocardiography can optimize SC care.
