Treatment

Treatment is mostly symptomatic and consists of supportive care and treatment of complications and comorbidities (e.g., acute heart failure, arrhythmias).

• Heart failure management

  • Treat as systolic heart failure (see “Treatment” in heart failure).

  • ACE inhibitors (e.g., lisinopril)

  • Low-dose beta blockers (e.g., metoprolol tartrate)

• Inotropic support: Dobutamine and dopamine can be used; however, both can cause tachycardia and worsening of takotsubo cardiomyopathy, and so other agents, e.g., levosimendan, may be preferable. Patients receiving inotropic support should be monitored closely for the development of LVOT. [1]

• Vasopressor support: if inotropes are insufficient [1]

• Advanced therapies: consider in refractory cases

  • Intra-aortic balloon pump (IABP)

  • Left ventricular assist device

  • ECMO

LVOT obstruction (occurs in up to 25% of cases) [1]

LVOT obstruction further impairs LV systolic function and can be very difficult to treat. Inotropic support should be avoided, as this can precipitate cardiogenic shock in patients with LVOT obstruction.

• IV fluids: may improve LV systolic function

• Beta blocker: Use of a short-acting, low-dose beta blocker (if tolerated) may be helpful to relieve LVOT obstruction but should be used with caution in patients with hypotension. [12]

• Vasopressor support: in cases of shock

• Advanced therapies: consider in refractory cases

  • Left ventricular assist device

  • ECMO

• The following therapies should be avoided:

  • Inotropes

  • Vasodilators

  • Nitroglycerin

  • Diuretics

  • IABP

Avoid inotropes, as they can worsen LVOT obstruction and precipitate cardiogenic shock.

• Empiric treatment of ACS: Consider until ACS is ruled out (see “Treatment” in acute coronary syndrome and “Diagnostic criteria” above).

• VTE prophylaxis: consider especially in patients with reduced apical motion and all unstable patients

• Prevention of arrhythmia

  • Monitor for at least 48 hours with continuous telemetry.

  • Consider beta-blocker therapy (e.g., metoprolol tartrate).

• Chronic therapy

  • Most standard heart failure therapies have no known significant benefits for patients with takotsubo cardiomyopathy.

  • Consider chronic beta blocker therapy (e.g., metoprolol tartrate).

  • Consider a chronic ACE inhibitor or ARB (e.g., lisinopril, losartan).

• Identify and treat the underlying cause: e.g., SSRI therapy for depression

Although most patients recover within days to weeks, relapses are not uncommon and in-hospital deaths occur especially in patients with complications leading to cardiogenic shock.

• Recovery: within 1–2 weeks in most cases [1]

• Recurrence rate: 2–4% per year [1]

• In-hospital mortality: up to 5%

Prevention:

• Avoid triggers of physical and/or emotional stress.

• Consider chronic beta blocker and/or ACE inhibitor/ARB therapy. [1][9]

• Consider assessment (and referral to treatment) for mental health comorbidities. [1]