Okay team, with spooky season in full swing, let’s talk about some scary stuff . . . chest pain. You’re on red team and they’ve just roomed a 54 year old female with a history of HTN presenting with acute onset chest pain immediately after hearing news that her brother had died, about 30 minutes prior to arrival. The pain is substernal, non-radiating, and described as “pressure-like”. Her systolic BP is in the 150s, but the rest of her vitals are normal. She appears distraught and in pain, but the rest of her exam is unrevealing.
The initial ECG is surprisingly unremarkable, but you aren’t fooled! In the back of your brain you hear the tickle of Dr. Murray whispering “consider the probe”, and those sound waves reveal some impressive regional wall motion abnormalities that prompt you to get cards on speed dial while reaching for the aspirin. When that trop comes back at 300, cards is convinced and she’s started on heparin and nitro gtt with a plan for LHC in the AM. Alas, what does that cath reveal? None other than some squeaky clean coronaries - just a sweet woman with a broken heart.
Let’s talk about TAKOTSUBO CARDIOMYOPATHY
Takotsubo means “octopus pot”, named after the fishing vessel used to trap octopus, in reference to the dilated cardiac apex often seen on imaging. Takotsubo is a classic mimic of ACS, but overwhelmingly found in women (90%), typically following an emotional or physical trigger, though roughly one-third of cases have no identifiable trigger. RWMAs are transient, usually apical (80%) followed by midventricular (15%), basal, and focal patterns, all extending beyond a single coronary distribution. While some patients may have co-existing CAD, the absence of a culprit occlusion defines this diagnosis - so everyone still gets a cath.
COMPARISON TO ACS
In a large groundbreaking study using the International Takotsubo Registry (N = 1,750), when compared to ACS sex and age-matched counterparts, Takotsubo patients had the following statistically significant findings1:
Higher rates of neurologic or psychiatric disorders (55.8% vs 25.7%)
Similar rates of STE (44% vs 50%) and lower STD (8% vs 30%) on ECG
QTc prolongation more common (39% vs 31%)
BNP markedly higher (5.89× ULN vs 2.91× ULN)
Higher rate of reduced LVEF (86.5% vs 54.2%)
PATHOPHYSIOLOGY
Why this happens is still up for debate, but a small case series noted that patients with Takotsubo had catecholamine levels 2–3× higher than those with MI2. Theories center on catecholamine-driven microvascular dysfunction, leading to spasm, supply-demand mismatch, inflammation, and myocardial stunning. A loss of estrogen-mediated vascular protection may also contribute given its predominance in post-menopausal women3.
OUTCOMES
Don’t be fooled—these patients can have significant complications. Compared to ACS, Takotsubo patients have similar rates of cardiogenic shock (12% vs 10%) and death (4% vs 5%). They may also develop new arrhythmias or an LV thrombus. One complication of acute heart failure to watch for is LV outflow tract obstruction (LVOTO), seen in around 7% of patients4.
PEDIATRICS
Takotsubo in kiddos is quite rare, but this Halloween there are no treats, only tricks. One small study of Takotsubo in peds revealed more associated physical triggers and a more balanced sex distribution when compared to adults. Perhaps less severe cases are not identified, but peds patients seem present sicker than adults, with increased need for vasoactive (70% vs 30% in the general population) and mechanical ventilatory support (50% vs 20% in the general population). Death and rates of recurrence are about the same as in our adult population5.
TREATMENT
Management is largely supportive, focusing on heart failure or volume overload. Use pressors and inotropes when needed, and have those pads ready for any unstable arrythmias, but beware of LVOTO. Not to get too in the weeds, but this is a dynamic obstruction caused by systolic anterior motion of the mitral valve. Unfortunately, inotropes can worsen this obstruction, while volume resuscitation and beta blockers may help, so consider this possibility if your current treatments are failing. Although recurrence of Takotsubo occurs in ~5%, thankfully 95% of patients recover fully within a few months3.
CONCLUSION
In the end your patient did great after their cath. Their pain resolved and follow up imaging a few weeks later revealed resolution of the RWMA. Despite the spooky presentation, you weren’t tricked by the octopus disguise, getting the patient the proper care so they can live to see another Halloween.
TL;DR
Even if you suspect Takotsubo, early angiography is essential.
Never forget the probe—your echo can make the diagnosis.
Watch for complications: shock, arrhythmia, LV thrombus, LVOTO
Most recover fully, but a broken heart can still break bad.
POCUS
Some comprehensive echo videos for your viewing pleasure from my own patient with Takotsubo:
CITATIONS
Templin C, Ghadri JR, Diekmann J, et al. Clinical features and outcomes of Takotsubo (stress) cardiomyopathy. NEJM. 2015;373(10):929–938.
Wittstein IS, Thiemann DR, Lima JAC, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. NEJM. 2005;352(6):539–548.
Li M, Nguyen CN, Toleva O, Mehta PK. Takotsubo syndrome: A current review. Maturitas. 2022;166:96–103.
Di Vece D, Bellino M, Silverio A, et al. Clinical characteristics and outcomes of patients with Takotsubo syndrome and LV outflow tract obstruction. JACC Cardiovasc Imaging. 2025;18(1):119–121.
Vazirani, R., Rodríguez-González, M., Castellano-Martinez, A., Andrés, M., Uribarri, A., Corbí-Pascual, M., Alfonso, F., Blanco-Ponce, E., Lluch-Requerey, C., Fernández-Cordón, C., Almendro-Delia, M., Cruz, O. V., & Núñez-Gil, I. J. (2024). Pediatric takotsubo cardiomyopathy: A review and insights from a National Multicentric Registry. Heart Failure Reviews, 29(4), 739–750. https://doi.org/10.1007/s10741-024-10394-x
Authored by Samson Frendo MD and Eric Leser MD