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Takotsubo cardiomyopathy is a sudden, transient and life-threatening cardiomyopathy. It usually occurs after severe emotional or physical stress, especially in postmenopausal women. A death of a loved one is an example of the emotional stress which can bring on this syndrome. It is also called transient left ventricular ballooning syndrome or stress cardiomyopathy. It can also occur with sepsis, shock, or be the result of a phaeochromocytoma. See Phaeochromocytoma.


During the attack, the shape of the LV changes. It becomes enlarged and rounded and resembles a ‘takotsubo’, a Japanese octopus trap (a chamber with a narrow neck and a round bottom). The cause is unknown, but it is hypothesised that:

  1. Severe emotional/physical stress leads to an intense sympathetic discharge.

  2. This excess catecholamine surge leads to myocardial stunning.

  3. The adrenaline surge suddenly increases SVR, raising blood pressure.

  4. Spasm of the coronary arteries may occur.

  5. There is sudden congestive heart failure.

Clinical presentation

The presentation is indistinguishable from an acute coronary syndrome. Symptoms and signs include:

  1. chest pain

  2. dyspnoea

  3. hypotension, syncope

  4. dysrhythmia/palpitations

  5. nausea

  6. cardiac arrest.


  1. ECG—may show changes consistent with anterior myocardial infarction.

  2. Troponin elevation may occur.

  3. Coronary angiography—normal coronary arteries or minimal disease, shape of ventricle as described for echocardiography.

  4. Echocardiography—bulging of the LV apex with a hypercontractile base (resembles a rounded container with a narrow, thickened neck).


  1. Treat this condition as a myocardial infarction until takotsubo cardiomyopathy is diagnosed.

    See Acute coronary syndrome and Cardiogenic shock.

  2. The use of catecholamines may be problematic as the condition is probably caused by catecholamine excess. Catecholamines may increase the degree of left ventricular outflow obstruction. Optimise fluid therapy and consider vasopressors. Mechanical circulatory support may be required. Seek expert cardiologist referral and management.

  3. Beta blocker drugs, or combined alpha and beta receptor blocker drugs e.g. labetalol may be used to prevent the recurrence of attacks.



Analgesic opioid drug agonist at the mu, delta and kappa opioid receptors used orally. See Opioid receptors. Also acts by inhibiting noradrenaline reuptake, which is useful for treating neuropathic pain. Tapentadol was developed from tramadol. It is a much weaker inhibitor of serotonin reuptake than tramadol.




Immediate-release (IR) form: 50–100 mg PO up to every 4–6 h. Max 600 mg/day. Extended-release (ER) form: 100 mg q 12 h.


  1. Effective oral analgesic—50 mg tapentadol is equivalent to ...

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