Behavioral Health: Complementary Therapy in Takotsubo Cardiomyopathy

Stress can be a daily occurrence in our personal and professional lives. Many would agree that stress is an unavoidable reality.

How do we cope with stress or traumatic emotional events? Are we aware of the negative impact of stress on our physical and mental well-being? According to the American Heart Association, depression, stress and anxiety can have immediate and long-term effects on our heart health and lead to cardiovascular disease. Takotsubo cardiomyopathy (TCM) is a form of acute, reversible heart failure precipitated by stress.

Our patient care is improved when we are aware of the effects of stress on the cardiac system, the incidence of TCM, its risk factors, diagnosis and treatment strategies, including stress and anxiety management.

TCM is a cardiac syndrome involving left ventricular akinesis. The estimated incidence is 0.02% of all U.S. hospitalizations and 2% of all acute coronary syndrome presentations.

First described in Japan in 1990, TCM is a temporary, reversible form of cardiomyopathy. Takotsubo is a Japanese term that refers to an octopus fishing pot. With its round bottom and narrow neck, the pot resembles the left ventricle in patients with TCM during systole.

Epidemiology

TCM is usually the result of severe or sudden emotional or physical stress. Ninety percent of cases occur in postmenopausal women ages 58-75. Most patients recover with no long-term damage. TCM is often referred to as stress-induced cardiomyopathy or broken heart syndrome. Jabri et al found that the incidence of TCM increased during the COVID-19 pandemic.

Causes and Risk Factors

Common examples of emotional or physical stress include labor/delivery, serious illness, severe pain, domestic violence, accidents, grief, receiving bad news, unexpected loss or surprise. Risk factors include estrogen deficiency, genetic factors, smoking, alcohol abuse, anxiety, hyperlipidemia and age over 50.

Pathophysiology

The accepted theory for TCM is that emotional/physical stress can lead to increased central nervous system stimulation and catecholamine (such as epinephrine and norepinephrine) release. High catecholamine levels lead to myocyte injury. In essence, "stress hormones" stun the myocardium, or blood vessels, and prevent the left ventricle from contracting effectively.

Clinical Presentation

The acute stage of TCM is suggestive of coronary artery disease. It mimics myocardial infarction: chest pain, dyspnea, diaphoresis, nausea, dysrhythmia and ECG changes. The majority of patients will remain hemodynamically stable, but some may develop severe left ventricular dysfunction, acute heart failure, cardiogenic shock or sudden cardiac death.

Diagnostic Tests

Diagnostic tests for TCM include ECG, troponin, echocardiogram and imaging (cardiac catheterization with ventriculogram, chest x-ray and MRI).

Diagnosis is based on Mayo Clinic criteria proposed in 2004. This criteria includes transient dyskinesis of the left ventricle with or without apical involvement, absence of obstructive coronary artery disease, new ECG abnormalities, ST segment elevation or T-wave inversion, modest elevation of troponin and absence of pheochromocytoma and myocarditis.

This ventriculogram image is characteristic of TCM, with akinesis and dyskinesis of the apex and mid apical segments, causing them to dilate or balloon, and hyperkinesis of the base of the ventricle. For greater detail on pathophysiology and diagnosis, see this review article.

Treatment

Initial medical treatment may include oxygen, IV heparin, ASA and beta blockers. Identify any signs of severe left ventricular dysfunction and provide supportive treatment. Ongoing treatment may include beta blockers, angiotensin converting-enzyme (ACE) inhibitors, angiotensin receptor blockers, anticoagulants (if LV thrombus is present) and, in our health system, behavioral health support/consult.

Stress and anxiety management are essential for the treatment of patients with TCM. Interventions may include risk reduction, education, exercise, relaxation breathing, mindfulness, supportive touch, observing and self-compassion. Many resources are available for these risk-reduction techniques.Stress may be an unavoidable reality in our lives; however, techniques can be routinely implemented to manage stress and lower the risk of developing cardiovascular disease.

Review these case studies for treatment strategies, including both medical and behavioral health recommendations that were individualized to each patient:

Case Study Number 1

A 55-year-old female was admitted with chest pain and hypertension. She has a history of anxiety, palpitations and hypothyroidism. She experienced stress during an intense discussion at a sporting event. Her initial tests showed serum troponin of 0.32 ng/mL (normal 0-0.04 ng/mL) and no ST elevation on ECG. She was started on IV heparin. An echocardiogram showed left ventricular hypokinesis with an ejection fraction (EF) of 35% (normal 50%-75%), and a coronary angiogram was normal.

Diagnosis: TCM
Treatment: Beta blocker, ACE inhibitor and clonazepam for anxiety. She was started on relaxation and meditation techniques.
Follow-up: Echo normal with an EF of 55%-60%

Case Study Number 2

A 40-year-old female was admitted with chest and arm pain. She has a history of anxiety, recent travel and grief, and coronary artery disease. Initial tests showed a serum troponin of 0.21 ng/mL and ST depression in anterior leads of the ECG. An echocardiogram and a coronary angiogram were normal.

Diagnosis: TCM based on elevated troponin, ECG changes and a recent stress/anxiety event.
Treatment: Sertraline, pravastatin
Follow-up: Integrated behavioral health for anxiety management including education, exercise, relaxation breathing and mindful self-compassion

Case Study Number 3

A 53-year-old female was admitted with chest pain, feeling foggy and palpitations that began during work-related stress, including co-workers quitting. Past medical history includes mitral valve prolapse. The initial serum troponin was 2.38 ng/mL, and an ECG demonstrated ST elevation in the inferior leads. A coronary angiogram was normal, but the left ventriculogram showed severe akinesis in the distal apical segments and an EF of 50%-55%.

Diagnosis: TCM
Treatment: Beta blocker, ACE inhibitor
Follow-up: Integrated behavioral health, stress management, yoga, journaling and family support

Prognosis

Most people recover from TCM in about three to four weeks, although treatment may be continued for up to 12 months. The death rate is less than 2% of all cases, and recurrence of TCM is rare. Reducing and managing stress is essential to recovery and decreases the risk of recurrence.

What stress-reducing methods are part of your daily routine to manage stress and decrease risk factors for developing cardiovascular disease?