Note: Takotsubo Syndrome is also referred to as ‘Takotsubo Cardiomyopathy’
Recovery from Takotsubo Syndrome
When Takotsubo Syndrome (TTS) was first recognised, it was thought to be a benign condition, from which most people recovered quickly and completely in a short period of time. People with TTS were generally discharged from hospital within 2-5 days of presentation with very little information about the condition and were not informed or prepared for the symptoms that many experienced after discharge.
The reality is that it is common to experience fatigue, shortness of breath and inability to exercise or continue normal activities for weeks to months after TTS. A 2018 study published by Scally and colleagues in Aberdeen found that many people have persistent limiting symptoms and reduced exercise capacity after TTS. Moreover, this important study showed that there were genuine changes in the heart muscle in the heart muscle’s ability to utilise energy. It was also found that TTS could progress to a persistent type of heart failure in some people.
Key point: Research has shown that quick and complete recovery is not the case for most people with TTS, but there is still a common misconception among some health professionals The TTS is a benign condition from which people recover quickly and completely.
If my echocardiogram and ejection fraction (EF) is normal now, why don’t I feel back to normal?
The ejection fraction (EF) reflects the percentage of blood pumped out of your heart’s lower chambers (ventricles) each time it contracts. The is used as an indicator of how well your heart is pumping. Usually it is the left ventricle is most affected by TTS, so it is the left ventricular ejection fraction (LVEF) that we are referring to when we talk about EF. The EF is measured using an echocardiogram (ultrasound of the heart).
A standard echocardiogram usually suggests that the EF has returned to normal limits (albeit usually the lower limits of normal) with a few days of TTS occurring. While the standard echocardiogram is a valuable tool in many cardiac conditions, standard EF measurement techniques have limitations for assessing recovery in TTS. For people with TTS, additional measurements including longitudinal strain and left ventricular twist using speckle tracking technology are more sensitive in detecting more subtle abnormalities on the echocardiogram.
Longitudinal strain measures the change in length of the heart muscle in different directions during contraction. Studies in patients with TTS have shown global abnormalities in longitudinal strain that affect the pumping ability of the entire left ventricle. These abnormalities often persist even after the EF on a standard echocardiogram appears to be within normal limits.
The other measurement is left ventricular twist. When the left ventricle contracts, it also has a wringing motion (twist) where the top of the ventricle rotates in one direction and the bottom of the ventricle rotates in the opposite direction as the LV contracts. Picture trying to squeeze water out of a dish cloth. If you just squeeze it some of the water will be removed. If you twist the top and bottom of the dish cloth in different directions in a wringing motion, more water will be removed than if you simply squeeze it. This wringing motion of the LV assists in pumping blood out of the LV to the rest of the body. After contraction, the LV untwists and this helps to pull more blood into the LV to send to the body during the next contraction. Reduced global left ventricular twist and untwist rate are found in people who have TTS and this negatively impacts on the hearts ability to pump efficiently. It can also produce persistent symptoms such as fatigue, shortness of breath, chest pain, palpitations, light-headedness, inability to exercise and perform some activities.
Key point: For people who have had TTS, longitudinal strain patterns and left ventricular twist measurements are more sensitive markers of how effectively the LV is pumping, compared to EF alone.
Key point: Medications including beta blockers and ace inhibitors or angiotensin receptor blockers are currently routinely prescribed following an episode of TTS and these may produce fatigue and light-headedness in some people.
This is a question that almost everyone asks, and there is no ‘one size fits all’ answer! Your physical activity at home will be largely guided by how you are feeling, but it is important to try and be as active as you can be without causing symptoms. If you have access to a Cardiac Rehabilitation program, this may help to guide your activity levels and offer information and support.
Cardiac rehabilitation (CR) is a supervised program that is supervised by health professionals, usually over the period of a few weeks. CR was created for patients with cardiovascular disease (CVD) with the aim of reducing cardiac risk factors and promoting a lifestyle for good cardiovascular health. CR generally involves exercise training, emotional support and education about a heart-healthy lifestyle.
CR programs are not consistently offered to people with TTS and you may need to ask your health provider about it if you would like to attend. Reasons for this are poor referral rates by doctors/nurses, and programs that are not resourced or designed to support patients without CVD. There are a small number of studies of safety and benefit of CR programs for patients with TTS, but evidence from larger randomised studies is lacking. Anecdotally from members of the TTS Support Group, benefit of the exercise program may be related to timing and stage of TTS recovery, which differs for individuals. Some people with TTS take longer to recover their exercise capacity, and starting an exercise program too soon does not work for them. For some people with TTS, CR support is important in that they do still maintain a source of contact with health professionals, receive information about optimal heart health, and have the opportunity to undertake supervised exercise, but more information and support that is TTS-specific would be useful.
In the general population, chest pain is quite common and has many causes. Some of these can be life threatening, such as heart attack. Many causes of chest pain are not related to the heart. Some causes of chest pain, such as musculoskeletal pain or indigestion, are more uncomfortable than medically dangerous, but it is not always easy to know the difference between life threatening and non-life threatening chest pain.
The chest pain initially experienced with TCM is the same type of pain experienced in a heart attack, and until tests are conducted in the hospital Emergency Department (ED), it is not clear whether the pain is caused by a blockage in one of the heart’s arteries (heart attack), TCM, or other cause.
Key point: It is not uncommon to experience chest pain during the recovery phase of TCM.
Chest pain is a common occurrence after TTS, but it is often different to the type of pain experienced at the onset of TTS. There are several potential causes of chest pain after TTS. Some may just require simple analgesia or rest, but some causes of chest pain following TTS may require urgent medical review. This presents a common problem for people soon after TTS: it is difficult to know whether to go to the ED, call an ambulance, or stay home. Some people who have been to the ED feel that they have not been taken seriously, or dismissed as being anxious. As with any chest pain, if you are concerned about it, then you should seek medical attention. The links to a few health authorities below provide information on what to do about chest pain. Each country has its own emergency number for an ambulance so it is a good idea to find the relevant authority in your country (if not listed here) to read content about chest pain management and emergency ambulance contact details.
To date, there have been no published studies of causes of chest pain following TTS, and it is difficult to say whether there is a common cause, or several different causes of pain after TTS. Is known that TTS results in inflammation in the muscle of the heart. This is a common cause of chest discomfort after the acute episode of TTS. The pain due to inflammation in the heart muscle tends to be a bit different in nature to the pain experienced in the initial hours of TTS. The pain may be less specific, and symptoms such as shortness of breath may be present. This inflammation can also spread to the pericardium, causing pericarditis. The pericardium is a sac that surrounds the heart. It has an inner and outer layer with a small amount of fluid between the layers. This fluid reduces friction between the outer layers of the pericardial sac as the heart beats within it. When the two layers become inflamed, as sometimes happens after TTS, the two layers rub together and cause pain. Fluid accumulation in the pericardial sac can also cause pain and lead to significant complications. The classic symptoms of pericarditis are sharp and severe chest pain that is worse when you breathe in deeply. The severity of the pain is usually altered by position in that it improves with sitting up and leaning forward, and is worse on lying down. However, when there is inflammation in the myocardium also, the pain may be less specific.
