Takotsubo cardiomyopathy and arrhythmic risk: the dark side of the moon

"Takotsubo" cardiomyopathy (TTC) is a clinical disorder usually triggered by intense emotional and/or physical stress, characterized by reversible severe localized left ventricular wall dyskinesia, transient changes of ST segment, without significant coronary artery stenoses, that can mimic acute myocardial infarction.

Although TTC is well known to have a good mid- and long-term prognosis, arrhythmic risk is increasingly recognized and we could provide, in view of the available literature, a mean for a prognostic stratification and some practical suggestions for management of these "vulnerable" patients.

Further studies with randomized trials will be needed to prove the optimal treatment of TTC.

TTC, generally considered a benign syndrome, should be reconsidered as a clinical condition at high risk for lethal arrhythmias in a subpopulation with QTc > 500 msec in acute phase. The studies about arrhythmias and TTC are based on case reports. TTC may present with sudden cardiac death: this results in a probable underestimate of the real arrhythmic risk. TTC is one of the causes of acquired long QT syndrome and could be a trigger able to unmask latent silent or inapparent congenital long QT syndrome. All factors that can exacerbate QT prolongation should be promptly removed. In the case of marked bradycardia and/or TdP should be implant a temporary pacemaker. In most cases, due to the transient nature of the syndrome, it is reasonable to recommend only beta-blocker therapy at discharge, despite the absence of randomized trials. If there are high-risk factor for long QT syndrome (QTc post-TCM > 500 ms, prior syncope, previous cardiac arrests) thought should be given an indication to ICD implant.