Cardiogenic shock in Takotsubo syndrome: Insights into phenotype-tailored management

Takotsubo syndrome (TTS) is an acute and reversible condition that mimics acute coronary syndromes but occurs in the absence of coronary disease. Cardiogenic shock in TTS (CS-TTS) represents its most severe complication, affecting up to 25% of the cases and multiplying by six by six in-hospital mortality. CS-TTS is heterogeneous, arising from multiple and often overlapping mechanisms. Beyond classical pump failure due to severe systolic dysfunction, distinct phenotypes include dynamic left ventricular outflow tract obstruction (LVOTO) with mitral regurgitation, isolated or combined right ventricular failure, and rare mechanical complications. Additionally, vasoplegic and mixed shock can further expand the hemodynamic spectrum. Phenotype recognition guides therapy: pure pump failure may require cautious short-term inotropes or unloading mechanical support; LVOTO-mediated shock contraindicates catecholamines and favors cautious volume, pure vasopressors, and short-acting β-blockers; vasoplegia requires vasopressors; RV failure needs inotropes and preload optimization. Prospective phenotype-guided trials are urgently needed.