Of Octopus Pots and Broken Hearts

To the Editor:

The angiographic finding of noncritical coronary stenoses in the setting of acute coronary syndrome and even myocardial infarction has been well described. One potential etiology is Prinzmetal’s angina or coronary spasm.¹ More recent Japanese literature, however, has described the so-called “octopus fishing pot”, or takotsubo cardiomyopathy, which refers to the distinctive left ventricular silhouette. The distinctive apical ballooning with basal hypercontractility resembles that of the pot used by Japanese fishermen for trapping octopi.² Also known as the “broken heart” syndrome, it is typically preceded by severe emotional trauma. Cardiac enzyme levels are normal or mildly elevated, despite typical angina and electrocardiographic ST-segment elevations.³

A representative catheterization is depicted in Figure 1. This 54-year-old male experienced severe and persistent substernal pain associated with precordial ST-segment elevation after completing a treadmill stress test. Emergent cardiac catheterization revealed no critical coronary stenoses. Left ventriculography, however, demonstrated a large akinetic apical area with compensatory hypercontractility of the basal segments. Although his angina continued for several hours post-angiography, cardiac marker elevation was only borderline. Subsequent questioning revealed that he had been deeply saddened by his infant granddaughter’s recent demise. Two months later, echocardiography showed near-normalization of left ventricular wall motion.

For these patients, treatment should be conservative, including hemodynamic support when required. Recent studies have demonstrated high plasma catecholamine levels during the event.² Unlike most other reported cases, physical exertion was the inciting event in this case. While his recent family tragedy likely provided the background emotional milieu, the exercise-induced catecholamine surge may have triggered the attack. The direct cardiotoxic effects of catecholamines are well documented.^4,5 Frequently, left ventricular function normalizes within weeks to months, and these individuals experience a benign prognosis.¹

Both epicardial and microvascular coronary spasm may be contributory. In their series of 30 takotsubo patients, Kurisu and colleagues observed simultaneous multivessel coronary spasm in 9 patients (3 spontaneous, and 6 in response to ergonovine or acetylcholine).³ However, no clear correlation has been demonstrated with Prinzmetal’s angina. The mechanism of the iconic apical ballooning, however, remains unclear.

Thus, while patients likely do not die from broken hearts, such emotional trauma can certainly result in organic consequences. Although long-term prognosis is usually benign in these individuals, some can experience significant clinical instability in the acute setting. When presented with this rare reversible cardiomyopathy, physicians can be reassured that their patient’s outlook, unlike that of the trapped octopus, may be quite positive.

References

1. Spritzler R, Corday E, Bergman HC, et al. Studies on the coronary circulation. VIII. Demonstration of spasm of the major coronary arteries. Cardiologia 1952;21:255–258.

2. Akashi YJ, Nakazawa K, Sakakibara M, et al. The clinical features of takotsubo cardiomyopathy. QJM 2003;96:563–573.

3. Kurisu S, Sato H, Kawagoe T, et al. Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction. Am Heart J 2002;143:448–455.

4. Mann D, Kent RL, Parsons B, et al. Adrenergic effects on the biology of the adult mammalian cardiocyte. Circulation 1992;85:790–804.

5. White M, Wiechmann RJ, Roden RL, et al. Cardiac beta-adrenergic neuroeffector systems in acute myocardial dysfunction related to brain injury. Circulation 1995;92:2183–89.