**10. Clinical management and therapeutic strategies**

**9.5. Coronary angiography and left ventriculography**

transpiring in the Takotsubo syndrome.

**9.6. Coronary computed tomography angiography**

the LVOT [42], see **Figure 3**.

224 Interventional Cardiology

**9.7. Radionuclide imaging**

The necessity to exclude an acute myocardial infarction in patients presenting with anginalike symptoms and typical ECG-changes predicates the use of coronary angiography. In TTS, the epicardial coronary arteries typically do not have any significant stenoses; however, there is possibility of bystander CAD considering the older age group of the presenting patients. A co-existing CAD has been reported in almost 10% of all TTS cases [50, 51]. The coronary stenosis in this scenario may or may not be hemodynamically significant; however, it is generally insufficient to explain the acute LV dysfunction and regional wall-motion abnormalities

The exclusion of occlusive coronary artery disease, acute plaque rupture, thrombus formation and coronary dissection should be followed by a left ventriculography (if not contraindicated). This is necessary to confirm the pattern of LV wall-motion abnormality and diagnose, if any, mitral regurgitation. It also allows direct measurement of the pressure gradient across

The role of coronary computed tomography angiography (CCTA) is limited to cases where a delay in access to urgent invasive coronary angiography is expected. Information acquired throughout the cardiac cycle (spiral or helical acquisition mode) during the acute phase could demonstrate the typical pattern of systolic dysfunction [52]; however, this would come at the cost of greater radiation exposure. Retrospective evaluation of patients with typical history of

Single-photon emission tomography (SPECT) with 201Thallium or 99mTechnetium-labelled radiopharmaceuticals and 123I-metaIodobenzyl-guanidine (mIBG) has been used to demonstrate

TTS could also theoretically include CCTA to exclude significant coronary stenosis.

**Figure 3.** Laevocardiography of TTS patient with typical apical ballooning triggered by emotional stress.

The clinical management protocol for Takotsubo syndrome is poorly defined as the debate explaining its pathophysiological evolution is yet to be resolved. As most patients present initially with symptoms of angina pectoris, it has been recommended that the first line of management be directed towards the treatment of possible myocardial ischemia. This essentially entails treatment with anticoagulants such as aspirin and heparin. Once occlusive coronary artery disease has been excluded, the objective of treatment is to minimise complications and ensure optimal supportive care. Patients are usually admitted to the coronary care unit to enable seamless continuous ECG-monitoring, serial lab tests and repeated echocardiographic examinations.

Takotsubo patients constituting a low-risk profile, with insignificant compromise to cardiac function (LVEF > 45%) could be discharged from the hospital early, however, only after a thorough review of the cardiovascular risk factors and heart failure medication. Recent preclinical trials have advocated therapy with beta-blockers such as metoprolol and carvedilol in patients with low-risk [26, 56], unless contraindications to use pre-exist.

Interesting observations in this regard are the results published from a study by Templin et al., where the use of angiotensin-converting enzyme-inhibitors or angiotensin-receptorblockers, and not beta-blockers, were associated with improved survival [9].

In patients presenting with severely depressed cardiac output and complications associated with the Takotsubo syndrome, it is advised to stop drugs with sympathomimetic properties (e.g. catecholamines and beta-2-agonists). A therapy with beta-blockers has been recommended in hemodynamically stable patients with atrial and ventricular tachyarrhythmias [10], as also in patients with a hemodynamically significant LVOT obstruction (in combination with an alpha-1-recpetor agonist). In severe manifestations like acute cardiogenic shock, options like use of temporary left ventricular assist devices and extracorporeal membrane oxygenation could be considered. The potential of IABP in this scenario has taken a backseat considering the neutral data presented in the recently concluded IABP-SHOCK II Trial.

The use of inotropes, like norepinephrine or dobutamine, is mostly contraindicated in the Takotsubo syndrome; however, experts have recommended treatment with Levosimendan in patients with advancing cardiogenic shock and multi-organ failure [57–61]. The role of prophylactic anticoagulation with unfractionated or low-molecular weight heparin is also debatable, but experts have suggested that TTS patients with extensive segmental akinesia could be started on a regimen with therapeutic doses of LMWH.
