Stress cardiomyopathy overview

# Overview
Stress cardiomyopathy is a relatively new disease, with the first case documented in literature under the name of Takotsobu Cardiomyopathy in Japan in 1991. It is not very well understood, but the disease is thought to arise following intense emotional or physical stress. Stress cardiomyopathy mostly affects post-menopausal women. The clinical presentation, laboratory findings and imaging studies largely mimic that of anterior MI. However, the absence of significant coronary artery stenosis supports the diagnosis of stress cardiomyopathy. It is generally a self-limiting disease and the majority of patients have a restored cardiac function within a matter of weeks. Complications and death are relatively rare, but they are mostly related to the development of heart failure and pulmonary edema.

# Historical Perspective
Stress cardiomyopathy is a relatively new disease, with the first case documented in literature in Japan in 1991. However, cases of death upon going through severe emotional or psychological stress have been described as early as the biblical times.

# Classification
Stress cardiomyopathy can be divided into several types, depending on the location of regional wall motion abnormality. The area of motion abnormality (whether hypokinesia, dyskinesia or akinesia) can be detected on echocardiography or left ventriculography. The most common type is the apical type, resulting in apical ballooning.

# Pathophysiology
The pathogenesis of stress cardiomyopathy is not completely understood. However, the most accepted theory behind it is thought to be due to catecholamine surge, which are thought to contribute to myocardial necrosis and stunning seen in stress cardiomyopathy. On biopsy, findings include an inflammatory infiltrate, fibrosis and formation of contraction bands, which may or may not be associated with myocardial necrosis. Stress cardiomyopathy is associated with various neurological and psychological conditions.

# Causes
The cause of stress cardiomyopathy is largely unknown. However, it is usually triggered by emotional and/or physical stress and may be related to certain medical conditions.

# Differentiating Stress Cardiomyopathy from Other Diseases
The clinical presentation, laboratory findings and imaging studies of stress cardiomyopathy resembles that of anterior MI and must be differentiated from it. Also, stress cardiomyopathy must be differentiated from other medical conditions, such as pheochromocytoma, dilated cardiomyopathy and hypertrophic cardiomyopathy.

# Epidemiology and Demographics
The true incidence and prevalence of stress cardiomyopathy is unknown. However, this disease most commonly affects post-menopausal women, with the mean age of diagnosis ranging between 58-75 years.

# Risk Factors
Stress cardiomyopathy seems to be triggered by intense emotional or physical stress, mostly the unexpected death of a loved one.

# Screening
There are no screening recommendations for stress cardiomyopathy.

# Natural History, Complications and Prognosis
The prognosis of stress cardiomyopathy is generally excellent, with most patients making a complete recovery within a matter of weeks. However, death from complications of heart failure and heart rupture may occur.

# Diagnostic Criteria
In 2004, researchers at the Mayo Clinic proposed a criteria for the diagnosis of stress cardiomyopathy. All 4 points of the criteria must be fulfilled, which include ruling out other medical conditions, such as obstructive coronary disease, myocarditis and pheochromocytoma.

# History and Symptoms
The most common presenting symptoms of stress cardiomyopathy are shortness of breath and chest pain.

# Physical Examination
Physical examination findings in patients with stress cardiomyopathy are non-specific and non-diagnostic. The diagnosis of stress cardiomyopathy is largely based on ECG, echocardiographic findings, as well as cardiac catheterization.

# Laboratory Findings
Elevated levels of catecholamines, cardiac enzymes and BNP may be seen in patients with stress cardiomyopathy. However, none of these laboratory findings are specific to stress cardiomyopathy.

# ECG
ECG findings in stress cardiomyopathy are similar to those seen in anterior MI. The most common findings include ST elevation in the precordial leads, T wave inversion and the formation of a Q wave. Findings on ECG include:

# Chest X-Ray
Typical findings on chest x-ray include apical ballooning and narrowing of the neck.

# CT Scan
A CT scan may be done in patients with stress cardiomyopathy to asses coronary anatomy, as well as detect the presence of regional wall motion abnormalities.

# MRI
Cardiac magnetic resonance (CMR) is a useful imaging modality in distinguishing between stress cardiomyopathy and myocarditis or MI. The most common findings on CMR in patients with stress cardiomyopathy include absence of gadolinium hyper-enhancement, as well as myocardial edema.

# Echocardiography
Echocardiography is done in patients with stress cardiomyopathy to document apical ballooning, dyskinesia/akinesia and reduced ejection fraction.

# Other Imaging Findings
In patients with stress cardiomyopathy, coronary angiography usually shows normal anatomy of the coronary arteries no evidence of coronary artery stenosis.

# Other Diagnostic Studies
Coronary angiography and cardiac catheterization are the diagnostic modalities of choice to distinguish between stress cardiomyopathy and acute anterior MI. Normal anatomy of the coronary arteries, along with a reduced ejection fraction supports the diagnosis of stress cardiomyopathy.

# Medical Therapy
Medical therapy in stress cardiomyopathy is indicated to treat the complications that may arise. The most common complications related to stress cardiomyopathy include heart failure and pulmonary edema. Diuretics and anti-heart failure medications are the treatment of choice in these conditions.

# Surgery
Treatment of stress cardiomyopathy is mostly supportive and medications are used to treat complications. There is no role for surgery in the treatment of stress cardiomyopathy.

# Primary Prevention
There are no means of prevention of stress cardiomyopathy.

# Secondary Prevention
Stress cardiomyopathy is a self-limiting disease, which usually resolves within a few weeks. However, medical therapy may be necessary during the acute phase of the illness or when complications arise.