--- title: Takotsubo syndrome description: What takotsubo syndrome, or "broken heart syndrome", is, why it resembles a heart attack, how it is told apart from one, how it is treated and when to call an ambulance. type: disease aliases: - takotsubo - takotsubo cardiomyopathy - stress cardiomyopathy - broken heart syndrome - apical ballooning syndrome - TTS sources: - tier: guideline org: esc title: 2023 ESC Guidelines for the management of acute coronary syndromes year: 2023 doi: 10.1093/eurheartj/ehad191 url: https://doi.org/10.1093/eurheartj/ehad191 - tier: guideline org: minzdrav-rf title: Острый коронарный синдром без подъема сегмента ST электрокардиограммы year: 2024 doi: 10.15829/1560-4071-2025-6319 url: https://cr.minzdrav.gov.ru/view-cr/154_4 - tier: review title: 'International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology' year: 2018 doi: 10.1093/eurheartj/ehy076 url: https://doi.org/10.1093/eurheartj/ehy076 - tier: review title: 'International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management' year: 2018 doi: 10.1093/eurheartj/ehy077 url: https://doi.org/10.1093/eurheartj/ehy077 - tier: reference org: msd-manuals title: Dilated Cardiomyopathy year: 2026 url: https://www.msdmanuals.com/home/heart-and-blood-vessel-disorders/cardiomyopathy/dilated-cardiomyopathy - tier: reference org: msd-manuals title: Acute Coronary Syndromes (Unstable Angina and Heart Attack/Myocardial Infarction) year: 2026 url: https://www.msdmanuals.com/home/heart-and-blood-vessel-disorders/coronary-artery-disease/acute-coronary-syndromes-unstable-angina-and-heart-attack-myocardial-infarction sources_checked: 2026-10-13 review: null --- Takotsubo syndrome is a temporary problem with how part of the left ventricle contracts; its features resemble an acute coronary syndrome, that is, a heart attack. It is also called stress cardiomyopathy, stress-induced cardiomyopathy or "broken heart syndrome". The name comes from Japanese: it is the word for an octopus trap, which the left ventricle resembles at the end of its contraction. The left ventricle usually recovers its full contraction within a few weeks, but in the acute phase the condition can be dangerous.

The diagram shows the left ventricle in a long-axis section: the solid outline is before contraction, the dashed one at the end of contraction. Normally all the walls, the apex included, contract, and the cavity gets smaller along its whole length. On a heart ultrasound the doctor assesses how the left ventricle contracts as a whole and in each region.

In the most common, apical type of takotsubo syndrome the mid and apical parts of the left ventricle do not contract, while the base contracts more strongly than usual. So at the end of contraction the ventricle has a narrow neck and a rounded, widened apex, like an octopus trap. This is not the only type: the abnormal contraction can also affect the mid part, the base or a small area. Contraction usually recovers completely within a few weeks.

## Why it happens The exact mechanism of takotsubo syndrome is not known. The main role is attributed to a sudden release of catecholamines — substances released by nerves and the adrenal glands when the body responds to stress. The condition is often preceded by severe stress. Emotional stress may be grief (for example, the death of someone close or of a pet), a conflict, fear or panic; sometimes even a happy event is the trigger. Physical stress may be heavy gardening or sport, an illness such as an asthma attack, an injury or a medical procedure. According to studies, about a third of patients have no obvious trigger. Women after the menopause are affected most often. The InterTAK expert consensus (2018) regards sympathetic stimulation as central: current evidence suggests the syndrome is caused by an acute release of catecholamines from sympathetic nerves, the adrenal medulla, or as drug therapy. According to registry data summarised in the consensus, physical triggers are more common than emotional ones; men more often have a physical trigger and women an emotional one. A trigger is not required for the diagnosis. According to the published literature summarised in the consensus, about 90% of patients are women, with a mean age of 67–70 years; men are being diagnosed more often, especially after a physical trigger. According to studies cited by the consensus, takotsubo syndrome is found in about 1–3% of all patients and 5–6% of women presenting with suspected ST-elevation myocardial infarction. The ESC guidelines list takotsubo syndrome among the causes of myocardial injury, that is, troponin release due to mechanisms other than myocardial ischaemia. The Russian Ministry of Health guideline includes stress-induced cardiomyopathy (takotsubo) in its list of causes of a raised troponin not related to type 1 myocardial infarction. Because of the wide range of triggers and patterns, the consensus authors consider it best described as a syndrome. ## Symptoms The most common symptoms are sudden chest pain, breathlessness or fainting. At first glance these cannot be told apart from a heart attack. Sometimes the first signs are complications: [heart failure](../heart-failure/), fluid on the lungs (pulmonary oedema), stroke, cardiogenic shock or cardiac arrest. Takotsubo syndrome is reversible, but in the acute phase the heart can be unstable: according to a large international registry, serious complications in hospital occur in about one in five patients. In patients already in hospital for another reason, takotsubo syndrome may present atypically, with tachycardia, hypotension, heart failure, raised cardiac biomarkers or ECG abnormalities. Contemporary observations show rates of cardiogenic shock and death comparable to those in acute coronary syndrome. Common in-hospital complications include arrhythmias, dynamic left ventricular outflow tract obstruction (LVOTO), cardiogenic shock, ventricular thrombus, pulmonary oedema, ventricular septal defect and free wall rupture. In apical ballooning the basal segments are hyperkinetic and may cause dynamic LVOTO. QT prolongation can trigger torsades de pointes, so the consensus regards takotsubo syndrome as a type of acquired [long QT syndrome](../long-qt-syndrome/). ## How it is diagnosed Takotsubo syndrome is hard to tell apart from a heart attack by its symptoms, so the person is assessed straight away as for a suspected heart attack. The [ECG](../../diagnostic/ecg/) may show changes like those of a heart attack, and the blood level of troponin rises — a protein released by damaged heart muscle cells. To tell takotsubo syndrome from a heart attack, doctors do coronary angiography — an X-ray of the heart's arteries with contrast — together with a contrast study of the left ventricular cavity (ventriculography). A [heart ultrasound (echocardiography)](../../diagnostic/echocardiography/) shows which parts of the ventricle are not contracting and is important for the diagnosis. Cardiac MRI helps to confirm takotsubo syndrome and to tell it apart from [myocarditis](../myocarditis/). Coronary angiography with left ventriculography is considered the gold standard. Under the InterTAK diagnostic criteria, left ventricular dysfunction is transient and presents as apical ballooning or as a midventricular, basal or focal pattern; right ventricular involvement can be present. The regional wall motion abnormality usually extends beyond a single epicardial vascular distribution. The ECG may show ST-segment elevation or depression, T-wave inversion and QTc prolongation, but rarely there are no ECG changes; troponin and creatine kinase are moderately elevated in most cases. Significant coronary artery disease does not exclude the diagnosis. If coronary angiography shows no significant stenoses, the ESC regards myocardial infarction with non-obstructive coronary arteries (MINOCA) as a working diagnosis rather than a final one; takotsubo cardiomyopathy is among its non-coronary cardiac causes. In the Russian Ministry of Health guideline, MINOCA is a working diagnosis in patients with criteria of myocardial infarction in whom coronary angiography shows no stenosis ≥ 50% in any major coronary artery; it requires further investigation to establish the cause. Cardiac MRI can confirm or exclude takotsubo syndrome and distinguish an ischaemic from an inflammatory cause of the damage. In most patients with takotsubo syndrome MRI shows myocardial oedema in the regions with abnormal contraction, and late gadolinium enhancement is usually absent. ## How it is treated No prospective randomised trials have shown how best to treat takotsubo syndrome, so treatment is largely supportive: the heart is supported while it recovers, and complications are treated. At first the person is managed as for a suspected heart attack, in a cardiology unit where coronary angiography can be done, with ECG monitoring. Which medicines are needed and for how long is decided by the doctor. The left ventricle usually recovers its full contraction within 4–8 weeks. Follow-up after discharge still matters: data on the long-term outlook are scarce, but in some studies long-term mortality after takotsubo syndrome was comparable to that of people with coronary artery disease, and in a small proportion of people the condition comes back, sometimes years later. Anxiety and depression are common in people with takotsubo syndrome; rehabilitation that combines cardiac and psychological care may help them. The ESC notes that the management of takotsubo syndrome is not informed by any prospective randomised controlled trials and is largely supportive and empiric. The Russian Ministry of Health guideline recommends managing patients with MINOCA according to the guidelines for the specific cause diagnosed. The InterTAK consensus proposes that on first presentation patients are transferred to a cardiology unit with imaging capabilities and a catheterisation laboratory and managed as for acute coronary syndrome; patients with cardiogenic shock or after cardiac arrest need intensive care, and ECG monitoring is essential because a prolonged QT interval may trigger malignant ventricular arrhythmias and AV block may occur. Patients with cardiogenic shock, particularly with apical ballooning, should be promptly evaluated for LVOTO. The consensus's drug recommendations rest on limited data and expert experience, so they are not given here. In a recurrent episode the trigger and the ballooning pattern may differ from the first. ## When to call an ambulance If you have sudden chest pain, pressure or discomfort, breathlessness or fainting, call your local emergency number (112 in the EU, 911 in the US and Canada, 999 in the UK) at once. At first glance takotsubo syndrome cannot be told apart from a heart attack, and only a doctor can find the cause. Heart attack pain is usually in the middle of the chest and may spread to the back, jaw or left arm; there may also be a feeling of faintness or actual fainting, sudden heavy sweating, nausea and breathlessness. Do not lose time phoning relatives or friends: prompt transport to hospital by ambulance may save a life. More about the signs of a heart attack is in the article on [coronary heart disease](../coronary-heart-disease/).