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cardio.cardiogenic-shock.takotsubo.v1

Cardiogenic shock — Takotsubo (stress) cardiomyopathy

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Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to Takotsubo (stress) cardiomyopathy with cardiogenic shock per InterTAK consortium (Ghadri 2018) + Templin NEJM 2015 PMID 26332547. Sudden severe LV apical ballooning (or atypical patterns: midventricular, basal, focal) following emotional/physical stressor; catecholamine surge + microvascular dysfunction + estrogen deficiency (postmenopausal predominance ~90%). Treatment pivots from standard CS bundle: AVOID β-blocker (paradoxical worsening; catecholamine sensitization), AVOID inotropes (worsen catecholamine excess) in NON-LVOT subtype; cautious NE for MAP ≥65; MCS (IABP / Impella / VA-ECMO) for bridge to recovery (typically days to weeks). LVOT-OBSTRUCTION subtype (15–25%) requires opposite physiology: β-blocker (esmolol) + IV fluids + phenylephrine; AVOID inotropes / diuretics. Mandatory emergency angiography to rule out obstructive CAD per InterTAK 2018; cardiac MRI confirms regional wall motion + edema + ABSENT LGE (vs ischemic CMP). Mural-thrombus prophylaxis with warfarin (INR 2–3) or apixaban × 3 mo if EF<35 + apical akinesia per AHA 2022 LV thrombus consensus extrapolation. Recovery: complete LV recovery typical at 4–8 wks; recurrence ~5–10% over follow-up per Templin NEJM 2015. Long-term ARNI / BB after recovery debated (no RCT-grade evidence — case-by-case). Psych follow-up required if emotional trigger. Inherits parent CS framework (vasopressor / inotrope ladder, MCS escalation, MDT activation); specialises for Takotsubo-specific physiology, LVOT-obstruction subtype distinct management, and recovery-focused trajectory. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute as Phase E wave 9 etiology variant.

Entry points (5)

  • imaging
    Bedside echo: apical ballooning (or midventricular / basal / focal pattern) + LV dysfunction + shock physiology — Takotsubo cardiomyopathy with CS
    echo_apical_ballooning_with_shock
  • history
    Recent severe emotional (death of loved one, divorce) or physical (surgery, sepsis, severe illness) stressor in postmenopausal female (~90% predominance) presenting with shock
    severe_emotional_or_physical_stressor
  • imaging
    Cath: no obstructive CAD + LV gram showing apical ballooning + RWMA crossing single coronary territory — InterTAK criteria (Ghadri 2018)
    cath_no_obstructive_cad_with_apical_akinesia
  • imaging
    Cardiac MRI: regional wall motion abnormality + edema on T2 + ABSENT LGE (vs ischemic CMP) — confirms Takotsubo
    cmr_lge_absent_with_apical_dysfunction
  • lab_abnormality
    Modest troponin rise that is disproportionately small relative to severe LV dysfunction — classical Takotsubo discordance pattern
    troponin_modest_rise_with_severe_lv_dysfunction

Required inputs (13)

  • agerequired
    demographic • used at CONTEXT
    Postmenopausal female (~90%) predominant; estrogen deficiency hypothesis; informs gender-specific catecholamine sensitivity
  • sex_female_postmenopausalrequired
    demographic • used at CONTEXT
    InterTAK registry — ~90% female, ~80% age >50; major epidemiologic anchor (Templin NEJM 2015 PMID 26332547)
  • sbprequired
    vital • used at RED_FLAGS
    SCAI 2022 staging baseline + LVOT-obstruction subtype gating (low SBP + dynamic gradient = LVOT-obstruction Takotsubo)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia worsens LVOT obstruction subtype — gates β-blocker (esmolol) decision in that variant
  • lactaterequired
    lab • used at RISK_STRATIFICATION
    SCAI 2022 staging + response to therapy; Takotsubo CS often has rapid lactate resolution with supportive care + recovery
  • creatininerequired
    lab • used at CONTEXT
    End-organ damage marker; eGFR for dosing of supportive agents
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Modest rise typical (much lower than expected for degree of LV dysfunction); discordance is a Takotsubo clue per Ghadri 2018 InterTAK criteria
  • bnp_ntprobnprequired
    lab • used at INITIAL_WORKUP
    BNP/NT-proBNP often markedly elevated (disproportionate to troponin) — Takotsubo discordance pattern
  • echorequired
    imaging • used at INITIAL_WORKUP
    Apical ballooning + RWMA crossing single coronary territory; LVOT gradient measurement (15–25% subset); pericardial effusion screen
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Diffuse T-wave inversion + QT prolongation typical; rule out STEMI; ST elevation possible (mimics LAD STEMI); marked QT prolongation (>500 ms) carries torsades risk
  • cor_angiorequired
    imaging • used at BRANCHING_WORKUP
    Mandatory rule-out of obstructive CAD per Ghadri 2018 InterTAK criteria; LV gram confirms apical ballooning pattern
  • cmr
    imaging • used at BRANCHING_WORKUP
    Confirms regional wall motion + edema (T2) + ABSENT LGE (vs ischemic CMP); helpful when cath ambiguous or for atypical patterns
  • recent_stressor_emotional_or_physicalrequired
    history • used at CONTEXT
    Identifying trigger (emotional vs physical) drives prognosis — physical-stressor Takotsubo has higher mortality than emotional per InterTAK PMID 26332547

12-phase flow (11)

  1. 1FRAME
    Confirm Takotsubo with cardiogenic shock per InterTAK criteria (Ghadri 2018) — apical (or atypical) ballooning + ABSENCE of obstructive CAD on cath + recent stressor + postmenopausal predominance; CS variant means SCAI Stage C+ overlay
    inputs: echo, cor_angio
    advance: Takotsubo confirmed + CS overlay documented
  2. 2ENTRY
    CS team activation; emergency cath to rule out obstructive CAD (mandatory per InterTAK 2018); echo for ballooning pattern + LVOT gradient assessment
    inputs: sbp, lactate
    advance: CS team activated + obstructive CAD excluded
  3. 3CONTEXT
    Recent stressor identification (emotional vs physical), comorbidities, prior Takotsubo episodes, baseline meds (current BB / inotrope use changes acute strategy), code status
    inputs: hr, creatinine, recent_stressor_emotional_or_physical
    advance: Context complete + trigger identified
  4. 4RED_FLAGS
    LVOT obstruction subtype (15–25%) — different physiology requires β-blocker + fluids + phenylephrine; mural thrombus from apical akinesia (anticoagulate if EF<35 + apical akinesia); torsades from QT prolongation; mechanical complication (free-wall rupture rare but reported)
    inputs: sbp
    actions: cardiogenic_shock, cardiac_tamponade
    advance: Subtype identified + LVOT vs non-LVOT pathway selected
  5. 5INITIAL_WORKUP
    ECG (diffuse T-wave inversion + QT prolongation), STAT echo (ballooning + LVOT gradient + RWMA), troponin (modest rise), BNP (markedly elevated), BMP, lactate, ABG, CXR; MERLIN-TT score for prognosis
    inputs: ecg, echo, troponin, bnp_ntprobnp, lactate
    actions: cardiogenic_shock, panel.cardiac, panel.renal, panel.abg
    advance: Diagnosis confirmed + LVOT status known
  6. 6BRANCHING_WORKUP
    Emergency coronary angiography mandatory (rule out obstructive CAD per InterTAK); cardiac MRI if cath ambiguous or atypical pattern (T2 edema + absent LGE); LV gram for ballooning pattern documentation
    inputs: cor_angio
    advance: Obstructive CAD ruled out + Takotsubo pattern confirmed
  7. 7RISK_STRATIFICATION
    MERLIN-TT scoring (Ghadri 2018) — physical stressor, neurologic / psychiatric comorbidity, troponin >10× ULN, EF <45% are high-risk features; SCAI 2022 stage; CardShock prognosis (Harjola EHJ 2015 PMID 26333869)
    inputs: sbp, lactate, troponin
    advance: Risk stratified
  8. 8TREATMENT
    NON-LVOT subtype: cautious NE for MAP ≥65; AVOID inotropes (worsen catecholamine excess); AVOID β-blocker acute (paradoxical sensitization); MCS bridge (IABP / Impella / VA-ECMO) per SCAI 2022 + DanGer Shock precedent if SCAI D-E. LVOT subtype: β-blocker (esmolol) + IV fluids + phenylephrine for SBP support; AVOID inotropes / diuretics. Anticoagulate if EF<35 + apical akinesia (mural thrombus prevention; warfarin or DOAC × 3 mo per AHA 2022 Class IIa LV thrombus consensus)
    inputs: sbp, lactate
    actions: cardiogenic_shock
    advance: Subtype-appropriate hemodynamic support running + anticoagulation decision documented
  9. 9DISPOSITION
    CICU at MCS-capable center if SCAI C+; advanced-HF center transfer for refractory; psych evaluation if emotional stressor identified
    advance: Disposition assigned + multidisciplinary team mobilised
  10. 10MONITORING
    A-line, central line, lactate clearance, urine output, telemetry (QT prolongation + torsades watch), serial echo q24h for LV recovery (typically resolves in days to weeks)
    inputs: lactate
    actions: panel.cardiac, panel.renal
    advance: Monitoring + reassessment cadence set
  11. 11FOLLOWUP
    Repeat echo at 4–8 wks to confirm complete LV recovery (Templin NEJM 2015); psych follow-up; long-term ARNI / BB after recovery debated (no RCT-grade evidence — case-by-case); recurrence ~5–10% over follow-up — patient education on stressor-mitigation
    advance: Recovery echo + psych follow-up booked