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cardio.acute-hf.takotsubo-decompensation.v1PRODUCTION
cardio.acute-hf.takotsubo-decompensation.v1

Acute HF — Takotsubo (apical ballooning) decompensation (non-shock)

cardiologyacuteadult
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Detailed

Confirm Takotsubo with ADHF (non-shock spectrum) per InterTAK 2018 criteria; postmenopausal female predominant; recent stressor often present (~70%); transient apical (or atypical) ballooning; ABSENT obstructive CAD; recovery is the rule by 4-8 wks; SCAI C+ shock routes to sister shock dossier

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Takotsubo ADHF (non-shock) framed

Patient inputs (13)

Mandatory rule-out of obstructive CAD per Ghadri 2018 InterTAK criteria; LV gram confirms ballooning pattern; can defer to non-emergent if low-risk presentation but most need cath given STEMI mimic potential

Postmenopausal female (~90%) predominant; age >50 in ~80% per InterTAK PMID 26332547; informs estrogen-deficiency hypothesis + epidemiology

InterTAK registry — ~90% female; major epidemiologic anchor

Identifying trigger (emotional vs physical) drives prognosis — physical-stressor Takotsubo has higher mortality than emotional per Templin PMID 26332547; absence of trigger does NOT exclude Takotsubo (~30% have no identifiable trigger)

Tachycardia + LVOT obstruction subset → β-blocker (esmolol) decision in LVOT subtype; informs catecholamine excess assessment

eGFR for diuretic + ACEi/ARB dosing; KDIGO 2021 race-free; informs DOAC dosing if mural-thrombus prophylaxis needed

Modest rise typical (much smaller than expected for degree of LV dysfunction); discordance is a Takotsubo clue per Ghadri 2018 InterTAK criteria; trend over 24-48h

BNP/NT-proBNP often markedly elevated (disproportionate to troponin); marker of HF severity; trend during admission for response to diuresis

QT prolongation common in Takotsubo (often >500 ms); torsades risk; aggressive K (≥4) + Mg (≥2) replacement per ACC/AHA QT management

Apical ballooning + RWMA crossing single coronary territory; LVOT gradient measurement (15–25% have dynamic LVOT obstruction subset); pericardial effusion screen; LV thrombus screen if severe apical akinesia

Diffuse T-wave inversion + QT prolongation typical Takotsubo evolution; rule out STEMI mimic; ST elevation possible (mimics LAD STEMI); marked QT prolongation (>500 ms) carries torsades risk

SBP <90 + lactate ≥2 + cool extremities = SCAI C+ shock → ROUTE OUT to cardio.cardiogenic-shock.takotsubo.v1 or cardio.cardiogenic-shock.takotsubo-lvot-obstruction.v1; this engine is SCAI A-B (warm + wet) only

Confirms regional wall motion + T2 edema + ABSENT LGE (distinguishes from ischemic and inflammatory CMP); helpful for atypical patterns or when cath ambiguous; recovery MRI at 4–8 wks documents complete recovery

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningprogression_to_takotsubo_cardiogenic_shock_route_to_sister_dossier
    Hemodynamic deterioration to SCAI C+ shock physiology (SBP <90 + lactate ≥2 + cool extremities + organ dysfunction) — Takotsubo CS requires routing to sister shock dossier (with or without LVOT obstruction)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningqt_prolongation_with_torsades_risk
    QT prolongation >500 ms in Takotsubo + electrolyte derangement (K <4 OR Mg <2) — torsades risk; aggressive electrolyte replacement + telemetry; MgSO4 + temporary pacing if torsades develops
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelvot_obstruction_subtype_discovered_in_takotsubo_adhf
    Significant dynamic LVOT gradient (≥30 mmHg at rest or ≥50 mmHg with provocation) in Takotsubo ADHF — requires opposite physiology pathway: β-blocker (esmolol) + IV fluids + phenylephrine; AVOID inotropes / nitrates / diuretics / vasodilators
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremural_thrombus_or_apical_akinesia_warranting_ac
    LV apical thrombus on echo OR severe apical akinesia + EF <35 in Takotsubo — initiate AC × 3 mo (warfarin INR 2-3 or apixaban 5 mg BID); risk peaks while LV remains dysfunctional
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepersistent_severe_lv_dysfunction_beyond_8_weeks_reconsider_diagnosis
    Persistent severe LV dysfunction (EF <40) beyond 8 wks despite supportive care — atypical for Takotsubo (recovery is the rule); reconsider diagnosis (myocarditis, ischemic CMP, infiltrative)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrent_takotsubo_episode_lifetime
    Recurrent Takotsubo episode (~5-10% lifetime per InterTAK PMID 26332547) — re-evaluate trigger management, stressor mitigation, consider long-term β-blocker / ARNI debate
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Takotsubo (apical ballooning) ADHF non-shock — supportive ADHF + AVOID INOTROPES + cautious BB (non-LVOT) or REQUIRED BB (LVOT subset) + LVOT-aware fluid/vasopressor strategy + mural-thrombus prophylaxis (Templin NEJM 2015 PMID 26332547; Ghadri 2018 InterTAK PMID 29850871; Lyon 2016 ESC HFA PMID 26890206; AHA 2024 Wright PMID 38258576)
axis: takotsubo_decompensation_phenotype
Selected axis "Takotsubo (apical ballooning) ADHF non-shock — supportive ADHF + AVOID INOTROPES + cautious BB (non-LVOT) or REQUIRED BB (LVOT subset) + LVOT-aware fluid/vasopressor strategy + mural-thrombus prophylaxis (Templin NEJM 2015 PMID 26332547; Ghadri 2018 InterTAK PMID 29850871; Lyon 2016 ESC HFA PMID 26890206; AHA 2024 Wright PMID 38258576)" by default fallback (first axis)
  • furosemide
    first line
    loop_diuretic
    40-80 mg IV (diuretic-naive); 2.5x outpatient PO dose IV if on chronic loop (DOSE-trial guided) • IV • q12h titrate to UOP
    triggers: volume_overload_with_pulmonary_or_systemic_congestion_in_non_lvot_subtype
    DOSE PMID 21366472 — titrate to UOP + symptom resolution; AVOID in LVOT-obstruction subtype (preload-dependent physiology); transition to PO before discharge
    rxcui 4603
  • nitroglycerin
    add on
    organic_nitrate_vasodilator
    5-20 µg/min IV titrate • IV • continuous
    triggers: hypertensive_adhf_with_sbp_above_140_in_non_lvot_subtype_only
    Preload + modest afterload reduction for hypertensive ADHF; AVOID in LVOT-obstruction subtype (preload reduction worsens dynamic gradient); avoid if SBP <100
    rxcui 4917
  • esmolol
    first line
    short_acting_beta_blocker
    500 µg/kg bolus then 50-200 µg/kg/min • IV • continuous, titrate
    triggers: takotsubo_lvot_obstruction_subtype_with_significant_dynamic_gradient
    LVOT-obstruction Takotsubo subset (15-25%) — β-blocker reduces dynamic gradient and improves forward flow; esmolol short-acting allows rapid titration; AVOID in non-LVOT subtype during acute catecholamine surge
    rxcui 49737
  • phenylephrine
    add on
    vasopressor_pure_alpha
    40-360 µg/min IV • IV • continuous
    triggers: takotsubo_lvot_obstruction_subtype_with_low_sbp
    Pure α-agonist; preferred in LVOT-obstruction subtype because raises afterload without inotropy (which worsens dynamic obstruction); ESC HFA 2016 Lyon position
    rxcui 8163
  • carvedilol
    add on
    beta_blocker_nonselective_alpha1
    3.125 mg PO BID titrate (initiate AS LV recovers + off catecholamine excess + no LVOT obstruction) • PO • BID
    triggers: takotsubo_recovery_phase_with_persistent_lv_dysfunction, absent_lvot_obstruction_with_lv_recovering
    CAPRICORN PMID 11356436 — but Lyon 2016 ESC HFA position cautions against acute initiation during catecholamine surge; introduce as LV recovers; debated long-term role per InterTAK protocols
    rxcui 20352
  • lisinopril
    add on
    acei
    5 mg PO daily titrate to 10-40 mg • PO • daily
    triggers: takotsubo_with_persistent_lv_dysfunction_during_recovery, sbp_above_100_post_acute_phase
    Lyon 2016 ESC HFA position + modified InterTAK protocols — initiate during recovery for residual LV dysfunction; standard ADHF afterload reduction; AVOID during acute catecholamine surge if hypotensive
    rxcui 29046
  • losartan
    contraindication substitute
    arb
    25-50 mg PO daily • PO • daily
    triggers: acei_intolerance_with_persistent_lv_dysfunction_during_takotsubo_recovery
    ARB alternative if ACEi cough or angioedema; same LV reverse-remodeling rationale during Takotsubo recovery
    rxcui 52175
  • spironolactone
    add on
    mineralocorticoid_receptor_antagonist
    12.5-25 mg PO daily • PO • daily
    triggers: takotsubo_with_persistent_ef_below_40_during_recovery_phase, k_below_5_and_egfr_above_30
    RALES PMID 10471456 extrapolated — modified InterTAK protocols suggest case-by-case use during recovery if persistent EF <40; debated for typical Takotsubo (recovery is the rule)
    rxcui 9997
  • warfarin
    comorbidity specific
    vitamin_k_antagonist
    5 mg PO daily INR target 2-3 • PO • daily × 3 mo
    triggers: takotsubo_with_severe_apical_akinesia_with_ef_below_35, lv_thrombus_on_echo_post_takotsubo
    AHA 2022 Class IIa for LV thrombus (extrapolated to Takotsubo) — apical-ballooning Takotsubo carries mural-thrombus risk while LV remains dysfunctional; 3-mo course typically sufficient given recovery timeline; INR monitoring
    rxcui 11289
  • apixaban
    comorbidity specific
    doac_factor_xa_direct
    5 mg PO BID (or 2.5 mg BID per dose-reduction criteria) • PO • BID × 3 mo for mural-thrombus prophylaxis
    triggers: takotsubo_with_apical_akinesia_warfarin_intolerant, patient_compliance_concern_with_inr_monitoring
    Off-label-but-rational DOAC alternative for LV thrombus prophylaxis; small RCTs (NoT-DAPT, Xarelto LV-thrombus) support non-inferiority to warfarin in LV thrombus prevention; 3-mo course
    rxcui 1364430
  • magnesium sulfate
    first line
    electrolyte_repletion
    2 g IV over 15-20 min for active torsades; 1-2 g IV q4-6h for prophylactic K/Mg replacement • IV • as needed for QT/torsades
    triggers: qt_prolongation_above_500ms_with_torsades_risk, active_torsades_de_pointes
    Standard QT prolongation + torsades management; Takotsubo QT typically resolves with LV recovery; aggressive K replacement to ≥4 + Mg to ≥2
    rxcui 6585

outpatient playbook — drug actions (4)

  1. 1. discontinue mural-thrombus AC at 3 mo if EF recovered + apical akinesia resolved
    rxcui 1364430
    taper / stop per AHA 2022 LV thrombus consensus • PO • discontinue
    trigger: normalized echo at 3 mo
    Mural thrombus risk resolves with LV recovery; 3-mo course typically sufficient
  2. 2. continue or up-titrate ACEi/BB if persistent LV dysfunction
    rxcui 29046
    lisinopril 10-40 + carvedilol 3.125→25 BID • PO • daily/BID
    trigger: persistent EF <50 beyond 8 wks (rare)
    Lyon 2016 ESC HFA + modified InterTAK protocols — case-by-case for the rare persistent-dysfunction subset
  3. 3. consider long-term BB for recurrence prevention (debated)
    rxcui 20352
    carvedilol 12.5-25 BID • PO • BID
    trigger: recurrent Takotsubo episodes
    Lyon 2016 — debated due to lack of RCT-grade evidence; consider in recurrent cases
  4. 4. maintain influenza + COVID vaccination
    annual flu + COVID booster per CDC • IM • annual + per CDC
    trigger: post-Takotsubo maintenance
    Standard CDC + AHA recommendations; no Takotsubo-specific contraindication

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Bedside echo: apical ballooning (or atypical pattern: midventricular, basal, focal) + LV systolic dysfunction + congestion BUT preserved perfusion (SBP ≥90 + lactate <2) → Takotsubo ADHF non-shock spectrum; Recent emotional (death of loved one, divorce, financial loss) or physical (surgery, severe illness, sepsis recovery) stressor in postmenopausal female (~90% predominance) presenting with new HF symptoms WITHOUT shock; Chest pain or new dyspnea + diffuse T-wave inversion + QT prolongation on ECG + LV dysfunction on echo + modest troponin rise (disproportionate to LV dysfunction).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute HF — Takotsubo (apical ballooning) decompensation (non-shock)** (cardio.acute-hf.takotsubo-decompensation.v1).
Scope: Confirm Takotsubo with ADHF (non-shock spectrum) per InterTAK 2018 criteria; postmenopausal female predominant; recent stressor often present (~70%); transient apical (or atypical) ballooning; ABSENT obstructive CAD; recovery is the rule by 4-8 wks; SCAI C+ shock routes to sister shock dossier

No severity triggers fired against current inputs.

Plan

Regimen axis: **Takotsubo (apical ballooning) ADHF non-shock — supportive ADHF + AVOID INOTROPES + cautious BB (non-LVOT) or REQUIRED BB (LVOT subset) + LVOT-aware fluid/vasopressor strategy + mural-thrombus prophylaxis (Templin NEJM 2015 PMID 26332547; Ghadri 2018 InterTAK PMID 29850871; Lyon 2016 ESC HFA PMID 26890206; AHA 2024 Wright PMID 38258576)**.
1. furosemide 40-80 mg IV (diuretic-naive); 2.5x outpatient PO dose IV if on chronic loop (DOSE-trial guided) IV q12h titrate to UOP (loop_diuretic, first line) — DOSE PMID 21366472 — titrate to UOP + symptom resolution; AVOID in LVOT-obstruction subtype (preload-dependent physiology); transition to PO before discharge
2. nitroglycerin 5-20 µg/min IV titrate IV continuous (organic_nitrate_vasodilator, add on) — Preload + modest afterload reduction for hypertensive ADHF; AVOID in LVOT-obstruction subtype (preload reduction worsens dynamic gradient); avoid if SBP <100
3. esmolol 500 µg/kg bolus then 50-200 µg/kg/min IV continuous, titrate (short_acting_beta_blocker, first line) — LVOT-obstruction Takotsubo subset (15-25%) — β-blocker reduces dynamic gradient and improves forward flow; esmolol short-acting allows rapid titration; AVOID in non-LVOT subtype during acute catecholamine surge
4. phenylephrine 40-360 µg/min IV IV continuous (vasopressor_pure_alpha, add on) — Pure α-agonist; preferred in LVOT-obstruction subtype because raises afterload without inotropy (which worsens dynamic obstruction); ESC HFA 2016 Lyon position
5. carvedilol 3.125 mg PO BID titrate (initiate AS LV recovers + off catecholamine excess + no LVOT obstruction) PO BID (beta_blocker_nonselective_alpha1, add on) — CAPRICORN PMID 11356436 — but Lyon 2016 ESC HFA position cautions against acute initiation during catecholamine surge; introduce as LV recovers; debated long-term role per InterTAK protocols
6. lisinopril 5 mg PO daily titrate to 10-40 mg PO daily (acei, add on) — Lyon 2016 ESC HFA position + modified InterTAK protocols — initiate during recovery for residual LV dysfunction; standard ADHF afterload reduction; AVOID during acute catecholamine surge if hypotensive
7. losartan 25-50 mg PO daily PO daily (arb, contraindication substitute) — ARB alternative if ACEi cough or angioedema; same LV reverse-remodeling rationale during Takotsubo recovery
8. spironolactone 12.5-25 mg PO daily PO daily (mineralocorticoid_receptor_antagonist, add on) — RALES PMID 10471456 extrapolated — modified InterTAK protocols suggest case-by-case use during recovery if persistent EF <40; debated for typical Takotsubo (recovery is the rule)
9. warfarin 5 mg PO daily INR target 2-3 PO daily × 3 mo (vitamin_k_antagonist, comorbidity specific) — AHA 2022 Class IIa for LV thrombus (extrapolated to Takotsubo) — apical-ballooning Takotsubo carries mural-thrombus risk while LV remains dysfunctional; 3-mo course typically sufficient given recovery timeline; INR monitoring
10. apixaban 5 mg PO BID (or 2.5 mg BID per dose-reduction criteria) PO BID × 3 mo for mural-thrombus prophylaxis (doac_factor_xa_direct, comorbidity specific) — Off-label-but-rational DOAC alternative for LV thrombus prophylaxis; small RCTs (NoT-DAPT, Xarelto LV-thrombus) support non-inferiority to warfarin in LV thrombus prevention; 3-mo course
11. magnesium sulfate 2 g IV over 15-20 min for active torsades; 1-2 g IV q4-6h for prophylactic K/Mg replacement IV as needed for QT/torsades (electrolyte_repletion, first line) — Standard QT prolongation + torsades management; Takotsubo QT typically resolves with LV recovery; aggressive K replacement to ≥4 + Mg to ≥2

Setting playbook (outpatient) — Long-term cardiology surveillance: 4-8 wk recovery echo confirms complete LV recovery typical (Templin PMID 26332547); discontinue mural-thrombus AC at 3 mo if EF normalized + apical akinesia resolved; long-term ARNI/BB after recovery debated case-by-case; psychiatry engagement; recurrence education + stressor mitigation; vaccination + secondary prevention
12. discontinue mural-thrombus AC at 3 mo if EF recovered + apical akinesia resolved taper / stop per AHA 2022 LV thrombus consensus PO discontinue — normalized echo at 3 mo (Mural thrombus risk resolves with LV recovery; 3-mo course typically sufficient)
13. continue or up-titrate ACEi/BB if persistent LV dysfunction lisinopril 10-40 + carvedilol 3.125→25 BID PO daily/BID — persistent EF <50 beyond 8 wks (rare) (Lyon 2016 ESC HFA + modified InterTAK protocols — case-by-case for the rare persistent-dysfunction subset)
14. consider long-term BB for recurrence prevention (debated) carvedilol 12.5-25 BID PO BID — recurrent Takotsubo episodes (Lyon 2016 — debated due to lack of RCT-grade evidence; consider in recurrent cases)
15. maintain influenza + COVID vaccination annual flu + COVID booster per CDC IM annual + per CDC — post-Takotsubo maintenance (Standard CDC + AHA recommendations; no Takotsubo-specific contraindication)

Non-pharmacologic actions:
- Cardiac rehab maintenance phase if persistent LV dysfunction
- Recurrence education ~5-10% lifetime per InterTAK PMID 26332547
- Stressor mitigation counseling (psychiatry engagement)
- Family + social support planning if emotional trigger
- Avoid known recurrence triggers when possible

AVOID / contraindication checks:
- Avoid_inotropes_in_takotsubo_acute_phase (worsen catecholamine excess underlying mechanism — dobutamine/milrinone/epinephrine all relatively contraindicated; ESC HFA 2016 Lyon PMID 26890206; AHA 2024 Wright PMID 38258576)
- Beta_blocker_avoid_acute_in_non_lvot_subtype (paradoxical worsening; catecholamine sensitization; ESC HFA 2016 Lyon position)
- Beta_blocker_required_in_lvot_subtype (esmolol reduces dynamic gradient — opposite physiology)
- Diuretics_avoid_in_lvot_obstruction_subtype (preload dependent physiology; reduces LV cavity size and worsens dynamic gradient)
- Nitrates_avoid_in_lvot_obstruction_subtype (preload reduction worsens dynamic gradient)
- Vasodilators_avoid_in_lvot_obstruction_subtype (afterload reduction worsens dynamic gradient)
- Warfarin_avoid_active_bleeding_or_pregnancy (AHA 2022)
- Apixaban_avoid_severe_renal_impairment_egfr_below_25 (drug label)
- K_repletion_to_4_for_qt_prolongation (AHA QT management)
- Mg_repletion_to_2_for_qt_prolongation (AHA QT management)
- Avoid_qt_prolonging_meds_in_acute_phase (ondansetron, fluoroquinolones, macrolides — already prolonged QT in Takotsubo)
- Long_term_arni_or_bb_role_debated_no_rct_evidence (Lyon 2016 ESC HFA position; case by case if persistent dysfunction)

Monitoring

Regimen monitoring:
- continuous telemetry with qt monitoring for torsades surveillance
- daily weight io strict
- daily bmp for diuretic safety and qt electrolyte management
- daily mg during initial admission for qt management
- serial troponin q4 to 6h x 2 or 3 to confirm takotsubo discordance pattern
- echo at 48 to 72h for lv recovery trajectory and lvot gradient evolution
- echo at 4 to 8 weeks for recovery confirmation per templin pmid 26332547
- cardiac mri at 4 to 8 weeks for lge assessment if initial atypical pattern
- inr q week during warfarin initiation for mural thrombus prophylaxis
- mural thrombus ac for 3 months if ef below 35 and apical akinesia
- discontinue mural thrombus ac at 3mo if ef normalized per aha 2022
- psychiatry follow up at 1 to 4 weeks if emotional trigger
- cardiology follow up 1 to 2 weeks then 4 to 8 weeks then 3 6 12 months
- recurrence education 5 to 10 percent lifetime per templin pmid 26332547

Setting (outpatient) monitoring:
- Quarterly cardiology + annual echo (more frequent if residual dysfunction)
- INR if on warfarin (discontinue at 3 mo if EF recovered)
- Holter for arrhythmia surveillance if symptomatic

Follow-up plan: Cardiology follow-up at 1-2 wks + 4-8 wks (recovery echo) + 3 mo + 6 mo + 12 mo; recovery echo at 4-8 wks confirms complete LV recovery typical (Templin PMID 26332547); discontinue mural-thrombus AC at 3 mo if EF normalized + apical akinesia resolved per AHA 2022 LV thrombus consensus; long-term ARNI/BB after recovery debated case-by-case (no RCT-grade evidence — Lyon 2016 ESC HFA position); psychiatry follow-up if emotional trigger; recurrence ~5-10% lifetime — patient education on stressor mitigation; cardiac MRI at 4-8 wks for LGE persistence assessment if initial atypical pattern
- Close-out criterion: long-term plan + recovery echo + psych follow-up booked

Monitoring phase: Continuous telemetry with QT monitoring (torsades surveillance); daily weight + I/O; daily BMP for diuresis safety; serial troponin trend (peak typically modest — Takotsubo discordance); echo at 48-72h to track recovery trajectory + LVOT gradient evolution; recovery echo at 4-8 wks (Templin PMID 26332547 — typical complete recovery); psychiatry follow-up if emotional trigger

Disposition

Current setting: outpatient — Long-term cardiology surveillance: 4-8 wk recovery echo confirms complete LV recovery typical (Templin PMID 26332547); discontinue mural-thrombus AC at 3 mo if EF normalized + apical akinesia resolved; long-term ARNI/BB after recovery debated case-by-case; psychiatry engagement; recurrence education + stressor mitigation; vaccination + secondary prevention

Disposition criteria:
- Complete recovery (EF ≥55 + symptom-free + AC discontinued at 3 mo) → routine surveillance only; if persistent LV dysfunction → continue ACEi/BB per modified InterTAK protocols + cross-link to cardio.hf.core.v1

Escalation triggers (move to higher acuity):
- Recurrent Takotsubo episode → ED + repeat full workup + reinforced stressor management
- Persistent symptoms despite normal echo → cardiac MRI for occult dysfunction
- New chest pain → standard ACS workup (Takotsubo recurrence vs new ischemic event)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Hemodynamic deterioration to SCAI C+ shock physiology (SBP <90 + lactate ≥2 + cool extremities + organ dysfunction) — Takotsubo CS requires routing to sister shock dossier (with or without LVOT obstruction)
- [LIFE_THREATENING] QT prolongation >500 ms in Takotsubo + electrolyte derangement (K <4 OR Mg <2) — torsades risk; aggressive electrolyte replacement + telemetry; MgSO4 + temporary pacing if torsades develops
- [SEVERE] Significant dynamic LVOT gradient (≥30 mmHg at rest or ≥50 mmHg with provocation) in Takotsubo ADHF — requires opposite physiology pathway: β-blocker (esmolol) + IV fluids + phenylephrine; AVOID inotropes / nitrates / diuretics / vasodilators

Citations

- InterTAK consortium / Ghadri 2018 Eur Heart J expert consensus Part I + II (PMID 29850871 + 29850820); Templin NEJM 2015 PMID 26332547 (InterTAK registry); Lyon 2016 ESC HFA position statement on Takotsubo (PMID 26890206); 2022 ACC/AHA HF Guideline (PMID 35363499); AHA scientific statement on Takotsubo (Wright Circulation 2024 PMID 38258576) [PMID:26332547](https://pubmed.ncbi.nlm.nih.gov/26332547/)
- Cited evidence (PMID 29850871) [PMID:29850871](https://pubmed.ncbi.nlm.nih.gov/29850871/)
- Cited evidence (PMID 29850820) [PMID:29850820](https://pubmed.ncbi.nlm.nih.gov/29850820/)
- Cited evidence (PMID 26890206) [PMID:26890206](https://pubmed.ncbi.nlm.nih.gov/26890206/)
- Cited evidence (PMID 35363499) [PMID:35363499](https://pubmed.ncbi.nlm.nih.gov/35363499/)

Last reconciled with current guidelines: 2026-05-15.
References
  • InterTAK consortium / Ghadri 2018 Eur Heart J expert consensus Part I + II (PMID 29850871 + 29850820); Templin NEJM 2015 PMID 26332547 (InterTAK registry); Lyon 2016 ESC HFA position statement on Takotsubo (PMID 26890206); 2022 ACC/AHA HF Guideline (PMID 35363499); AHA scientific statement on Takotsubo (Wright Circulation 2024 PMID 38258576) — PMID:26332547
  • Cited evidence (PMID 29850871) — PMID:29850871
  • Cited evidence (PMID 29850820) — PMID:29850820
  • Cited evidence (PMID 26890206) — PMID:26890206
  • Cited evidence (PMID 35363499) — PMID:35363499