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Acute coronary syndromes
Takotsubo syndrome: aetiology, presentation and treatment
  1. Ken Kato1,2,
  2. Alexander R Lyon3,
  3. Jelena-R Ghadri2,
  4. Christian Templin2
  1. 1 Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
  2. 2 Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
  3. 3 NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College, London, UK
  1. Correspondence to Prof Christian Templin, Director Acute Cardiology, Andreas Grüntzig Heart Catheterization Laboratories, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091 Zurich, Switzerland; christian.templin{at}

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Learning objectives

  • To understand postulated hypotheses about the pathophysiology of Takotsubo syndrome.

  • To obtain knowledge on clinical presentation and the examination findings of Takotsubo syndrome, which is helpful in differentiating between Takotsubo syndrome and acute coronary syndrome.

  • To learn the general strategy for the treatment of Takotsubo syndrome based on the limited evidence.


In the clinical setting, Takotsubo syndrome (TTS) is one of the most important diseases that must be accurately differentiated from acute coronary syndrome (ACS) to enable appropriate follow-up and medical management. The prevalence of TTS is estimated to be approximately 2%–3% in all patients presenting with suspected ACS.1 However, it may be underestimated because knowledge of diagnostic criteria is often incomplete, such as the possible coexistence of coronary artery disease (CAD). According to the widely used Mayo Clinic Diagnostic Criteria modified in 2008, incidental obstructive CAD not related to the wall motion abnormality may be an inclusion criterion for the diagnosis of TTS. However, this fact has been cited only as a footnote in a paper by Prasad and colleagues.2 In addition, atypical variants are not very well recognised by physicians, which may contribute to the underestimation of TTS.3 In 2015, the International Takotsubo Registry (, which is the largest systematic database on patients suffering from TTS, revealed novel data pertaining to TTS, which aided to the understanding of this enigmatic disease.4 This review summarises current knowledge on the aetiology, presentation and treatment of TTS.


The exact aetiology of TTS is still unknown, but several hypotheses are considered relevant for its pathophysiology. A number of observational clinical studies and preclinical models have helped to illuminate how the cardiovascular system responds to sudden extreme stress. These studies frequently provide a simplified and reductionist approach to a complex situation; therefore, it is important to note that a full understanding …

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  • Contributors Conception or design of the work: KK, J-RG; ARL, CT. Drafting the article: KK, J-RG, ARL. Critical revision of the article: J-RG, ARL, CT. Final approval of the version to be published: CT.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Author note References which include a * in the reference list have been identified as a key reference.