Takotsubo or heart attack:
how to tell them apart and what to do

Article written and reviewed by Dr Luca Moretti

Takotsubo syndrome and a heart attack can present in an almost indistinguishable way: chest pain, shortness of breath, ECG changes and increased troponin can occur in both conditions. For this reason, there is no symptom that can reliably tell someone at home whether it is "broken heart syndrome" or a heart attack.
If new or significant chest pain develops, especially when associated with shortness of breath, sweating, nausea, weakness, palpitations or loss of consciousness, call 112 or 118. Takotsubo is diagnosed after other urgent causes have been excluded or identified, not before seeking emergency care.

In hospital, the distinction is based mainly on:

• the characteristics of the symptoms and the presence of any triggering factors;
• the electrocardiogram and how its changes evolve;
• troponin and other blood tests;
• echocardiography and the distribution of abnormalities in contractility;
• coronary angiography or, in selected patients, coronary CT angiography;
• cardiac magnetic resonance imaging when Takotsubo, myocardial infarction and myocarditis need to be distinguished;
• recovery of ventricular function documented during follow-up.

Takotsubo syndrome is an acute and generally reversible form of myocardial dysfunction. Myocardial infarction, by contrast, results from ischemic damage to the heart muscle, often caused by occlusion or severe impairment of a coronary artery. In the first hours, however, this pathophysiological difference cannot be recognized from symptoms alone.

Why Takotsubo and a heart attack can look the same

The most frequent symptom in Takotsubo is chest pain; shortness of breath can also occur and, less often, syncope. In the large International Takotsubo Registry, chest pain was present in about three quarters of patients and dyspnea in almost half. These manifestations are very similar to those that raise suspicion of an acute coronary syndrome.
The ECG may also show ST-segment elevation, T-wave inversion, QT prolongation or other abnormalities. However, no single electrocardiographic pattern is sufficiently reliable to exclude a heart attack in advance.

Troponin, a biomarker of myocardial injury, often also increases in Takotsubo. In many cases, the increase is relatively modest compared with the extent of dysfunction visible on imaging, whereas natriuretic peptides can be very high. This relationship, however, is also only a clue and not diagnostic proof.
Consequently, a person with chest pain, an abnormal ECG and positive troponin must initially be managed as a possible acute coronary syndrome until investigations clarify the cause.

Emotional stress can be a clue, but it is not enough

Takotsubo is known as "broken heart syndrome" because it can occur after bereavement, conflict, fear or other intense emotions. Severe emotional stress before onset increases suspicion, especially in a postmenopausal woman, but it does not have to be present.
In the international registry, physical stressors such as acute illnesses, medical procedures or other events that place the body under major stress were also common overall; moreover, no obvious trigger had been identified in more than one quarter of patients.

For this reason, the question "have you experienced stress?" cannot distinguish Takotsubo from a heart attack. A heart attack can occur after intense emotion and Takotsubo can develop without any recognizable emotional event. Men and younger people can also develop it, although most cases occur in postmenopausal women.
Some forms are associated with acute neurological conditions, pheochromocytoma or major physical stress and can have a particularly complex course.

Echocardiography and coronary angiography: tests that guide the diagnosis

An echocardiogram may show a characteristic abnormality of contractility. The classic form has so-called apical ballooning: the apex and mid-segments of the left ventricle contract poorly or are akinetic, whereas the base contracts more vigorously. Mid-ventricular, basal and focal forms also exist and do not have the classic "balloon" appearance.
In Takotsubo, contractility abnormalities often extend beyond the territory of a single coronary artery, whereas in myocardial infarction they tend to follow the region supplied by the involved vessel. This distinction also has exceptions and is not sufficient on its own.

When a patient presents with a picture compatible with ST-segment elevation myocardial infarction, urgent coronary angiography remains fundamental to determine whether a coronary occlusion requiring revascularization is present. If no culprit lesion is found and imaging shows a typical pattern, Takotsubo becomes highly likely.
The presence of coronary artery disease does not, however, exclude Takotsubo: the two conditions can coexist. In stable, carefully selected patients, coronary CT angiography may in some contexts be used to assess coronary anatomy without an invasive examination.

Cardiac MRI: when myocarditis also needs to be distinguished

Cardiac magnetic resonance imaging can be very useful when coronary angiography and echocardiography do not fully clarify the diagnosis or when Takotsubo must be distinguished from myocarditis or myocardial infarction with non-obstructive coronary arteries.
In Takotsubo, MRI typically shows edema in the involved regions without the characteristic pattern of ischemic necrosis seen in myocardial infarction. Myocarditis may instead show a different tissue distribution. The meaning of the images must be interpreted in the clinical context and not on the basis of a single sequence.

Another important diagnostic characteristic of Takotsubo is reversibility. Contractility abnormalities tend to regress and ventricular function recovers over time. A follow-up echocardiogram documents this recovery and helps confirm the clinical picture.
If abnormalities persist longer than expected, the diagnosis should be reassessed and further tests may be needed to look for cardiomyopathies, myocarditis or other causes of ventricular dysfunction.

Takotsubo is not a heart attack, but it is not always harmless

The fact that the ventricle recovers does not mean that the acute phase is free of risk. Takotsubo can be complicated by acute heart failure, pulmonary edema, cardiogenic shock, ventricular arrhythmias, dynamic outflow tract obstruction, mitral regurgitation and intracardiac thrombi. In the international registry, the overall frequency of serious in-hospital complications was comparable to that observed in the patients with acute coronary syndrome used for comparison.
For this reason, the term "broken heart" should not suggest a harmless psychological disorder or a simple emotional reaction.

There is currently no specific treatment proven to immediately stop the mechanism of Takotsubo. Management is adapted to ventricular function and any complications. In the initial phase, until a heart attack has been excluded, treatment necessarily follows the acute coronary emergency pathway.
After discharge, follow-up is arranged to document recovery and reassess symptoms, cardiac function and possible complications. Recurrences are possible even years later.

What to do if chest pain suddenly appears

Takotsubo should not be diagnosed on the basis that chest pain began after a strong emotion. If the symptom is compatible with an acute cardiac event, the correct action is the same as described for heart attack symptoms: call 112 or 118 and do not drive yourself to the emergency department.
This applies especially to pain or pressure in the center of the chest that persists or recurs, significant shortness of breath, sweating, nausea, pain radiating to the arms, back, neck or jaw, marked weakness or loss of consciousness.

A previous diagnosis of Takotsubo does not make it safe to attribute a new episode to the same cause. A person who has already had the syndrome can still develop a heart attack or another cardiovascular emergency.
Likewise, a previously normal coronary angiogram does not guarantee that new chest pain is benign. Every acute episode must be assessed on the basis of the current situation.

Frequently asked questions about Takotsubo and heart attack

How can I tell whether it is Takotsubo or a heart attack?
It is not possible to distinguish them reliably at home. Both can cause chest pain, dyspnea, an abnormal ECG and elevated troponin.

Does Takotsubo always occur after emotional stress?
No. It can be triggered by emotional or physical stress and can also occur without an obvious trigger.

Does troponin also increase in Takotsubo?
Yes. A positive value indicates myocardial injury but cannot, on its own, establish whether the cause is Takotsubo or myocardial infarction.

Is coronary angiography always needed?
It is very often necessary, particularly when the initial picture suggests ST-segment elevation myocardial infarction. Alternative strategies may be used in selected stable patients to assess the coronary arteries.

Does Takotsubo recover completely?
Ventricular function typically recovers, but the acute phase can have important complications, some symptoms may persist and recurrences are possible. Follow-up therefore remains necessary.