while the original case studies reported on individuals in japan, takotsubo cardiomyopathy has been noted more recently in the united states and western europe. it is likely that the syndrome previously went undiagnosed before it was described in detail in the japanese literature. evaluation of individuals with takotsubo cardiomyopathy typically includes a coronary angiogram to rule out occlusion of the left anterior descending artery, which will not reveal any significant blockages that would cause the left ventricular dysfunction. provided that the individual survives their initial presentation, the left ventricular function improves within two months. the diagnosis of takotsubo cardiomyopathy may be difficult upon presentation. the ecg findings often are confused with those found during an acute anterior wall myocardial infarction. it classically mimics st-segment elevation myocardial infarction, and is characterised by acute onset of transient ventricular apical wall motion abnormalities (ballooning) accompanied by chest pain, shortness of breath, st-segment elevation, t-wave inversion or qt-interval prolongation on ecg. cardiac enzymes are usually negative and are moderate at worst, and cardiac catheterization usually shows absence of significant coronary artery disease. the diagnosis is made by the pathognomonic wall motion abnormalities, in which the base of the left ventricle is contracting normally or is hyperkinetic while the remainder of the left ventricle is akinetic or dyskinetic. this is accompanied by the lack of significant coronary artery disease that would explain the wall motion abnormalities. although apical ballooning has been described classically as the angiographic manifestation of takotsubo, it has been shown that left ventricular dysfunction in this syndrome includes not only the classic apical ballooning, but also different angiographic morphologies such as mid-ventricular ballooning and, rarely, local ballooning of other segments. the ballooning patterns were classified by shimizu et al. as takotsubo type for apical akinesia and basal hyperkinesia, reverse takotsubo for basal akinesia and apical hyperkinesia, mid-ventricular type for mid-ventricular ballooning accompanied by basal and apical hyperkinesia, and localised type for any other segmental left ventricular ballooning with clinical characteristics of takotsubo-like left ventricular dysfunction. in short, the main criteria for the diagnosis of takotsubo cardiomyopathy are: the patient must have experienced a stressor before the symptoms began to arise; the patient's ecg reading must show abnormalities from a normal heart; the patient must not show signs of coronary blockage or other common causes of heart troubles; the levels of cardiac enzymes in the heart must be elevated or irregular; and the patient must recover complete contraction and be functioning normally in a short amount of time. left ventriculography during systole showing apical ballooning akinesis with basal hyperkinesis in a characteristic takotsubo ventricle left ventriculogram during systole displaying the characteristic apical ballooning with apical motionlessness in a patient with takotsubo cardiomyopathy (a) echocardiogram showing dilatation of the left ventricle in the acute phase (b) resolution of left ventricular function on repeat echocardiogram six days later ecg showing sinus tachycardia and non-specific st and t wave changes from a person with confirmed takotsubo cardiomyopathy treatment the treatment of takotsubo cardiomyopathy is generally supportive in nature, for it is considered a transient disorder. treatment is dependent on whether patients experience heart failure or acute hypotension and shock. in many individuals, left ventricular function normalizes within two months. aspirin and other heart drugs also appear to help in the treatment of this disease, even in extreme cases. after the patient has been diagnosed, and myocardial infarction (heart attack) ruled out, the aspirin regimen may be discontinued, and treatment becomes that of supporting the patient. there is currently no internationally agreed protocol for treatment of this condition. while medical treatments are important to address the acute symptoms of takotsubo cardiomyopathy, further treatment includes lifestyle changes. it is important that the individual stay physically healthy while learning and maintaining methods to manage stress, and to cope with future difficult situations. although the symptoms of takotsubo cardiomyopathy usually go away on their own and the condition completely resolves itself within a few weeks, some serious short and long-term complications can happen that must be treated. these most commonly include congestive heart failure and very low blood pressure, and less commonly include blood clotting in the apex of the left ventricle, irregular heart beat, and tearing of the heart wall. heart failure for patients in acute heart failure, ace inhibitors, angiotensin receptor blockers, and beta blockers, are considered mainstays of heart failure treatment. but use of beta blockers specifically for takotsubo cardiomyopathy is controversial, because they may confer no benefit. low blood pressure for people with cardiogenic shock, medical treatment is based on whether a left ventricular outflow tract (lvot) obstruction is present. therefore, early echocardiography is necessary to determine proper management. for those with obstructed lvots inotropic agents should not be used, but instead should be managed like patients with hypertrophic cardiomyopathy, (e.g. phenylephrine and fluid resuscitation). for cases in which the lvot is not obstructed, inotropic therapy (e.g. dobutamine and dopamine) may be used, but with the consideration that takotsubo is caused by excess catecholamines. furthermore, mechanical circulatory support (mcs) with an intra-aortic balloon pump (iabp) is well-established as supportive treatment. prognosis despite the grave initial presentation in some of the patients, most of the patients survive the initial acute event, with a very low rate of in-hospital mortality or complications. once a patient has recovered from the acute stage of the syndrome, they can expect a favorable outcome and the long-term prognosis is excellent for most. even when ventricular systolic function is heavily compromised at presentation, it typically improves within the first few days and normalises within the first few months. although infrequent, recurrence of the syndrome has been reported and seems to be associated with the nature of the trigger. while men experience tts at much lower rates than women, they also experience much higher rates of complication, reoccurrence, and mortality; the cause of this sex difference is still unknown, but it is hypothesized that the social aspect of the doctor-patient interaction affects the way that physicians recognize and generate individual treatment plans for men compared to women. stress cardiomyopathy is now a well-recognized cause of acute congestive heart failure, lethal abnormal heart rhythms, and rupture of the heart wall. epidemiology takotsubo syndrome represents about 2% of all patients (and 5–6% of all female patients) who are initially diagnosed with acute coronary syndrome (acs). it accounts for 0.02% of all hospitalizations in the us. about 90% of tts patients are women, whose mean age is about 68 years, and 80% of whom are older than 50 years. about 2.2% of tts cases had the reversed (basal) variant. recurrence rate of tts is about 1.8% per-patient year. history the japanese octopus traps after which this disease is named rees, et al. wrote in 1967 that the death of a close relative increases the risk of dying within one year by a factor of seven. engel wrote about sudden and rapid death during psychological stress in 1971 and itemized 8 causation categories: (1) on the impact of the collapse or death of a close person; (2) during acute grief; (3) on threat of loss of a close person; (4) during mourning or on an anniversary; (5) on loss of status or self-esteem; (6) personal danger or threat of injury; (7) after the danger is over; (8) reunion, triumph, or happy ending. he proposed these events provoke neurovegetative responses, involving both the flight-fight and conservation-withdrawal systems, conducive to lethal cardiac events, particularly in individuals with preexisting cardiovascular disease. although the first scientific description of takotsubo cardiomyopathy was not until the 1990s, cebelin and hirsch wrote about human stress cardiomyopathy in 1980. the two looked at homicidal assaults that had happened in cuyahoga county, ohio, the past 30 years, specifically those with autopsies who had no internal injury, but had died of physical assault. they found that 11 of 15 had myofibrillar degeneration similar to animal stress studies. in the end, they concluded their data supported "the theory of catecholamine mediation of these myocardial changes in man and of the lethal potential of stress through its effect on the heart". the syndrome reached international audiences through the media in 2005 when the new england journal of medicine wrote about the syndrome. in popular culture in episode 11, season 3 ("words and deeds", 2007) of the tv series house, firefighter derek suffers from this syndrome. the name and title track of the 2021 album tako tsubo by french band l'impératrice refers to the intense emotional stress that may provoke this syndrome.