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PubMed This is a summary of 17 peer-reviewed journal articles Updated
Cardiology · Takotsubo Cardiomyopathy

Solving the Mystery: How Doctors Diagnose Takotsubo

At a Glance

To diagnose Takotsubo cardiomyopathy, doctors must prove the heart is stunned by stress rather than blocked arteries. They use angiograms to confirm arteries are clear, blood tests to measure stress markers, and cardiac MRIs to verify there is no permanent heart scarring.

When you are rushed to the hospital with heart attack symptoms, the diagnostic process is a race to find out why your heart is struggling. For Takotsubo patients, the journey often involves several specialized tests to prove that the heart muscle is “stunned” by stress rather than damaged by a blocked artery [1][2].

The “Clean” Angiogram

The first and most critical step is often a coronary angiogram (a procedure using dye and X-rays to see your heart’s arteries) [2].

  • Heart Attack: A heart attack is usually caused by a “culprit” blockage—a ruptured plaque or blood pool that stops blood flow [3].
  • Takotsubo: In Takotsubo, the large coronary arteries are typically “clean” or show no blockages severe enough to explain the heart’s weakness [2][4]. This is the first major clue that you may have “Broken Heart Syndrome” rather than a traditional heart attack.

Clinical Risk Factors (The InterTAK Criteria)

Doctors often use specific scoring systems, like the InterTAK Diagnostic criteria, to help distinguish Takotsubo from a heart attack at the very beginning [5][6]. Instead of relying on one single test, they look at a combination of clinical factors, including:

  • Being female
  • Having a recent severe emotional or physical trigger
  • Having a history of psychiatric disorders (e.g., anxiety, depression) or neurological disorders (e.g., seizures)
  • Specific electrical patterns on your EKG (electrocardiogram)

When a combination of these factors is present, it makes it much more likely that your diagnosis is Takotsubo [5][7].

Blood Markers: The BNP-to-Troponin Ratio

Your blood contains proteins called biomarkers that reveal how much stress the heart is under. In Takotsubo, doctors look at the balance between two specific markers [8]:

  • Troponin: This marker indicates muscle damage. In Takotsubo, it is often only mildly elevated compared to a massive heart attack [8].
  • BNP or NT-proBNP: This marker indicates “stretch” or stress on the heart walls. In Takotsubo, this is often very high [8].
  • The Ratio: When doctors see a very high BNP compared to only a mildly elevated Troponin, it strongly points toward Takotsubo [9]. It suggests the heart is very stressed but not necessarily dying.

Imaging: Seeing the “Ballooning”

Two types of imaging are essential for confirming the diagnosis and ruling out other conditions like myocarditis (inflammation of the heart muscle).

1. Transthoracic Echocardiogram (TTE)

This ultrasound shows the “typical” shape of Takotsubo—the apical ballooning, where the bottom of the heart doesn’t move and bulges out like an octopus trap [10][11]. (For more on the different shapes, read about The Shapes of a Stunned Heart).

2. Cardiac MRI (CMR)

A Cardiac MRI is the “gold standard” for differentiating Takotsubo from other conditions [12].

  • Edema (Swelling): Takotsubo shows significant swelling (edema) in the heart muscle during the acute phase [13][14].
  • Lack of Permanent Scarring: In a heart attack or myocarditis, a special MRI dye will show bright spots (Late Gadolinium Enhancement), indicating permanent scarring [15][16]. In Takotsubo, there is typically no permanent scarring seen on this scan, confirming that the muscle is expected to recover [16][17].

Common questions in this guide

How do doctors tell the difference between Takotsubo and a heart attack?
Doctors use a coronary angiogram to check for blocked arteries. In a traditional heart attack, there is usually a major blockage, but in Takotsubo, the arteries are typically clear of severe blockages.
What are the InterTAK diagnostic criteria?
The InterTAK criteria is a scoring system used to estimate the likelihood of Takotsubo. It looks at clinical factors like being female, experiencing a recent severe stress trigger, and having a history of psychiatric or neurological disorders.
What blood tests are used to diagnose broken heart syndrome?
Doctors check the ratio between two blood markers: BNP (which indicates heart stress) and Troponin (which indicates heart muscle damage). A very high BNP level combined with only a mild Troponin elevation strongly points to Takotsubo.
What does an echocardiogram show if I have Takotsubo?
An echocardiogram often reveals 'apical ballooning.' This is a distinct shape where the bottom of the stunned heart stops moving normally and bulges outward, resembling a traditional Japanese octopus trap.
Why might I need a Cardiac MRI for Takotsubo?
A Cardiac MRI is the gold standard for confirming Takotsubo. It can reveal temporary swelling in the heart muscle and prove there is no permanent scarring, which helps distinguish it from other conditions like myocarditis.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.What clinical factors made you suspect Takotsubo rather than a traditional heart attack when I arrived?
  2. 2.Did my coronary angiogram show any plaque at all, and how did you determine that none of it was the 'culprit' for my symptoms?
  3. 3.On my Cardiac MRI, did you see 'edema' (swelling) without 'Late Gadolinium Enhancement' (scarring), and what does that tell you about my recovery?
  4. 4.Did my bloodwork show a very high BNP compared to troponin, confirming the stress on my heart walls?
  5. 5.Based on my imaging, how long do you expect it to take for the shape of my heart to return to normal?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (17)
  1. 1

    Takotsubo Syndrome Associated With Structural Brain Alterations of the Limbic System.

    Hiestand T, Hänggi J, Klein C, et al.

    Journal of the American College of Cardiology 2018; (71(7)):809-811 doi:10.1016/j.jacc.2017.12.022.

    PMID: 29447745
  2. 2

    Coexistence of acute takotsubo syndrome and acute coronary syndrome.

    Sharkey SW, Kalra A, Henry TD, et al.

    Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions 2020; (96(4)):825-829 doi:10.1002/ccd.28595.

    PMID: 31696663
  3. 3

    International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management.

    Ghadri JR, Wittstein IS, Prasad A, et al.

    European heart journal 2018; (39(22)):2047-2062 doi:10.1093/eurheartj/ehy077.

    PMID: 29850820
  4. 4

    A rare long-term undetected pheochromocytoma leading to Takotsubo syndrome in an older male patient: a case report.

    Chen M, Zhao T, Chen G, Hu S

    BMC endocrine disorders 2020; (20(1)):93 doi:10.1186/s12902-020-00578-5.

    PMID: 32576166
  5. 5

    A novel clinical score (InterTAK Diagnostic Score) to differentiate takotsubo syndrome from acute coronary syndrome: results from the International Takotsubo Registry.

    Ghadri JR, Cammann VL, Jurisic S, et al.

    European journal of heart failure 2017; (19(8)):1036-1042 doi:10.1002/ejhf.683.

    PMID: 27928880
  6. 6

    [Takotsubo syndrome. Clinical and pathogenetic aspects. Basics of diagnosis and treatment].

    Suspitsyna IN, Sukmanova IA

    Kardiologiia 2019; (60(2)):96-103 doi:10.18087/cardio.2020.2.n521.

    PMID: 32345205
  7. 7

    Validation of the InterTAK Diagnostic Score for Differentiating Takotsubo Syndrome from Acute Coronary Syndrome in a Middle Eastern Population.

    Jamil G, Al Shamisi A, AlShamsi F, Agha A

    Journal of clinical medicine 2025; (14(21)) doi:10.3390/jcm14217806.

    PMID: 41227202
  8. 8

    Comparison of troponin and natriuretic peptides in Takotsubo syndrome and acute coronary syndrome: a meta-analysis.

    Couch LS, Garrard JW, Henry JA, et al.

    Open heart 2024; (11(1)) doi:10.1136/openhrt-2024-002607.

    PMID: 38508657
  9. 9

    NT-proBNP/cardiac troponin T ratio >7.5 on the second day of admission can differentiate Takotsubo from acute coronary syndrome with good accuracy.

    Rallidis LS, Iordanidis D, Papathanasiou KA, et al.

    Hellenic journal of cardiology : HJC = Hellenike kardiologike epitheorese 2024; (76()):22-30 doi:10.1016/j.hjc.2023.05.010.

    PMID: 37269943
  10. 10

    Takotsubo Syndrome as a Cause of False Acute Abdomen in the Early Postoperative Period After Bariatric Surgery-a Report of Two Cases.

    Viegas F, Viegas C, França E, et al.

    Obesity surgery 2016; (26(10)):2547-51 doi:10.1007/s11695-016-2326-6.

    PMID: 27503323
  11. 11

    Variants of Takotsubo syndrome in the perioperative period: A review of potential mechanisms and anaesthetic implications.

    Gibson LE, Klinker MR, Wood MJ

    Anaesthesia, critical care & pain medicine 2020; (39(5)):647-654 doi:10.1016/j.accpm.2020.01.010.

    PMID: 32920217
  12. 12

    An Extensive Review on Imaging Diagnosis Methods in Takotsubo Syndrome.

    Paraschiv C, Paduraru L, Balanescu S

    Reviews in cardiovascular medicine 2023; (24(10)):300 doi:10.31083/j.rcm2410300.

    PMID: 39077560
  13. 13

    Myocardial microvascular function assessed by cardiovascular magnetic resonance first-pass perfusion in patients with Takotsubo syndrome.

    Cau R, Pitzalis C, Pisu F, et al.

    European radiology 2025; (35(7)):3917-3926 doi:10.1007/s00330-024-11340-z.

    PMID: 39841202
  14. 14

    Cardiac Magnetic Resonance in Takotsubo Syndrome.

    Bratis K

    European cardiology 2017; (12(1)):58-62 doi:10.15420/ecr.2017:7:2.

    PMID: 30416553
  15. 15

    Perioperative Takotsubo Cardiomyopathy Revealed by Ventricular Arrhythmia After a Minor Surgery in a Young Woman.

    Hafid S, Lebbar S, Bennis G, et al.

    Cureus 2026; (18(1)):e101699 doi:10.7759/cureus.101699.

    PMID: 41700236
  16. 16

    Left anterior descending artery stenosis coexisting with Takotsubo cardiomyopathy: Innocent bystander or underlying culprit?

    Jabri M, Ismaili N, Ouafi NE

    Radiology case reports 2026; (21(2)):669-675 doi:10.1016/j.radcr.2025.10.036.

    PMID: 41332968
  17. 17

    Late Gadolinium Enhancement on Cardiac MRI in Patients With Takotsubo Syndrome: Insights From the Multicenter EVOLUTION Registry.

    Cau R, Arcari L, Pontone G, et al.

    AJR. American journal of roentgenology 2026; doi:10.2214/AJR.26.34546.

    PMID: 41738731

This page explains diagnostic testing for Takotsubo cardiomyopathy for educational purposes only. Always consult your cardiologist or healthcare provider for an official diagnosis and medical advice.

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