TAKOTSUBO CARDIOMYOPATHY IN DIVERS: A NARRATIVE REVIEW OF THE ASSOCIATION WITH IMMERSION PULMONARY OEDEMA

Karolina Chudecka; Michał Chylewski; Aleksandra Kędzierska; Jakub Lamorski; Izabela Szubert; Julia Suchecka; Wiktor Nesterak; Katarzyna Józwa; Gabriela Stępień; Urszula Przewoźna

doi:10.31435/ijitss.2(50).2026.5867

Authors

Karolina Chudecka Independent Public Provincial Integrated Hospital in Szczecin, Szczecin, Poland https://orcid.org/0009-0004-0262-5036
Michał Chylewski University Clinical Hospital No. 1 PMU in Szczecin, Szczecin, Poland https://orcid.org/0009-0007-4789-1903
Aleksandra Kędzierska Independent Public Provincial Integrated Hospital in Szczecin, Szczecin, Poland https://orcid.org/0009-0008-7050-4139
Jakub Lamorski Independent Public Provincial Integrated Hospital in Szczecin, Szczecin, Poland https://orcid.org/0009-0004-5456-7413
Izabela Szubert Independent Public Provincial Integrated Hospital in Szczecin, Szczecin, Poland https://orcid.org/0009-0006-7162-6651
Julia Suchecka Independent Public Provincial Integrated Hospital in Szczecin, Szczecin, Poland https://orcid.org/0009-0001-9975-355X
Wiktor Nesterak Pomeranian Medical University, Szczecin, Poland https://orcid.org/0009-0009-5322-903X
Katarzyna Józwa Independent Public Provincial Integrated Hospital in Szczecin, Szczecin, Poland https://orcid.org/0009-0003-5615-2388
Gabriela Stępień University Clinical Hospital No. 2 PMU in Szczecin, Szczecin, Poland https://orcid.org/0009-0006-4505-5162
Urszula Przewoźna University Clinical Hospital No. 2 PMU in Szczecin, Szczecin, Poland https://orcid.org/0009-0003-2186-6604

DOI:

https://doi.org/10.31435/ijitss.2(50).2026.5867

Keywords:

Takotsubo Cardiomyopathy; Stress Cardiomyopathy; Apical Ballooning Syndrome; Immersion Pulmonary Oedema; Scuba Diving; Diving Medicine

Abstract

Background: Takotsubo cardiomyopathy (TTC), also known as stress cardiomyopathy or broken heart syndrome, is a transient form of left ventricular dysfunction classically triggered by acute physical or emotional stress. An emerging body of literature has documented TTC occurring in the context of underwater diving, frequently in association with immersion pulmonary oedema (IPO). The exact nature of this relationship — whether IPO precipitates TTC, TTC precipitates IPO, or both arise from a shared catecholaminergic surge — remains incompletely understood.

Objectives: To perform a systematic narrative review of all published cases describing TTC in association with diving or immersion, to characterise patient demographics, clinical presentations, diagnostic findings, management strategies, and outcomes, and to discuss proposed pathophysiological mechanisms and implications for diving medicine practice.

Methods: A systematic literature search was conducted in PubMed/MEDLINE, the Cochrane Library, and Google Scholar (January 2000 – December 2025) using pre-specified search terms combining TTC terminology with diving-related terms. Seven primary studies meeting inclusion criteria were identified and narratively synthesised. Quality appraisal of non-randomised evidence was guided by the Scale for the Assessment of Narrative Review Articles (SANRA).

Results: A total of approximately 30 cases of diving-associated TTC were identified across the included studies. Affected individuals were predominantly middle-aged to elderly women, though cases in men were also documented. Presentations consistently featured acute dyspnoea during or after diving, pulmonary oedema on chest imaging, troponin elevation, ECG changes including T-wave inversion and QTc prolongation, and reversible left ventricular wall motion abnormalities on echocardiography with preserved or normal coronary arteries on angiography. Cardiac magnetic resonance imaging (CMR), when performed, showed myocardial oedema and patchy late gadolinium enhancement in the mid-to-apical segments, consistent with TTC. All surviving patients demonstrated complete cardiac recovery within days to weeks. Mortality was confined to cases complicated by fatal arrhythmias or out-of-water cardiac arrest.

Conclusions: Diving represents a recognised and likely underappreciated trigger for TTC, typically in the context of IPO. The association is mediated by an intense catecholaminergic surge provoked by physiological diving stressors including cold-water immersion, increased preload, exertion, and psychological stress. Clinicians evaluating divers presenting with acute cardiorespiratory distress should consider TTC in the differential diagnosis and initiate prompt cardiac investigations. Guideline-based management and long-term restriction from diving are advisable following confirmed episodes.

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