Assessment of Takotsubo (ampulla) cardiomyopathy using 99mTc-tetrofosmin myocardial SPECT--comparison with acute coronary syndrome

24 hour ST segment analysis in transient left ventricular apical ballooning

Objective

The etiologic basis of transient left ventricular apical ballooning, a novel cardiac syndrome, is not clear. Among the proposed pathomechanisms is coronary vasospasm. Long-term ST segment analysis may detect vasospastic episodes but has not been reported.

Methods

30 consecutive patients with transient left ventricular apical ballooning, left ventricular dysfunction and normal or near-normal coronary arteries were investigated. A 24-hour Holter ECG was obtained after emergency admission. ST segment analysis was performed automatically in 2 leads and confirmed by visual inspection. Criteria for an ischemic event were: 1. ST elevation or 2. horizontal or down-sloping ST segments ≥1 min duration and ≥100 µV J+80 point deviation corrected for baseline ST-deviation.

Results

Patients presented with ST segment elevation (n = 19) and/or T wave inversion (n = 20) on admission ECG. Ejection fraction was 50±12%. No transient ST elevations were observed during Holter ECG analysis. In 3 patients, 8 transient episodes of ST depression were recorded. Durations of episodes varied between 75s and 790s (mean 229s). Maximal ST deviation averaged −191±71 µV. Ischemic burden was −1 to −22 mVs (mean −8 mVs). 27 patients showed no ischemic events.

Conclusions

ST segment analysis of 24 h Holter recordings revealed minor ischemic events in only 10% of patients with transient left ventricular apical ballooning. Overall, ST segment changes were not indicative of recurrent coronary spasm playing a major role in the genesis of transient left ventricular apical ballooning.

The preoperative management of a patient with a large aneurysm of the sinus of valsalva and takotsubo cardiomyopathy

We report a case of a 43-year-old woman, who presented with thoracic interscapular pain at a peripheral hospital. In addition, the patient reported retrosternal pain, which had occurred only hours before-after an upsetting telephone call. The CT imaging ruled out an aortic dissection but revealed a huge sinus valsalva aneurysm (SVA) while the laboratory parameters showed slightly elevated troponin T value. Echocardiography showed an akinesia of the midventricular and apical left ventricular wall, accompanied by normal basal contractility. Stenotic coronary disease and endomyocarditis could be excluded as the origin of the contractility disorders. The synopsis of the findings and patient's medical history led to the assumption of the takotsubo cardiomyopathy triggered by stress due to the worrying telephone call and the pain originating from the symptomatic SVA. We decided to perform an elective operation of the symptomatic aneurysm after restitution of the ejection fraction--as expected in takotsubo cardiomyopathy--instead of an emergency operation.

Unique morphological variations of transient midventricular syndrome: a case series-review

Older individuals (especially women) enduring an inciting emotional or physical event are prone to developing left ventricular ballooning syndrome. Ballooning of apical distribution is the most common type. However, a midventricular variant is increasingly reported. As this variant becomes further delineated, we describe a case series in which various morphological patterns of midleft ventricular segments are seen. Each case involves a female patient with a presumptive diagnosis of acute coronary syndrome, who upon further cardiac workup demonstrated normal epicardial coronary blood flow. Subsequent cardiac imaging, including transthoracic echocardiography, revealed unique midventricular dilation and akinesis, with preserved or hypercontractility of the basal and apical segments. However, more unique to this, was the fact that the left ventricular regional wall motion abnormalities were of either "symmetric" ballooning morphology, involving all mid segments of the left ventricle; or more dramatically, "asymmetric" ballooning morphology, which involves abnormal regional motion of only a focal left ventricular wall. Furthermore, we review current literature on midventricular ballooning and propose likely mechanisms and optimal treatment strategies in the face of potential complications of midventricular ballooning syndrome.

Prevalence of Takotsubo cardiomyopathy in the United States

BACKGROUND

The aim of this study was to describe the prevalence of Takotsubo cardiomyopathy (TTC), age-gender interaction, and various comorbidities associated with it based on nationwide hospitalization records. Takotsubo cardiomyopathy is an increasingly reported clinical syndrome; however, there are no data on its prevalence in the general US population.

METHODS

The Nationwide Inpatient Sample discharge records were queried for the year 2008 using the International Classification of Diseases, Ninth Revision, code 429.83.

RESULTS

There were 6,837 patients diagnosed with TTC among 33,506,402 hospitalizations in the Nationwide Inpatient Sample database. Women were found to have higher odds of developing TTC (odds ratio 8.8). Women >55 years old had 4.8 times higher odds for developing TTC when compared with women <55 years old. Smoking, alcohol abuse, anxiety states, and hyperlipidemia were commonly associated with TTC. The peak incidence of hospitalization for TTC was in summer.

CONCLUSION

Takotsubo cardiomyopathy was diagnosed in about 0.02% of all hospitalizations in the United States, mostly in elderly women with history of smoking, alcohol abuse, anxiety states, and hyperlipidemia.

Clinical characteristics, sex hormones, and long-term follow-up in Swiss postmenopausal women presenting with Takotsubo cardiomyopathy

BACKGROUND

The overwhelming majority of patients with stress cardiomyopathy (SC) are postmenopausal women, suggesting an important pathophysiologic role of the female sex hormones. Preliminary data suggest that myocardial stunning might be provoked by estrogen deficiency.

HYPOTHESIS

We hypothesized that, compared with age- and gender-matched patients with myocardial infarction (MI) or patients with normal coronary arteries, patients with SC would exhibit altered levels of sex hormones. Furthermore, we aimed to describe the clinical course and the pattern of sex hormones of the SC patients during long-term follow-up.

METHODS

Blood samples obtained on hospital admission were analyzed for estradiol (E2), progesterone (P), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) in women with SC (n = 17), age-matched women with acute MI (n = 16), and women with normal coronary arteries (n = 15). Six years after the initial event, SC patients underwent a clinical and echocardiographic follow-up and reassessment of sex hormones.

RESULTS

Estrogen concentrations at hospital admission were significantly higher in the SC group compared with the MI and the control groups, with no difference in P, FSH, and LH concentrations. Follow-up E2 after 6 years in SC patients was lower than during the acute SC episode. Follow-up P in these patients was lower than P in the MI and control groups during the acute event, with a similar trend for E2. After a median follow-up of 6.4 years, 1 sudden cardiac death occurred and 2 patients suffered from SC recurrence.

CONCLUSIONS

During the acute event, E2 concentrations are elevated in postmenopausal SC patients compared with women with acute MI or with normal coronary arteries. The higher E2 concentrations might have exerted atheroprotective effects and thus diverted the stress response to SC rather than MI. Recurrence and/or sudden cardiac death remains a potential risk of SC.

Scintigraphic imaging in Tako-Tsubo cardiomyopathy

Tako-Tsubo cardiomyopathy (TTC, stress cardiomyopathy) is more common in elderly women and its symptoms can be deceptively similar to those of acute myocardial infarction. Although coronary arteries appear normal on coronary angiograms, a shape like a Tako-Tsubo (a Japanese fishing pot for trapping octopuses) can be observed on left ventriculogram. TTC is generally considered to be a trigger for sudden cardiac death. The onset mechanism of TTC is still controversial. Catecholamine cardiotoxicity and/or coronary circulation disturbance due to coronary microvascular spasm and/or neurogenic stunned myocardium as a result of autonomic imbalance are considered to be the most likely causes. In this review, we assess the usefulness of myocardial scintigraphic imaging in TTC patients on the basis of the results obtained from earlier studies and case reports in order to establish a deeper understanding of the pathophysiological mechanism of this syndrome.

Stress cardiomyopathy: diagnosis, pathophysiology, management, and prognosis

Stress cardiomyopathy is now a well-recognized reversible cardiomyopathy, with a clinical presentation mimicking Acute Coronary syndrome in the absence of significant coronary artery disease. It is often encountered in postmenopausal females and is usually precipitated by acute emotional or physical stressors. In this review, we have attempted to summarize relevant data regarding diagnosis, typical and atypical presentations, pathophysiology, management options, and prognosis. Typically, patients present with chest pain and shortness of breath, transient electrocardiographic changes, moderate troponin elevation, and are found to have wall motion abnormalities (apical and midventricular akinesis with preserved basal segment systolic function) without obstructive coronary lesions, with complete resolution in next few weeks. The precise pathophysiology remains unclear, but excessive catecholamine stimulation, metabolic disturbances, and dysfunction of microcirculation are thought to be the underlying mechanisms.

Takotsubo cardiomyopathy after a dancing session: a case report

Introduction

Stress-induced (Takotsubo) cardiomyopathy is a rare form of cardiomyopathy which presents in a manner similar to that of acute coronary syndrome. This sometimes leads to unnecessary thrombolysis therapy. The pathogenesis of this disease is still poorly understood. We believe that reporting all cases of Takotsubo cardiomyopathy will contribute to a better understanding of this disease. Here, we report a patient who, in the absence of any recent stressful events in her life, developed the disease after a session of dancing.

Case presentation

A 69-year-old Caucasian woman presented with features suggestive of acute coronary syndrome shortly after a session of dancing. Echocardiography and a coronary angiogram showed typical features of Takotsubo cardiomyopathy and our patient was treated accordingly. Eight weeks later, her condition resolved completely and the results of echocardiography were totally normal.

Conclusions

Takotsubo cardiomyopathy, though transient, is a rare and serious condition. Although it is commonly precipitated by stressful life events, these are not necessarily present. Our patient was enjoying one of her hobbies (that is, dancing) when she developed the disease. This case has particular interest in medicine, especially for the specialties of cardiology and emergency medicine. We hope that it will add more information to the literature about this rare condition.

Apical ballooning syndrome after attempted suicidal hanging

We report a case of "Apical Ballooning Syndrome" following attempted suicidal hanging. Our patient developed retrosternal chest pain and ischemic changes on electrocardiography (ECG), a day after the suicidal attempt. She underwent an angiogram considering the possibility of acute coronary syndrome. However, her coronary arteries were normal; the left ventricle showed the typical ballooning pattern characterized by hypokinesia of the distal septum and apex. On follow-up a week later, she remained asymptomatic; her ECG changes had reversed and the left ventricular contractility was normal on echocardiography.

Stress cardiomyopathy syndrome: a contemporary review

Stress cardiomyopathy (SC) syndrome represents a reversible form of cardiomyopathy that commonly presents proximate to an acute emotional or physiologic stressor. The clinical presentation is similar to an acute coronary syndrome in the absence of obstructive coronary artery disease to explain the unusual distribution of associated transient wall motion abnormalities. Postmenopausal women seem particularly prone to SC for unclear reasons. The pathophysiology of the syndrome is unknown but may involve pathologic sympathetic myocardial stimulation.

Tako-tsubo-like left ventricular dysfunction: transient left ventricular apical ballooning syndrome

AIMS/OBJECTIVES

This review examines the 'tako-tsubo-like' syndrome or transient left ventricular apical ballooning. The aim of this review is a complete evaluation of epidemiology, clinical and instrumental features, pathophysiological mechanisms, therapy and prognosis of this syndrome.

METHODS

We have evaluated the data from literature for a comprehensive consideration of multiple aspects of this syndrome.

RESULTS/FINDINGS

Transient left ventricular apical ballooning typically affects women, and the clinical presentation is comparable to acute coronary syndrome with chest pain or sudden dyspnoea, changes in ECG and elevated cardiac enzymes in the absence of significant coronary stenosis, with complete resolution of wall-motion abnormalities in a period of days or weeks. This syndrome is triggered by marked psychological or physiological stress. Several pathophysiological mechanisms have been proposed, such as cathecolamine-mediated cardiotoxicity, abnormalities in coronary microvascular function and multivessel coronary vasospasm. The highest incidence of transient left ventricular apical ballooning is in the Japanese population, but it has been recently identified also in the USA and Europe. Treatment is empirical and supportive. The prognosis is generally favourable, although some deaths have been reported, usually the result of irreversible cardiogenic shock, refractory ventricular arrhythmias, or other catastrophic cardiovascular event.

CONCLUSIONS/INTERPRETATIONS

We conclude by emphasising the importance of a more deeper knowledge of this syndrome for general physicians and cardiologists and it should be often considered as a possible diagnosis occurring in emergency department and in patients admitted in the Chest Pain Units with a diagnosis of coronary acute syndrome.

Takotsubo cardiomyopathy: Report of the first case series in Serbia and review of the literature

Introduction. Takotsubo cardiomyopathy is a relatively novel cardiac syndrome that is characterized by transient left ventricular asynergy involving apical and mid-ventricular segments. Epidemiology and pathophisiology. It occurs predominantly in elderly women in the absence of obstructive coronary artery disease and is usually associated with severe emotional or physical stress. This syndrome is manifested with chest pain, electrocardiographic changes that mimic acute myocardial infarction, and minimal myocardial enzy?matic release. Several different mechanisms have been proposed: coronary artery spasm, dynamic left ventricular outflow/intracavitary obstruction, coronary microvascular dysfunction and direct catecholamine-mediated cardiomyocite injury. Therapy and prognosis. Complete recovery usually occurs after dramatic presentation, frequently complicated with acute heart failure. Therapy is empiric and directed towards supportive measures against cardiogenic shock, acute heart failure, dysrhythmias. In-hospital mortality rate is less than 1%, but long-term prognosis is still unknown. In addition to the review of the literature on takotsubo cardiomyopathy, we present the first series of patients with this syndrome detected in Clinical Hospital Center Zemun.

Sympathetic overstimulation during critical illness: adverse effects of adrenergic stress

The term ''adrenergic'' originates from ''adrenaline'' and describes hormones or drugs whose effects are similar to those of epinephrine. Adrenergic stress is mediated by stimulation of adrenergic receptors and activation of post-receptor pathways. Critical illness is a potent stimulus of the sympathetic nervous system. It is undisputable that the adrenergic-driven ''fight-flight response'' is a physiologically meaningful reaction allowing humans to survive during evolution. However, in critical illness an overshooting stimulation of the sympathetic nervous system may well exceed in time and scope its beneficial effects. Comparable to the overwhelming immune response during sepsis, adrenergic stress in critical illness may get out of control and cause adverse effects. Several organ systems may be affected. The heart seems to be most susceptible to sympathetic overstimulation. Detrimental effects include impaired diastolic function, tachycardia and tachyarrhythmia, myocardial ischemia, stunning, apoptosis and necrosis. Adverse catecholamine effects have been observed in other organs such as the lungs (pulmonary edema, elevated pulmonary arterial pressures), the coagulation (hypercoagulability, thrombus formation), gastrointestinal (hypoperfusion, inhibition of peristalsis), endocrinologic (decreased prolactin, thyroid and growth hormone secretion) and immune systems (immunomodulation, stimulation of bacterial growth), and metabolism (increase in cell energy expenditure, hyperglycemia, catabolism, lipolysis, hyperlactatemia, electrolyte changes), bone marrow (anemia), and skeletal muscles (apoptosis). Potential therapeutic options to reduce excessive adrenergic stress comprise temperature and heart rate control, adequate use of sedative/analgesic drugs, and aiming for reasonable cardiovascular targets, adequate fluid therapy, use of levosimendan, hydrocortisone or supplementary arginine vasopressin.

Striking observations during emergency catecholamine treatment of cardiac syncope in a patient with initially unrecognized takotsubo cardiomyopathy

A case is presented of initially unrecognized takotsubo cardiomyopathy with a dramatic clinical course after emergency catecholamine treatment for circulatory support during stress-induced cardiac syncope followed by complete recovery of cardiac function after catecholamine withdrawal and starting beta-blocker therapy. Echocardiography including 2D-strain imaging suggested that the left ventricle (LV) wall motion abnormality was mainly the consequence of geometry-induced regional differences in wall stress (progressively amplified by catecholamines), which might be another possible pathophysiological mechanism involved in the development of LV dysfunction in takotsubo cardiomyopathy. This case also suggests that in emergency, before coronary angiography is possible, echocardiography can be helpful for initial therapeutic decisions, especially to avoid emergency inotropic therapy in such patients.

Takotsubo cardiomyopathy: state-of-the-art review

Takotsubo cardiomyopathy (TC) is characterized by transient, often severe, left ventricular dysfunction and electrocardiographic changes that might mimic acute myocardial infarction in the absence of significant obstructive coronary artery disease. It is often encountered in elderly women after physical or emotional stress. Excessive catecholamine stimulation, metabolic abnormalities, and microcirculatory dysfunction are thought to be responsible for the manifestations of this disorder. This comprehensive review summarizes relevant published data, atypical presentations, pathophysiology, and management strategy. It also includes a review of 789 patients with TC including nine illustrative cases encountered at our institution.

Acute stress cardiomyopathy

A unique syndrome of heart failure and transient left ventricular systolic dysfunction precipitated by acute emotional or physical stress has recently emerged in the medical literature. The syndrome is referred to by several names, including stress cardiomyopathy, takotsubo cardiomyopathy, left ventricular apical ballooning syndrome, and broken heart syndrome. Because most patients with stress cardiomyopathy present with chest pain, electrocardiographic abnormalities, elevated cardiac enzymes, and focal left ventricular wall motion abnormalities, it is not surprising that for years this syndrome went relatively unrecognized because physicians mistook it for acute myocardial infarction. As reports of this condition have increased worldwide during the past 5 years, it has become clear that stress cardiomyopathy has unique clinical features that can be readily distinguished from those of an acute myocardial infarction. This article reviews the clinical features of stress cardiomyopathy and discusses potential pathophysiologic mechanisms of this disorder.

Takotsubo cardiomyopathy

BACKGROUND

Takotsubo cardiomyopathy is a novel, yet well-described, reversible cardiomyopathy triggered by profound psychological or physical stress with a female predominance.

OBJECTIVE

This review is designed to increase general clinician awareness about the diagnosis, incidence, pathogenesis, and therapies of this entity.

DATA SOURCES

A complete search of multiple electronic databases (Pubmed, EMBASE, Science Citation Index) was carried out to identify all full-text, English-language articles published from 1980 to the present date and relevant to this review.

REVIEW METHODS

The following search terms were used: takotsubo cardiomyopathy, stress-induced cardiomyopathy, and left ventricular apical ballooning syndrome. Citation lists from identified articles were subsequently reviewed and pertinent articles were further identified.

RESULTS

Takotsubo cardiomyopathy is typically characterized by the following: 1) acute onset of ischemic-like chest pain or dyspnea, 2) transient apical and mid-ventricular regional wall-motion abnormality, 3) minor elevation of cardiac biomarkers, 4) dynamic electrocardiographic changes, and 5) the absence of epicardial coronary artery disease. The pathogenesis of the syndrome is unknown but has mostly been associated with acute emotional or physiologic stressors. Dote, Sato, Tateishi, Uchida, Ishihara (J Cardiol. 21(2):203-214, 1991); Desmet, Adriaenssens, Dens (Heart. 89(9):1027-1031, Sep., 2003); Bybee, Kara, Prasad, et al. (Ann Intern Med. 141(11):858-865, Dec 7, 2004); Sharkey, Lesser, Zenovich, et al. (Circulation. 111(4):472-479, Feb 1, 2005) The short and long-term prognosis of these patients is overwhelmingly favorable and often only requires supportive therapy.

CONCLUSION

Whether an emotional or physical event precedes one's symptoms, it is apparent that takotsubo cardiomyopathy case presentations mimic ST-segment elevation myocardial infarction, and thus is an important entity to be recognized by the medical community.

Takotsubo cardiomyopathy complicated by Dressler's syndrome

Takotsubo cardiomyopathy is an increasingly recognised syndrome characterised by transient apical left ventricular dysfunction in the absence of significant coronary artery disease. We describe a case of Takotsubo cardiomyopathy complicated by Dressler's syndrome. To our knowledge, these two conditions have not previously been reported in combination.

Transient apical ballooning syndrome--clinical characteristics, ballooning pattern, and long-term follow-up in a Swiss population

BACKGROUND

Transient apical ballooning syndrome (TABS) or Takotsubo cardiomyopathy mimics acute ST-elevation myocardial infarction, but is considered to have a good prognosis with only moderate elevation of myocardial enzymes and full recovery of left ventricular function. Although it is increasingly reported, its exact incidence, clinical presentation, and prognosis in non-Asian populations remain largely unknown.

OBJECTIVE

To describe the clinical characteristics and long-term follow-up of patients who presented with TABS at our institution over a 3 year-period.

METHODS

Patients were retrospectively retrieved from our local database. Patient charts were carefully reviewed and the diagnosis of TABS was based on the Mayo Clinic diagnostic criteria. Moreover, psychosocial stress or gastrointestinal disease was recorded.

RESULTS

During the study period, 13,715 coronary angiographies were performed at our institution, including 2459 patients presenting with an acute coronary syndrome (ACS). Forty-one TABS were diagnosed, which represents an incidence of 1.7% of ACS-patients and 0.3% of all coronary angiographies performed, respectively. Mean age was 65 years, with 85% women. Clinical presentations included chest pain, dyspnoea, and cardiogenic shock. A preceding psychological or physical condition perceived as "stress" was reported in 61%. At a mean follow-up of 675+/-288 days, none of the patients died of cardiac causes, but two patients had a recurrence of symptoms.

CONCLUSIONS

This is the largest cohort of TABS patients reported out of Europe so far. The good overall prognosis and low likelihood of recurrence were confirmed.

Takotsubo cardiomyopathy: pathogenetic insights and myocardial perfusion kinetics using myocardial contrast echocardiography

Transient apical ballooning syndrome or Takotsubo cardiomyopathy (TC) is a novel acute cardiac syndrome, characterized by regional systolic dysfunction involving the apex and mid-ventricular segments, with hyperkinesis of the basal segments. Mid-ventricular ballooning cardiomyopathy (MVBC) is a recently recognized variant of TC. Both disorders share the same precipitating factors, clinical features and course; however, unlike TC, MVBC is characterized by ballooning and akinesis of the mid-ventricular segments with hypercontractility of the basal and apical segments. While the precise pathogenetic mechanism of this disorder remains elusive, microvascular dysfunction from excessive catecholamine release has been implicated. We report findings on regional contractile dysfunction (strain imaging), myocardial blood flow (semi-quantitative), and perfusion kinetics using myocardial contrast echocardiography in a series of three illustrative cases of TC.

A case of takotsubo cardiomyopathy after surgery for common bile duct stones

Takotsubo cardiomyopathy (TC) is a rare reversible circulatory syndrome often detected in elderly patients after general surgery. We report the case of an 85-year-old woman who was admitted for obstructive jaundice and underwent ERCP and ENBD before operation. She finally underwent cholecystectomy and choledocholithotomy with the diagnosis of gallbladder and common bile duct stones. In the evening just after the operation, without symptoms of cardiac failure, her ECG suddenly exhibited abnormal ST-T elevation in leads II, III, and V2-V6, though neither CPK(MB) nor troponin T was elevated. Echocardiogram demonstrated basal hyperkinesis and apical dyskinesis, suggesting TC. Conservative treatment enabled recovery, ECG was normalized in a month, and the postoperative course was satisfactory. The stress on her during treatment might have been a cause of this unique cardiomyopathy, and it should be recalled that TC is a potential complication of hepato-biliary-pancreatic surgery.

[Takotsubo cardiomyopathy: transient apical dysfunction of the left ventricle]

Transient apical dysfunction syndrome, ballooning or Takotsubo cardiomyopathy is a recently described syndrome. It is a disease with a partially known mechanism, characterized by the morphology adopted by the left ventricle secondary to hypokinesis and dyskinesis of the apical segments and hypercontractibility of the basal segments. In most of the cases published, it is a syndrome with ST segment elevation in the precordial leads, whose presentation form is also thoracic pain or dyspnea, with the possible existence of moderate elevation of cardiac biomarkers. On the contrary to the acute coronary syndrome, patients with left ventricle dysfunction do not have atherothrombotic disease in the coronary arteries. Furthermore, the alterations described have a reversible character. Some diagnostic clinical criteria have been proposed and there is presently some controversy on them and on the complementary examination needed to diagnose it.

Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: A systematic review

BACKGROUND

Transient left ventricular apical ballooning syndrome (TLVABS) is an acute cardiac syndrome mimicking ST-segment elevation myocardial infarction characterized by transient wall-motion abnormalities involving apical and mid-portions of the left ventricle in the absence of significant obstructive coronary disease.

METHODS

Searching the MEDLINE database 28 case series met the eligibility criteria and were summarized in a narrative synthesis of the demographic characteristics, clinical features and pathophysiological mechanisms.

RESULTS

TLVABS is observed in 0.7-2.5% of patients with suspected ACS, affects women in 90.7% (95% CI: 88.2-93.2%) with a mean age ranging from 62 to 76 years and most commonly presents with chest pain (83.4%, 95% CI: 80.0-86.7%) and dyspnea (20.4%, 95% CI: 16.3-24.5%) following an emotionally or physically stressful event. ECG on admission shows ST-segment elevations in 71.1% (95% CI: 67.2-75.1%) and is accompanied by usually mild elevations of Troponins in 85.0% (95% CI: 80.8-89.1%). Despite dramatic clinical presentation and substantial risk of heart failure, cardiogenic shock and arrhythmias, LVEF improved from 20-49.9% to 59-76% within a mean time of 7-37 days with an in-hospital mortality rate of 1.7% (95% CI: 0.5-2.8%), complete recovery in 95.9% (95% CI: 93.8-98.1%) and rare recurrence. The underlying etiology is thought to be based on an exaggerated sympathetic stimulation.

CONCLUSION

TLVABS is a considerable differential diagnosis in ACS, especially in postmenopausal women with a preceding stressful event. Data on longterm follow-up is pending and further studies will be necessary to clarify the etiology and reach consensus in acute and longterm management of TLVABS.

Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): frequency, mechanisms, and prognosis

BACKGROUND

The frequency and potential differences between patients with apical ("typical") and midventricular ("atypical") ballooning have not been described.

METHODS

Consecutive patients with the diagnosis of a troponin-positive acute coronary syndrome (ACS) were prospectively included into a registry (n = 3,265). Of those, 2,944 patients underwent left-heart catheterization and form the study population. Demographic, clinical, and angiographic data including assessment of microvascular dysfunction (Thrombolysis in Myocardial Infarction [TIMI] blush grade, corrected TIMI frame count), as well as clinical outcome were assessed in all patients.

RESULTS

In patients with troponin-positive ACS, the frequency of transient cardiomyopathy was 1.2% (35 of 2,944 patients). Typical apical wall motion abnormality was observed in 21 of 35 patients (60%), as compared to an atypical (midventricular) pattern in 14 of 35 patients (40%). Both groups did not differ regarding demographic, clinical, laboratory, or angiographic parameters. Scintigraphy and PET studies were performed in 17 of 35 patients (49%) with transient cardiomyopathy, and showed a strong correlation between location of wall motion abnormality and myocardial metabolism defects, with a significantly higher apical decrease in glucose uptake in patients with a typical pattern.

CONCLUSIONS

Transient cardiomyopathy affects approximately 1% of patients with a troponin-positive ACS. A typical apical wall motion abnormality is seen in only 60% of patients. Transient cardiomyopathy, also termed Tako-Tsubo cardiomyopathy, therefore should no longer be regarded as an exclusively apical ballooning syndrome, but rather a transient left ventricular dysfunction syndrome with an apical or midventricular pattern of wall motion abnormality.

Takotsubo syndrome in African-American women with atypical presentations: a single-center experience

BACKGROUND

Takotsubo syndrome is comprised of the clinical presentation of an acute myocardial infarction with electrocardiographic (ECG) changes of acute ischemia, chest pain, positive biomarkers, a pathognomonic left ventricular apical wall motion abnormality, and no culprit coronary disease at cardiac catheterization.

HYPOTHESIS

This study aimed at a further definition of the clinical characteristics of this syndrome in African-American (AA) patients based on our experience at a single center.

METHODS

Patients who presented with this syndrome between June 2003 and June 2005 were evaluated. All patients underwent coronary angiography and noninvasive cardiac investigation, including transthoracic two-dimensional echocardiography.

RESULTS

Five AA women (mean age 65 years) presented with the characteristics of the syndrome. No patient experienced chest pain, with three presenting with shortness of breath and two with nausea. Hypertension was the most common risk factor for coronary artery disease (CAD) in these patients. All but one patient had ST elevation on ECG, and troponin I elevation was present in all. Cardiac catheterization showed no obstructive CAD. The most common trigger was exacerbation of a current medical condition. All five patients developed deep, broad, diffuse T-wave inversions with a prolonged QT interval. There was no mortality during the hospital stay.

CONCLUSIONS

Takotsubo syndrome is experienced by AA patients. Female AA patients may experience atypical symptoms at presentation. The development of broad, diffuse, T-wave inversions with a prolonged QT interval within 2-48 h of presentation should be considered an additional criterion when diagnosing Takotsubo syndrome.

Takotsubo syndrome in African-American women with atypical presentations: a single-center experience

BACKGROUND

Takotsubo syndrome is comprised of the clinical presentation of an acute myocardial infarction with electrocardiographic (ECG) changes of acute ischemia, chest pain, positive biomarkers, a pathognomonic left ventricular apical wall motion abnormality, and no culprit coronary disease at cardiac catheterization.

HYPOTHESIS

This study aimed at a further definition of the clinical characteristics of this syndrome in African-American (AA) patients based on our experience at a single center.

METHODS

Patients who presented with this syndrome between June 2003 and June 2005 were evaluated. All patients underwent coronary angiography and noninvasive cardiac investigation, including transthoracic two-dimensional echocardiography.

RESULTS

Five AA women (mean age 65 years) presented with the characteristics of the syndrome. No patient experienced chest pain, with three presenting with shortness of breath and two with nausea. Hypertension was the most common risk factor for coronary artery disease (CAD) in these patients. All but one patient had ST elevation on ECG, and troponin I elevation was present in all. Cardiac catheterization showed no obstructive CAD. The most common trigger was exacerbation of a current medical condition. All five patients developed deep, broad, diffuse T-wave inversions with a prolonged QT interval. There was no mortality during the hospital stay.

CONCLUSIONS

Takotsubo syndrome is experienced by AA patients. Female AA patients may experience atypical symptoms at presentation. The development of broad, diffuse, T-wave inversions with a prolonged QT interval within 2-48 h of presentation should be considered an additional criterion when diagnosing Takotsubo syndrome.

[The "tako-tsubo" syndrome: report of two cases]

The "tako-tsubo" syndrome, initially described by Japanese authors is an apical akinesis of the left ventricule without significant coronary artery disease, with a moderate elevation of troponine I. We report 2 cases of women (with an average age of 68 years). They were refered for suspected acute coronary syndrome including on admission chest pain and ST segment elevation. Cardiac ultrasonography shew an apical akinesis. Coronary angiography didn't show significant coronary lesion. A moderate elevation of troponine was noted but no significant elevation of CPK. The prognosis has been excellent for these 2 patients. We observed a ventricular tachycardia due to QT lengthening in 1 case treated anteriorly by Flecaïn which spontaneously resolved. The first month, the electrocardiogram and cardiac ultrasonography anomalies disappeared totally. The treatment is based on beta-blockers, aspirin, statines, ACE. In the two cases, we didn't find arguments for myocarditis, recanalized thrombosis, coronary spasm, pheochromocytomas, but a risk factor is inboth: emotional stress. Maybe the diagnosis could be easier with the submillimeter cardiac computed tomography.

Transient left ventricular dysfunction (tako-tsubo phenomenon): Findings and potential pathophysiological mechanisms

Tako-tsubo-like left ventricular dysfunction phenomenon (TTP) is characterized by transient left ventricular apical ballooning associated with symptoms, electrocardiographic changes and minimal cardiac enzyme release in the absence of coronary artery disease. Initially described in Japan, TTP occurs worldwide, predominantly in women and frequently after emotional or physical stress. Symptoms include anginal chest pain, dyspnea and syncope. Electrocardiographic ST elevations may be present only for several hours, and are followed by negative T waves that persist for months. Arterial hypertension is found in up to 76% of TTP patients, hyperlipidemia in up to 57% and diabetes mellitus in up to 12%. Potential pathophysiological mechanisms for TTP include catecholamine-induced myocardial stunning or hyperkinesis of the basal left ventricular segments, coronary vasospasm, plaque rupture, myocarditis and genetic factors. TTP patients should be monitored similarly to myocardial infarction patients because organ failure, cardiogenic shock, ventricular fibrillation or rupture may occur. Beta-blockers are indicated, whereas catecholamines and nitrates should be avoided. The long-term prognosis is unknown.

Recurrence of Stress-Induced (Takotsubo) Cardiomyopathy

Takotsubo cardiomyopathy is a recently recognized form of transient left ventricular dysfunction that is presumably precipitated by stress and may clinically resemble an acute coronary syndrome. These patients have an akinetic left ventricular apex in an unusual shape that resembles a takotsubo. Although reports of single episodes of takotsubo cardiomyopathy are not infrequent in recent medical literature, we report a case of recurrence that may provide more insight into the nature of this syndrome.

Acute impairment of regional myocardial glucose uptake in the apical ballooning (takotsubo) syndrome

BACKGROUND

Apical ballooning syndrome (ABS) is a poorly understood clinical entity characterized by acute, transient systolic dysfunction of the left ventricular (LV) apex in the absence of epicardial coronary artery disease and commonly associated with acute emotional stress. We report abnormal regional myocardial perfusion and glucose uptake in 4 consecutive ABS patients studied using positron emission tomography with 13N-ammonia and 18F-fluorodeoxyglucose within 72 hours of presentation with ABS.

METHODS

All patients were postmenopausal females, 3 of whom had a major recent life stress event. Coronary angiography revealed no or minimal obstructive epicardial coronary artery disease. All patients exhibited reduced glucose uptake in the mid-LV and apical myocardial segments, which was out of proportion to perfusion abnormalities in half of the cases.

CONCLUSION

In all 4 patients, affected regions subsequently recovered regional LV systolic function within 6 weeks.

Acute impairment of regional myocardial glucose uptake in the apical ballooning (takotsubo) syndrome

BACKGROUND

Apical ballooning syndrome (ABS) is a poorly understood clinical entity characterized by acute, transient systolic dysfunction of the left ventricular (LV) apex in the absence of epicardial coronary artery disease and commonly associated with acute emotional stress. We report abnormal regional myocardial perfusion and glucose uptake in 4 consecutive ABS patients studied using positron emission tomography with 13N-ammonia and 18F-fluorodeoxyglucose within 72 hours of presentation with ABS.

METHODS

All patients were postmenopausal females, 3 of whom had a major recent life stress event. Coronary angiography revealed no or minimal obstructive epicardial coronary artery disease. All patients exhibited reduced glucose uptake in the mid-LV and apical myocardial segments, which was out of proportion to perfusion abnormalities in half of the cases.

CONCLUSION

In all 4 patients, affected regions subsequently recovered regional LV systolic function within 6 weeks.

[Transient left ventricular apical ballooning syndrome or Takotsubo cardiomyopathy. About 11 cases]

Takotsubo cardiomyopathy is a clinical entity mimicking an ST elevation myocardial infarction recently identified. Are associated a chest pain, electrocardiographics abnormalities, minor elevation of enzyme biomarkers in patients who don't have any significant angiographic stenosis on the coronary angiography and where left ventricle angiography shows apical regional wallmotion abnormalities with a characteristic apical ballooning aspect. Between march 2003 and march 2005, we included 11 patients for whom this syndrom was suspected. Mean age was 70, 3 years old. Electrocardiogram was abnormal in all cases. Biological markers show for all patients an elevation of troponin I. All patients had a coronary angiography and coronary arteries were normal. Left ventricle angiography showed in all cases wall-motion abnormalities in the apex with a ballooning aspect. A psychological or physical inducing factor has been found for 8 patients. The evolution was simple for all patients with no complications noted and no recurrence with a mean follow up of 15 months. Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrom have a good long-term prognosis even if serious complications sometimes deathly can be seen. The cause of this syndrom is unknown but it must be considered as a possible diagnosis of ST elevation myocardial infarction with normal coronary arteries.

Transient left ventricular apical ballooning after cocaine use: is catecholamine cardiotoxicity the pathologic link?

We describe a patient who developed acute chest pain after using cocaine and had ST-segment elevation in the anterior leads on electrocardiography with mild elevation of cardiac enzymes. Cardiac catheterization showed normal coronary arteries with no coronary vasospasm. Left ventricular angiography revealed typical ballooning of the left ventricular apex during systole with an estimated left ventricular ejection fraction of 25%. The symptoms improved during the next few hours, and follow-up echocardiography 4 days later showed complete resolution of the left ventricular dysfunction. Transient left ventricular apical ballooning (LVAB) was diagnosed. To our knowledge, LVAB (also known as Takotsubo cardiomyopathy or "broken heart syndrome") has not been reported previously in association with cocaine use. We discuss the possible pathophysiologic link between LVAB and cocaine-induced cardiotoxicity.

Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review

AIMS

To clarify the major features of the apical ballooning syndrome, we performed a systematic review of the existing literature.

METHODS AND RESULTS

Review of all relevant case series using the MEDLINE and EMBASE databases resulted in the identification of 14 studies. These studies suggest that the apical ballooning syndrome accounts for approximately 2.0% of ST-segment elevation infarcts, with most cases described in post-menopausal women. The most common clinical presentations are chest pain and dyspnoea, reported in 67.8 and 17.8% of the patients, respectively. Cardiogenic shock (4.2% of the patients) and ventricular fibrillation (1.5%) were not infrequent. ST-segment elevation was reported in 81.6% of the patients, T wave abnormalities in 64.3%, and Q waves in 31.8%. Cardiac biomarkers were usually mildly elevated, as reported in 86.2% of the patients. Typically, patients had left ventricular (LV) dysfunction on admission, with mean ejection fraction ranging from 20 to 49%. However, over a period of days to weeks, all patients experienced dramatic improvement in LV function. The onset of symptoms was often preceded by emotional (26.8%) or physical stress (37.8%). Norepinephrine concentration was elevated in 74.3% of the patients. Prognosis was generally excellent, with full recovery in most patients. In-hospital mortality was 1.1%. Only 3.5% of the patients experienced a recurrence.

CONCLUSION

Clinicians should consider this syndrome in the differential diagnosis of patients presenting with chest pain, especially in post-menopausal women with a recent history of emotional or physical stress.

Clinical Characteristics, Demographics and Prognosis of Transient Left Ventricular Apical Ballooning Syndrome

BACKGROUND

Transient left ventricular apical ballooning syndrome also called Tako-Tsubo cardiomyopathy is defined as a syndrome consisting of stress induced apical ballooning of the left ventricle and normal coronary arteries. The majority of the published reports are case reports or case series with a small number of patients. The goal of this study was to perform statistical analysis of reported cases and case series in the literature in order to study demographic, clinical characteristics and prognosis of this syndrome.

METHOD

A PubMed search of the terms transient left ventricular apical ballooning, Tako-Tsubo, takotsubo, and apical cardiomyopathy was conducted for this study. All reports that contained information about individual patients were included in the statistical analysis.

RESULTS

The majority of the patients were women (93.5%). Asians were the largest group (57.2%) followed by Caucasians (40%). The presentations mimics an acute myocardial infarction. The most frequent presenting symptom was chest pain (65.9%) followed by dyspnea (16.2%). ST elevation was the most common ECG abnormality (87.5%). Contrary to most reports, this is not a benign disease with complications occurring in 18.9% and death in 3.2%. The most common complication was shock followed by left ventricular thrombus formation and congestive heart failure.

CONCLUSION

Apical ballooning syndrome occurs most commonly in women and is associated with high complication rate. There are significant differences in presenting symptoms between race and gender which warrant further investigation.

Reproducible microvascular dysfunction with dobutamine infusion in Takotsubo cardiomyopathy presenting with ST segment elevation

Takotsubo (ampulla) cardiomyopathy, or broken heart syndrome, is an underrecognized cardiac illness that usually presents as an acute coronary syndrome in postmenopausal females. The disorder is frequently associated with episodes of mental or physical stress, implicating an abnormal cardiac response to increased catecholamines. Although death has been reported during the index event, the long-term prognosis is good with full recovery of left ventricular function. We present a case of Takotsubo cardiomyopathy mimicking anterior ST segment elevation myocardial infarction precipitated by dobutamine stress testing. Reinfusion of dobutamine in the catheterization laboratory reproduced symptoms with angiography and intravascular ultrasound supporting the theory of abnormal microvascular circulation as the etiology of Takotsubo cardiomyopathy. Acute and delayed magnetic resonance imaging demonstrated no infarction with complete recovery of ventricular function.

Assessment of Takotsubo cardiomyopathy (transient left ventricular apical ballooning) using 99mTc-tetrofosmin, 123I-BMIPP, 123I-MIBG and 99mTc-PYP myocardial SPECT

We compared Takotsubo cardiomyopathy (transient left ventricular apical ballooning) with acute myocardial infarction (AMI) using two-dimensional echocardiography, 99mTc-tetrofosmin, 99mTc-PYP, 123I-BMIPP and 123I-MIBG myocardial SPECT.

METHODS

We examined 7 patients with Takotsubo cardiomyopathy and 7 with AMI at the time of emergency admission (acute phase), and 2-14 days (subacute phase), one month (chronic phase), and 3 months (chronic II phase) after the attack. The left ventricle was divided into nine regions on echocardiograms and SPECT images, and the degree of abnormalities in each region was scored according to five grades from normal (0) to severely abnormal (4).

RESULTS

Coronary angiography showed the absence of stenotic regions in patients with Takotsubo cardiomyopathy, and severely stenotic and/or occlusive lesions in patients with AMI. The total ST segment elevation on electrocardiograms (mm) was 7.8 +/- 3.7 in those with Takotsubo cardiomyopathy, and 7.3 +/- 3.9 in patients with AMI. Abnormal wall motion scores on echocardiograms were 14.2 +/- 4.6, 4.7 +/- 4.0, 1.7 +/- 2.0 and 0.5 +/- 0.4 during the acute, subacute, chronic and chronic II phases, respectively, in patients with Takotsubo cardiomyopathy, and 14.0 +/- 4.3, 11.4 +/- 3.9, 8.8 +/- 3.6 and 5.2 +/- 4.8 in those with AMI. Abnormal myocardial perfusion scores on 99mTc-tetrofosmin images were 11.8 +/- 3.5, 3.2 +/- 3.0, 0.5 +/- 1.2 and 0.2 +/- 0.4 during the acute, subacute, chronic and chronic II phases, in patients with Takotsubo cardiomyopathy, and 16.2 +/- 4.3, 13.9 +/- 4.6, 7.9 +/- 4.6 and 5.0 +/- 4.5, respectively, in those with AMI. Abnormal myocardial fatty acid scores on 123I-BMIPP images were 12.6 +/- 3.7, 6.8 +/- 3.2 and 0.4 +/- 0.6 during the subacute, chronic and chronic II phases, respectively, in patients with Takotsubo cardiomyopathy, and 16.5 +/- 5.1, 14.7 +/- 4.8 and 7.5 +/- 4.5 in those with AMI. Abnormal myocardial sympathetic nerve function scores on 123I-MIBG images were 14.8 +/- 4.0, 8.8 +/- 4.0 and 0.4 +/- 0.6 during the subacute, chronic, chronic II phases, respectively, in patients with Takotsubo cardiomyopathy, and 18.6 +/- 6.5, 16.8 +/- 6.8 and 12.9 +/- 5.2 in those with AMI. Myocardial 99mTc-PYP uptake was abnormal not only in patients with AMI but also in those with Takotsubo cardiomyopathy during the acute phase.

CONCLUSIONS

Takotsubo cardiomyopathy might represent a stunned myocardium caused by a disturbance of the coronary microcirculation.

Early Diagnosis of Stress-Induced Apical Ballooning Syndrome Based on Classic Echocardiographic Findings and Correlation with Cardiac Catheterization

Stress-induced apical ballooning has been described as a reversible condition involving the apical left ventricular wall, sparing the base, and causing a ballooning appearance of the left ventricle during systole despite normal coronaries. We are presenting 4 cases of apical ballooning seen at our institution with echocardiographic correlation. Echocardiography showed similar anatomical apical ballooning of the left ventricular apex. The diagnosis of apical ballooning syndrome was suspected based on echocardiography in conjunction with clinical data before cardiac catheterization was performed. In one case, in addition to classic left ventricular apical ballooning, marked right ventricular apical akinesia was present on the initial echocardiographic examination. This makes diagnosis of apical ballooning syndrome most likely in this patient before cardiac catheterization. Therefore, we suggest using echocardiography more often for the early diagnosis of this disease, based on careful anatomic evaluation in conjunction with clinical data. Wall motion analysis should reveal an apical ballooning appearance involving many coronary territories. Furthermore, the additional presence of right ventricular apical akinesia during echocardiographic examination makes the diagnosis of this syndrome more likely.