Systematic review and meta-analysis of incidence and correlates of recurrence of takotsubo cardiomyopathy

Takotsubo Syndrome: Translational Implications and Pathomechanisms

Takotsubo syndrome (TTS) is identified as an acute severe ventricular systolic dysfunction, which is usually characterized by reversible and transient akinesia of walls of the ventricle in the absence of a significant obstructive coronary artery disease (CAD). Patients present with chest pain, ST-segment elevation or ischemia signs on ECG and increased troponin, similar to myocardial infarction. Currently, the known mechanisms associated with the development of TTS include elevated levels of circulating plasma catecholamines and their metabolites, coronary microvascular dysfunction, sympathetic hyperexcitability, inflammation, estrogen deficiency, spasm of the epicardial coronary vessels, genetic predisposition and thyroidal dysfunction. However, the real etiologic link remains unclear and seems to be multifactorial. Currently, the elusive pathogenesis of TTS and the lack of optimal treatment leads to the necessity of the application of experimental models or platforms for studying TTS. Excessive catecholamines can cause weakened ventricular wall motion at the apex and increased basal motion due to the apicobasal adrenoceptor gradient. The use of beta-blockers does not seem to impact the outcome of TTS patients, suggesting that signaling other than the beta-adrenoceptor-associated pathway is also involved and that the pathogenesis may be more complex than it was expected. Herein, we review the pathophysiological mechanisms related to TTS; preclinical TTS models and platforms such as animal models, human-induced pluripotent stem cell-derived cardiomyocyte (hiPSC-CM) models and their usefulness for TTS studies, including exploring and improving the understanding of the pathomechanism of the disease. This might be helpful to provide novel insights on the exact pathophysiological mechanisms and may offer more information for experimental and clinical research on TTS.

Dopamine D1/D5 Receptor Signaling Is Involved in Arrhythmogenesis in the Setting of Takotsubo Cardiomyopathy

Background

Previous studies suggested involvement of non-ß-adrenoceptors in the pathogenesis of Takotsubo cardiomyopathy (TTC). This study was designed to explore possible roles and underlying mechanisms of dopamine D1/D5 receptor coupled signaling in arrhythmogenesis of TTC.

Methods

Human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) were challenged by toxic concentration of epinephrine (Epi, 0.5 mM for 1 h) for mimicking the catecholamine excess in setting of TTC. Specific receptor blockers and activators were used to unveil roles of D1/D5 receptors. Patch clamp, qPCR, and FACS analyses were performed in the study.

Results

High concentration Epi and two dopamine D1/D5 receptor agonists [(±)-SKF 38393 and fenoldopam] reduced the depolarization velocity and prolonged the duration of action potentials (APs) and caused arrhythmic events in iPSC-CMs, suggesting involvement of dopamine D1/D5 receptor signaling in arrhythmogenesis associated with QT interval prolongation in the setting of TTC. (±)-SKF 38393 and fenoldopam enhanced the reactive oxygen species (ROS)-production. H₂O₂ (100 μM) recapitulated the effects of (±)-SKF 38393 and fenoldopam on APs and a ROS-blocker N-acetylcysteine (NAC, 1 mM) abolished the effects, suggesting that the ROS-signaling is involved in the dopamine D1/D5 receptor actions. A NADPH oxidases blocker and a PKA- or PKC-blocker suppressed the effects of the dopamine receptor agonist, implying that PKA, NADPH oxidases and PKC participated in dopamine D1/D5 receptor signaling. The abnormal APs resulted from dopamine D1/D5 receptor activation-induced dysfunctions of ion channels including the Na⁺ and L-type Ca²⁺ and I_Kr channels.

Conclusions

Dopamine D1/D5 receptor signaling plays important roles for arrhythmogenesis of TTC. Dopamine D1/D5 receptor signaling in cardiomyocytes might be a potential target for treating arrhythmias in patients with TTC.

Direct current cardioversion-triggered atypical Tako-tsubo cardiomyopathy: a case report and review of literature

Background

Tako-tsubo stress cardiomyopathy is a clinical syndrome marked by transient reduction of left ventricular function in the setting of emotional or physical stress and in the absence of obstructive coronary artery disease. We describe a case of an atypical variant of Tako-tsubo in a male patient following an elective direct current cardioversion (DCCV).

Case summary

A 78-year-old male whose atrial fibrillation persisted after earlier unsuccessful direct current DCCV and radiofrequency ablations presented to the emergency department for acutely worsening dyspnoea and orthopnoea 12 h following his most recent DCCV. Previously, he was known to have non-obstructive coronary artery disease. Evaluation was notable for troponin I 0.019 ng/mL (negative <0.050 ng/mL), pro-brain natriuretic peptide 2321 pg/mL (reference range 0.0–900 pg/mL). There were no acute electrocardiogram abnormalities. He required bilevel positive airway pressure but was weaned off eventually to room air. Transthoracic echocardiogram revealed newly reduced left ventricular ejection fraction of 45–50%, associated with hypokinesis of the basal anteroseptal segment, as well as akinesis of mid-inferoseptal and mid-anteroseptal segments. Apical contractility was preserved. On Day 5 of hospitalization, diagnostic left heart catheterization again revealed benign coronary anatomy, and he was discharged home the following day.

Discussion

Only five other cases of cardioversion mediated Tako-tsubo cardiomyopathy have been reported in the literature. To our knowledge, this is the first case of DCCV-induced atypical Tako-tsubo cardiomyopathy. Although overall prognosis is favourable, some have been observed to require advanced support therapy. Given risk for life-threatening complications, patients undergoing cardioversion should be educated on symptoms of congestive cardiomyopathy.

Smidt Heart Institute Takotsubo Registry - Study design and baseline characteristics

Background

Takotsubo syndrome (TTS) is an acute form of transient systolic heart failure that occurs predominantly among women and in association with emotional or physical stressors. The Smidt Heart Institute Takotsubo Registry aims to establish a database through an online patient-advocate registry for deep phenotyping of this syndrome.

Methods

The Takotsubo Registry is a retrospective and prospective observational registry of individuals with a prior history of TTS. Participants are sourced through physician referrals, medical records review, peer- and self-referrals using social media. Research Electronic Data Capture (REDCap) and Mitra® microsamplers are used to collect questionnaire data and blood samples to facilitate completely remote study enrollment and participation for most participants.

Results

From January 2019 to May 2021, 125 participants (99% female, mean age: 61.5 ± 9.9 years) enrolled in the registry across 25 US states and 3 international countries, with reported first TTS event a median of 2 years prior to enrollment. Psychosocial characteristics determined by standardized questionnaires at baseline include relatively high anxiety trait (44%), moderate to severe depression severity (19%), moderate to high severity of posttraumatic stress disorder symptoms (58%) and a history of childhood trauma/abuse (50%).

Conclusions

The Smidt Heart Institute Takotsubo Registry will contribute to advancing the management of TTS by deep phenotyping to understand its pathophysiology, and identify treatment targets in a participant base for future clinical trials.

Takotsubo Syndrome in Octogenarians and Nonagenarians

Background: Takotsubo syndrome (TTS) in the very elderly is poorly understood. We sought to clarify the characteristics of octogenarians and nonagenarians with TTS. Methods and Results: From 148 patients with TTS who underwent coronary angiography, 68 very elderly patients aged ≥80 years (octogenarians/nonagenarians) were compared with 80 younger patients aged ≤79 years. Emotional triggers of TTS were less frequent (7% vs. 19%; P=0.043), whereas physical triggers were more frequent (69% vs. 46%; P=0.005), in octogenarians/nonagenarians than in patients aged ≤79 years. As initial clues to the diagnosis, electrocardiogram changes were more frequent (71% vs. 46%; P=0.003) and chest pain and/or dyspnea were less common (25% vs. 51%; P=0.001) in octogenarians/nonagenarians than in patients aged ≤79 years. Twenty-nine patients had acute heart failure (AHF) as a complication. AHF was more frequently found in octogenarians/nonagenarians than in patients aged ≤79 years (29% vs. 11%, respectively; P=0.006). Cardiac death occurred in 2 octogenarians/nonagenarians; non-cardiac death occurred in 3 octogenarians/nonagenarians and in 2 patients aged ≤79 years. Conclusions: Emotional triggers of TTS were infrequent in octogenarians/nonagenarians with TTS. AHF was common and there was significant in-hospital all-cause mortality among octogenarians/nonagenarians.

Left Ventricular Ballooning Patterns in Recurrent Takotsubo Cardiomyopathy: A Systematic Review and Meta-analysis of Reported Cases

Recurrent takotsubo cardiomyopathy (TTC) and the clinical profiles and outcomes of patients have not been fully evaluated, nor has the effect of left ventricular ballooning pattern. After searching the medical literature for reports of patients with recurrent TTC, we identified 84 articles with 101 case descriptions. We divided the cases into those with only apical left ventricular ballooning patterns at recurrence (typical, n=60), and those with at least one midventricular or basal ballooning pattern (atypical, n=41). We then compared their clinical profiles and outcomes. The groups were similar in terms of baseline demographic characteristics, presence and types of triggers, use of heart failure medications at TTC recurrence, electrocardiographic changes at presentation, initial left ventricular ejection fractions, timespans between recurrent TTC episodes, and recovery times after each event. However, patients in the atypical group had significantly fewer severe adverse events (cardiogenic shock and cardiac arrest) than did those in the typical group, with an estimated 63% lower odds (adjusted odds ratio=0.37; 95% CI, 0.14-0.97; P=0.039). Survival to hospital discharge was statistically similar but lower in the typical group (n=53; 88.3%) than in the atypical group (n=24; 96%). Our results suggest that left ventricular ballooning patterns influence clinical outcomes, and that outcomes are more favorable in patients with recurrent TTC who have atypical left ventricular ballooning patterns.

Prognostic factors of Takotsubo cardiomyopathy: a systematic review

Takotsubo cardiomyopathy (TCM), characterized by reversible ventricular dysfunction, has similar mortality to acute coronary syndrome. With the growing interest in the diagnosis of and interventions for TCM, many risk factors had been found to affect the prognosis of TCM patients, such as age, sex, and pre-existing diseases. Because of the incomplete understanding of the pathophysiologic mechanism in TCM, evidence-based medical therapy for this condition is lacking. Early intervention on risk factors may improve the outcomes of TCM. In this review, we sought to provide up-to-date evidence on risk factors and medical therapies that affect TCM outcome. We found that male sex, physical triggers, and certain comorbidities such as chronic kidney disease, malignant disease, higher body mass index, sepsis, chronic obstructive pulmonary disease, and anaemia were associated with poor TCM prognosis. In contrast, race, hyperlipidaemia, diabetes mellitus, and mood disorders were not clearly associated with TCM prognosis. We also reviewed the effect of medical therapies on TCM outcome, including angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, calcium channel blockers, and statins. The evidence that these medications confer a survival benefit on TCM patients is limited. Understanding these prognostic factors could help develop risk-stratification tools for TCM and establish effective prevention and interventions for this not-so-benign condition. Further multicentre clinical studies with large samples and meta-analyses of findings from previous studies are needed to address the inconsistent findings among the many potential risk factors for TCM.

Takotsubo Syndrome: Optimizing Care with a Multidisciplinary Approach

Symptoms of takotsubo syndrome (TTS) include acute and transient regional systolic dysfunction of the left ventricle, as well as a variety of wall-motion abnormalities. The clinical features of TTS, including initial symptoms, cardiac biomarkers, and electrocardiogram (ECG) changes, are similar to those of acute coronary syndrome, with the exception that TTS patients typically have no obstructive coronary artery disease. TTS primarily affects elderly women, and emotional or physical stress is a common cause of the disease. Exaggerated sympathetic stimulation associated with dysfunction of the limbic system has also been reported to be related to TTS occurrence. Cancer also induces emotional and physical stress. Therefore, optimization of TTS care should involve cardiac, neurological, psychiatric, and oncological approaches. The first step in optimizing TTS care is to diagnose it by cardiac means. Multimodality imaging, including ECG, echocardiogram, angiography, ventriculography, and cardiac magnetic resonance imaging, is indispensable for diagnosis, therapy management, and the evaluation of prognosis in the acute and chronic phases of TTS. The current cardiac approach during the acute phase is primarily supportive, with the goal of preventing life-threatening complications. As central nervous system diseases frequently trigger TTS, a neurological approach is also required. Appropriate psychiatric medication may reduce the risk of TTS recurrence, as not only psychiatric disorders themselves but also psychiatric medications can be the trigger for TTS. Several conditions are associated with TTS, including the novel coronavirus disease 2019. We present current knowledge of TTS in this review and describe how to optimize TTS care through a multidisciplinary approach.

Spontaneous coronary artery dissection and Takotsubo syndrome: comparison of baseline clinical and angiographic characteristics and in-hospital outcomes

BACKGROUND

Spontaneous coronary artery dissection (SCAD) and Takotsubo syndrome (TTS) constitute two relatively common nonatherosclerotic causes of acute coronary syndrome particularly frequent in women.

METHODS

This study sought to compare the baseline clinical and angiographic characteristics and in-hospital outcomes of patients from two large prospective registries on SCAD and TTS (the prospective nation-wide Spanish SCAD Registry and a prospective single-center TTS registry).

RESULTS

A total of 318 SCAD and 106 TTS consecutive patients were included. Most patients in both groups (88%) were women. Patients in the TTS group were older [74 (interquartile range, IQR 67-81) vs. 53 years-old (IQR 47-60), P < 0.001] and presented a higher prevalence of cardiovascular risk factors. Precipitating triggers were more frequent in TTS (56% vs. 42%, P = 0.009) but emotional stress was more common in the SCAD group (25% vs. 15%, P = 0.037). TTS patients showed a reduced release of cardiac biomarkers but had more severe left ventricular dysfunction (ejection fraction <50%: 73% vs. 12%, P < 0.001). In-hospital major adverse cardiovascular events occurred more frequently in TTS patients (12% vs. 4.7%, P < 0.001). Notably, TTS patients showed more frequently congestive heart failure (10% vs. 0.6%, P < 0.001), atrial fibrillation (11% vs. 1%, P < 0.001) and had a higher all-cause in-hospital mortality (5.7% vs. 1.3%, P = 0.032).

CONCLUSION

TTS patients are older and present a higher prevalence of some cardiovascular risk factors than patients with SCAD. TTS is linked to a worse in-hospital prognosis with higher mortality.

Takotsubo cardiomyopathy following pericardiectomy: A case report

BACKGROUND

Takotsubo cardiomyopathy (TC) is defined as a temporary and reversible systolic abnormality of the left ventricle's apical area resembling myocardial infarction in the nonexistence of coronary artery disease. Only a few cases have been reported after cardiac operations or after pericardiocentesis.

AIM

To emphasize the need to be aware of the possibility of the occurrence of this potentially fatal complication after cardiac surgery.

MATERIALS AND METHODS

A 66-year-old man underwent a pericardiectomy. He progressed to exacerbation of hemodynamic instability postoperatively and was diagnosed with TC, finally, he had to be supported by an intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO).

RESULTS

Patient's left ventricle function recovered fully in 2 weeks.

DISCUSSION

We discussed the pathogenesis and treatment of postoperative TC.

CONCLUSION

TC has to be carefully considered in the differential diagnosis in case of acute left ventricle dysfunction following cardiac surgery.

Thirty-Day Readmission Rates after Takotsubo Syndrome with or without Malignancy: A Nationwide Readmissions Database Analysis

The association between malignancy and readmission after Takotsubo syndrome (TTS) hospitalization has not been fully described. We sought to examine the rates, cause, and cost of 30-day readmissions of TTS, with or without malignancy, by utilizing Nationwide Readmissions Databases from 2010 to 2014. We identified 61,588 index hospitalizations for TTS. TTS patients with malignancy tended to be older (70.6 ± 0.2 vs. 66.1 ± 0.1, p < 0.001), and the overall burden of comorbidities was higher than in those without malignancy. TTS patients with malignancy had significantly higher 30-day readmission rates than those without malignancy (15.9% vs. 11.0%; odds ratio (OR), 1.35; 95% confidence interval (CI), 1.18–1.56). Non-cardiac causes were the most common causes of readmission for TTS patients with malignancy versus without malignancy (75.5% vs. 68.1%, p < 0.001). The 30-day readmission rate due to recurrent TTS was very low in both groups (0.4% and 0.5%; p = 0.47). The total costs were higher by 25% (p < 0.001) in TTS patients with vs. without malignancy. In summary, among patients hospitalized with TTS, the presence of malignancy was associated with increased risk of 30-day readmission and increased costs. These findings highlight the importance of optimized management for TTS patients with malignancy.

Alpha 1-adrenoceptor signalling contributes to toxic effects of catecholamine on electrical properties in cardiomyocytes

AIMS

This study aimed to investigate possible roles and underlying mechanisms of alpha-adrenoceptor coupled signalling for the pathogenesis of Takotsubo syndrome (TTS).

METHODS AND RESULTS

Human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) were treated with a toxic concentration of epinephrine (Epi, 0.5 mM for 1 h) to mimic the setting of TTS. Patch-clamp technique, polymerase chain reaction (PCR) and Fluorescence-activated cell sorting (FACS) were employed for the study. High concentration Epi suppressed the depolarization velocity, prolonged duration of action potentials and induced arrhythmic events in hiPSC-CMs. The Epi effects were attenuated by an alpha-adrenoceptor blocker (phentolamine), suggesting involvement of alpha-adrenoceptor signalling in arrhythmogenesis related to QT interval prolongation in the setting of TTS. An alpha 1-adrenoceptor agonist (phenylephrine) but not an alpha 2-adrenoceptor agonist (clonidine) mimicked Epi effects. Epi enhanced ROS production, which could be attenuated by the alpha- adrenoceptor blocker. Treatment of cells with H2O2 (100 µM) mimicked the effects of Epi on action potentials and a reactive oxygen species (ROS)-blocker (N-acetyl-I-cysteine, 1 mM) prevented the Epi effects, indicating that the ROS signalling is involved in the alpha-adrenoceptor actions. Nicotinamide adenine dinucleotide phosphate hydrogen (NADPH) oxidases were involved in alpha 1-adrenoceptor signalling. A protein kinase C (PKC) blocker suppressed the effects of Epi, phenylephrine and ROS as well, implying that PKC participated in alpha 1-adrenoceptor signalling and acted as a downstream factor of ROS. The abnormal action potentials resulted from alpha 1-adrenoceptor activation-induced dysfunctions of ion channels including the voltage-dependent Na+ and L-type Ca2+ channels.

CONCLUSIONS

Alpha 1-adrenoceptor signalling plays important roles for arrhythmogenesis of TTS. Alpha-adrenoceptor blockers might be clinically helpful for treating arrhythmias in patients with TTS.

Takotsubo Syndrome: Uncovering Myths and Misconceptions

PURPOSE OF REVIEW

Takotsubo syndrome (TTS) was described in Japan 3 decades ago to affect predominately postmenopausal women after emotional stress. This history is the basis of commonly held beliefs which may contribute to the underdiagnosis and misperception of TTS.

RECENT FINDINGS

TTS affects not only women, but can be present in both sexes, and can appear in children as well as in the elderly. TTS is characterized by unique clinical characteristics with morphological variants, and incurs a substantial risk for recurrent events and adverse outcomes. Physical triggers are more common than emotional triggers and are major disease determinants. TTS seems not to be completely transient as patients report ongoing chest pain, dyspnea, or fatigue even after months of the acute event. Knowledge of the clinical features and outcomes of TTS patients has evolved substantially over the past decades. The heterogeneous appearance of TTS needs to be recognized in all medical disciplines to maximize therapy and improve outcomes.

Incidence and clinical/laboratory correlates of early hypotension in takotsubo syndrome

Aims

Takotsubo syndrome (TTS) is a form of acute myocardial inflammation, often triggered by catecholamine release surges, which accounts for approximately 10% of ‘myocardial infarctions’ in female patients above the age of 50. Its associated substantial risk of in‐hospital mortality is mainly driven by the development of hypotension and shock. While hypotension is induced largely by factors other than low cardiac output, its precise cause is unknown, and clinical parameters associated with hypotension have not been identified previously. We therefore sought to identify the incidence and clinical/laboratory correlates of early hypotension in TTS.

Methods and results

We analysed the in‐hospital data of patients recruited to the South Australian TTS Registry. Associations between the development of hypotension, patient demographics, severity of the acute TTS attack, and key biochemical markers were sought. One hundred thirteen out of 319 patients (35%) were hypotensive (median systolic blood pressure 80 mmHg) during their index hospitalization. Development of hypotension preceded all in‐hospital deaths (n = 8). On univariate analyses, patients who developed hypotension had lower left ventricular ejection fraction (P = 0.009), and higher plasma N‐terminal pro brain natriuretic peptide and troponin‐T concentrations (P = 0.046 and 0.008, respectively), all markers of severity of the TTS attack; hypotension also occurred less commonly in male than in female patients (P = 0.014). On multivariate linear regression analysis, female sex and lower left ventricular ejection fraction were independent correlates of the development of hypotension (P = 0.009 and 0.010, respectively).

Conclusions

Early development of hypotension is very common in TTS, and its presence is associated with a substantial risk of in‐hospital mortality. Hypotension is a marker of severe TTS attacks and occurs more commonly in female TTS patients.

Takotsubo cardiomyopathy: Review of broken heart syndrome

Takotsubo cardiomyopathy, also known as broken heart syndrome, apical ballooning syndrome, or stress cardiomyopathy, occurs when a stressful emotional or physical event causes the left ventricle of the heart to dilate, leading to acute heart failure. The syndrome was first described in Japan in 1990. Signs and symptoms of Takotsubo cardiomyopathy are similar to acute myocardial infarction. The syndrome presents with similar ECG and biomarker indications, so it often goes undiagnosed until coronary angiography is performed and reveals no blockage. Treatment is largely supportive. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) may reduce the likelihood of recurrent episodes. Overall, the prognosis is very good, with about 95% of patients making a full recovery.

Takotsubo syndrome: the broken-heart syndrome

Takotsubo syndrome - also known as broken-heart syndrome, Takotsubo cardiomyopathy, and stress-induced cardiomyopathy - is a recently discovered acute cardiac disease first described in Japan in 1991. This review aims to update understanding on the epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment of Takotsubo syndrome, highlighting aspects of interest to cardiologists and general practitioners.

Indications of beta-adrenoceptor blockers in Takotsubo syndrome and theoretical reasons to prefer agents with vasodilating activity

Takotsubo syndrome (TTS) is estimated to account for 1-3% of all patients presenting with suspected ST-segment elevation myocardial infarction. A sudden surge in sympathetic nervous system is considered the cause of TTS. Nonetheless, no specific recommendations have been provided regarding β-blocking therapy. Apart from specific contra-indications (severe LV dysfunction, hypotension, bradycardia and corrected QT interval >500 ms), treatment with a β-blocker seems reasonable until full recovery of LV ejection fraction, though evidence is limited to a few animal studies, case reports or observational studies. In this review, we will reappraise the rationale for β-blocker therapy in TTS and speculate on the pathophysiologic basis for preferring non-selective agents with vasodilating activity over β₁-selective drugs.

Recurrent Takotsubo Cardiomyopathy Presenting With Anterior Wall ST-Elevation Myocardial Infarction

Takotsubo cardiomyopathy (TC) or stress cardiomyopathy with the presence of transient apical ballooning of the left ventricle in the absence of obstructive coronary artery disease. The recurrence of TC is extremely rare, with an annual recurrence risk of 1.5% and approximately 5% recurrence risk after six years. We present a case of a patient with a history of TC who presented with chest pain and ST-segment elevation in her electrocardiogram and was found to have normal coronaries and diagnosed with recurrent TC.

Left ventricular contraction patterns in Takotsubo Syndrome and their correlation with long-term clinical outcome

BACKGROUND

Takotsubo Syndrome (TTS) is diagnosed in 1-2% of all patients presenting with acute coronary syndrome. Next to the typical apical manifestation, other locations of left ventricular contraction abnormality are possible, but their relationship to patient characteristics, clinical correlates as well as long-term outcome are poorly understood.

METHODS & RESULTS

We retrospectively analyzed 126 patients presenting TTS. Cases were categorized according to left ventricular contraction abnormality patterns: typical apical pattern (71%, n = 89) vs. atypical patterns (29%, n = 37). Cases with typical TTS showed significantly higher levels of troponin I (3.12 ng/ml vs. 1.32 ng/ml, p = 0.013) and creatin kinase (CK) on admission (461 (±1207)U/l vs. 173 (±177) U/l, p = 0.03) as well as peak CK (973 (±2860)U/l vs. 301 (±328) U/l, p = 0.03) and more often ischemia related ECG changes (p = 0.02). Follow-up data was available for 85% of the patients. Median FU time was 4.4 years (IQR 1.4-7.7 years). All-cause mortality during follow-up was 39%, with no significant difference between patients with typical or atypical TTS (43% vs. 29%, p = 0.17). In multivariate logistic regression analysis, only anemia was predictive for long-term mortality (OR 3.93, 95%CI 1.02-2.08, p = 0.015). The majority of surviving patients (69%) reported good quality of life, even though only 56% reported being symptom-free.

CONCLUSION

Patients with TTS have poor long-term prognosis with an overall mortality of 39.1% within 4 years and nearly half of all patients report persisting symptoms. Even though the apical contraction pattern is associated with higher elevation of serum markers for myocardial damage, it was not associated with higher long-term mortality.

[Takotsubo syndrome (stress-induced cardiomyopathy)]

The article presents published and own data about Takotsubo syndrome, a relatively rare heart disease that is similar to acute coronary syndrome, but without significant damage of coronary arteries. The leading pathogenetic factor is the catecholamine-induced stress damage of myocardium with involvement of microvessels. There is a certain underestimation of Takotsubo syndrome by both clinicians and pathologists, so some cases of Takotsubo syndrome are misdiagnosed as acute coronary syndrome. Morphological manifestations of Takotsubo syndrome are characterized by mucoid edema of interstitial myocardial tissue, round-cell infiltration of stroma and focal damage of cardiomyocytes.

Current Knowledge and Future Challenges in Takotsubo Syndrome: Part 1-Pathophysiology and Diagnosis

First recognized in 1990, takotsubo syndrome (TTS) constitutes an acute cardiac condition that mimics acute myocardial infarction commonly in the absence of obstructive coronary artery disease; it is characterized by temporary left ventricular dysfunction, regularly in a circumferential apical, midventricular, or basal distribution. Considering its acute clinical presentation, coronary angiography with left ventriculography constitutes the gold standard diagnostic tool to exclude or confirm TTS. Frequently, TTS is related to severe emotional or physical stress and a subsequent increased adrenergic stimulation affecting cardiac function. Beyond clinical presentation, epidemiology, and novel diagnostic biomarkers, this review draws attention to potential pathophysiological mechanisms for the observed reversible myocardial dysfunction such as sympathetic overdrive-mediated multi-vessel epicardial spasms, microvascular dysfunction, the direct toxicity of catecholamines, lipotoxicity, and inflammation. Considering the long-term prognosis, further experimental and clinical research is indispensable to elucidate further pathophysiological mechanisms underlying TTS before randomized control trials with evidence-based therapeutic management can be performed.

Typical and reverse Takotsubo syndromes as initial manifestations of consecutive Addisonian crises in a 38-year-old patient: the heart has its reasons!

We report an interesting case of a 38-year-old woman presenting with reverse Takotsubo syndrome (TTS) secondary to an Addisonian crisis, her second such episode. A few years prior, she had presented with typical TTS in the setting of Addisonian crisis; diagnostic work-up revealing Auto-Immune Polyglandular Syndrome Type II (APS II). We believe this to be the first case report of typical and variant phenotypes of TTS in a patient with APS II. The pathogenic link between these two conditions is explored. In patients presenting with Addisonian crises and refractory shock, the possibility of concurrent TTS should be considered. TTS muddies the diagnostic waters and poses therapeutic challenges as outlined.

Takotsubo cardiomyopathy with LVOT obstruction in a case of STEMI: a rare cause of peri-PCI hypotension

Takotsubo cardiomyopathy (TCM) associated with left ventricular outflow tract (LVOT) obstruction in the event of an ST-elevation myocardial infarction (STEMI) is a rare cause of hypotension during percutaneous coronary intervention (PCI). Herein, we describe a 57-year-old woman who presented with STEMI and underwent PCI. She developed hypotension which worsened during inotropic therapy. Echocardiography revealed evidence of LVOT obstruction in the setting of TCM. Therefore, inotropic support was promptly discontinued. Beta blockers and phenylephrine were rapidly administrated, resulting in improved blood pressure and stabilisation of the patient.

Takotsubo cardiomyopathy associated with adrenal insufficiency in the context of long-term steroid use mimicking acute coronary syndrome

Takotsubo cardiomyopathy (TCMP) is an important, though under-recognised, syndrome which mimics acute coronary syndrome (ACS) presenting with similar clinical, biochemical and ECG features. A 68-year-old man was referred as ACS for emergency coronary angiography; however, a history of lethargy, weight loss and electrolyte abnormalities prompted further investigations. Angiography was postponed, adrenal insufficiency confirmed and steroid replacement commenced. Echocardiography demonstrated reduced left ventricular (LV) function (45%) with regional wall motion abnormalities, although angiography confirmed unobstructed arteries. Steroid replacement induced a rapid improvement in symptoms and LV function. Few cases of TCMP associated with adrenal insufficiency have been reported. This appears to be the first case describing TCMP precipitated by new-onset secondary adrenal insufficiency following long-term steroid use in a male patient, and highlights the importance of considering TCMP in patients presenting with suspected ACS. Here, prompt recognition and treatment of a serious underlying disorder prevented a potentially life-threatening Addisonian crisis.

Quadruple episodes of takotsubo cardiomyopathy: a case report

Background

Takotsubo syndrome (TTS) is characterized by transient left ventricular (LV) dysfunction, often preceded by emotional or physical trigger. The recurrence of TTS has been investigated, however, cases of multiple recurrences are scarcely reported.

Case summary

A 79-year-old woman was admitted to the hospital with the complaint of dyspnoea following emotional stress. Electrocardiogram showed terminal T-wave inversion with QT interval prolongation in anterior leads. Transthoracic echocardiogram revealed severe hypokinesis of mid- and apical-anterior segments. She was diagnosed with focal TTS. After 3 months, she complained of orthopnoea subsequent to upper-respiratory infection. Coronary angiography (CAG) depicted normal coronary arteries. She had recurrence of TTS with bi-ventricular dysfunction, and complicated cardiac collapse requiring intra-aortic balloon pumping. One month after the second episode, she had dyspnoea after herpes zoster infection. She was diagnosed with recurrence of focal TTS. After 4 months, she complained of central chest pain without evident trigger factors. CAG showed no coronary artery stenosis, and left ventriculography revealed mid-inferior and apical segment akinesis. She was diagnosed with the 4th occurrence of TTS.

Discussion

We describe the case of an elderly female experiencing quadruple episodes of TTS with various triggers, LV dysfunctions and severities in a short period of 10 months. Although multiple recurrences of TTS is rare, it can occur with variable trigger factors and patterns of myocardial dysfunction. An analysis of multiple recurrences could aid in clarifying the pathophysiology of TTS.

Survival and risk of recurrence of takotsubo syndrome

OBJECTIVE

The goal of this study is to evaluate the long-term outcomes of patients with takotsubo syndrome and assess factors associated with death or recurrence.

METHODS

This is a retrospective population-based cohort study of consecutive patients who presented to an integrated health system in Southern California with takotsubo syndrome between 2006 and 2016. Medical records were manually reviewed to confirm diagnosis and to identify predisposing factors, medication treatment and long-term outcomes. Factors associated with death or recurrent takotsubo syndrome were tested using Cox regression models.

RESULTS

Between 2006 and 2016, there were 519 patients with a confirmed diagnosis of takotsubo syndrome. Patients were followed for 5.2 years (IQR 3.0-7.2). During the follow-up period, 39 (7.5%) had recurrent takotsubo syndrome and 84 (16.2%) died. In multivariate modelling, factors associated with higher risk of recurrence or death were age (HR 1.56 per 10-year increase, 95% CI 1.29 to 1.87), male sex (HR 2.52, 95% CI 1.38 to 4.60), diabetes (HR 1.6, 95% CI 1.06 to 2.43), pulmonary disease (HR 2.0, 95% CI 1.37 to 2.91) and chronic kidney disease (HR 1.58, 95% CI 1.01 to 2.47). Treatment with beta-blockers were associated with lower risk of recurrence or death (HR 0.46, 95% CI 0.29 to 0.72). No association was observed between treatment with ACE inhibitors or angiotensin-receptor blockers and recurrence or death (HR 0.92, 95% CI 0.59 to 1.42).

CONCLUSIONS

Recurrent takotsubo syndrome occurred in a minor subset of patients. Treatment with beta-blocker was associated with higher event-free survival.

Clinical characteristics of patients with takotsubo syndrome recurrence: An observational study with long-term follow-up

BACKGROUND

Research investigating takotsubo syndrome (TTS) recurrence yielded conflicting results. Aim of the present study is to describe clinical characteristics of patients with TTS recurrence in a cohort with available long-term follow-up.

METHODS

The study population included 234 TTS patients enrolled in a prospective multicenter registry, median follow-up of 1328 (407, 2526) days. To investigate factors associated with TTS recurrence, we analyzed patients with recurrence (Group A) in comparison with a subgroup of TTS patients within the whole population (group B) who had similar age, sex and median follow-up length (Group A 2280 days vs Group B 2361 days).

RESULTS

We observed 9 TTS recurrences affecting 8 patients, all women, with a rate of 0.9% patients/year. Median time to first recurrence was 1593 days (interquartile range: 950, 2516). We detected no significant differences between patients with and without recurrences regarding cardiovascular risk factors, symptoms, ECG and echocardiographic findings at presentation, discharge therapy. Physical trigger and chronic obstructive pulmonary disease (COPD) were more prevalent in patients who experienced a recurrence (75% vs 27% and 50% vs 14% with p = 0.01 and p = 0.022 respectively). Univariable Cox regression analysis identified physical trigger and history of COPD to be both associated with TTS recurrence [hazard ratio (HR) 11.4, 95% confidence interval (CI) 2.29-56.8, p = 0.003 and HR 4.94, 95% CI 1.16-20.99 p = 0.031 respectively].

CONCLUSION

TTS recurrence is relatively uncommon. Association with physical trigger and COPD would suggest a closer follow-up in this subgroup of patients.

Takotsubo Syndrome: Finally Emerging From the Shadows?

It is now 30 years since Japanese investigators first described Takotsubo Syndrome (TTS) as a disorder occurring mainly in ageing women, ascribing it to the impact of multivessel coronary artery spasm. During the intervening period, it has become clear that TTS involves relatively transient vascular injury, followed by prolonged myocardial inflammatory and eventually fibrotic changes. Hence symptomatic recovery is generally slow, currently an under-recognised issue. It appears that TTS is induced by aberrant post-β₂-adrenoceptor signalling in the setting of "surge" release of catecholamines. Resultant activation of nitric oxide synthases and increased inflammatory vascular permeation lead to prolonged myocardial infiltration with macrophages and associated oedema formation. Initially, the diagnosis of TTS was made via exclusion of relevant coronary artery stenoses, plus the presence of regional left ventricular hypokinesis. However, detection of extensive myocardial oedema on cardiac MRI imaging offers a specific basis for diagnosis. No adequate methods are yet available for definitive diagnosis of TTS at hospital presentation. Other major challenges remaining in this area include understanding of the recently demonstrated association between TTS and antecedent cancer, the development of effective treatments to reduce risk of short-term (generally due to shock) and long-term mortality, and also to accelerate symptomatic recovery.

Update of takotsubo syndrome in the era of COVID-19

Takotsubo cardiomyopathy or takotsubo syndrome (TTS) has become a well-known disease not only in Japan but also in the rest of the world. Early reports suggested that TTS is a self-limiting disease with better prognosis than acute coronary syndrome. However, recent data showed that TTS is not a benign disease as compared with acute coronary syndrome. In addition to the apical ballooning, several other types of wall motion abnormalities have been classified as variants of TTS. In particular, right ventricular involvement, or biventricular TTS, is not uncommon and is associated with poor in-hospital as well as long-term outcomes. With respect to the pathophysiology, modulation (desensitization) of the beta-adrenergic receptor is suspected as a possible mechanism for transiently depressed myocardial contraction. Although specific treatments to improve prognosis of TTS are still uncertain, observational data suggest favorable impact of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Finally, in the era of COVID-19, we should pay attention to a variety of cardiovascular conditions related to COVID-19. TTS is one of these conditions that can be triggered by both emotional and physical impact of the COVID-19 pandemic.

Reversible exercise-induced left ventricular dysfunction in symptomatic patients with previous Takotsubo syndrome: insights from stress echocardiography

AIMS

Takotsubo syndrome (TTS) is usually associated with rapid and spontaneous recovery of left ventricular (LV) function. However, a proportion of patients may have persistent symptoms. This study aimed to determine the haemodynamic and LV contractile responses to exercise in these patients.

METHODS AND RESULTS

Thirty symptomatic TTS patients referred for exercise echocardiography, a median of 15 months following the index TTS episode, were matched with 30 controls with normal exercise echocardiography. Beta-blockers were withheld prior to the test. LV volumes, ejection fraction (EF) and wall motion score index (WMSI), were measured at rest and stress. The TTS cohort were Caucasian women with mean age of 64.6 ± 7.4 years and similar coronary risk factor profile and EF to controls. Resting systolic blood pressure (SBP), LV end-diastolic volume, wall stress, and right ventricular fractional area change were higher in TTS patients compared with controls. Stress echo data showed similar exercise time, peak heart rate, and peak SBP in TTS patients vs. controls, but TTS patients had higher LV volumes, lower exercise LVEF (70 ± 10% vs. 78 ± 7%; P = 0.001), ΔLVEF (4 ± 8% vs. 12 ± 5%; P < 0.001), and WMSI (1.4 ± 0.4 vs. 1 ± 0; P < 0.001) compared with controls. Twenty TTS patients had clear exercise-induced wall motion abnormalities, mainly involving the apex or more globally, with a mean ΔLVEF of 1% compared with 12% in controls. Among the other 10 TTS patients, the ΔLVEF was 10%.

CONCLUSION

Symptomatic patients with previous TTS have a blunted contractile response to exercise. The therapeutic and prognostic implications of these findings need further investigation.

Factors Associated with Recurrence in Takotsubo Syndrome: A Systematic Review

Fundamento:

A síndrome de Takotsubo (STT) é caracterizada por uma disfunção sistólica temporária do ventrículo esquerdo (VE) relacionada a um evento estressante. No entanto, os fatores associados à sua recorrência ainda não estão bem estabelecidos.

Objetivo:

Analisar os principais fatores associados à recorrência da STT.

Métodos:

Uma revisão sistemática foi realizada usando o modelo PRISMA. Foram incluídos estudos observacionais, publicados entre janeiro de 2008 e outubro de 2017, que apresentaram uma taxa de recorrência de pelo menos 3% e/ou 5 ou mais pacientes com recidiva e que preencheram pelo menos 80% dos critérios STROBE.

Resultados:

Seis artigos atenderam aos critérios para esta revisão sistemática. A taxa de recorrência variou de 1 a 3,5% ao ano (taxa de recorrência global 3,8%). Um estudo associou maior taxa de recorrência ao sexo feminino, quatro relataram o tempo entre o primeiro e o segundo episódio, um estudo associou o índice de massa corporal (IMC) e a hipercontratilidade da parede anterior média do VE a uma maior taxa de recorrência. Não foi determinada associação entre recorrência e alterações eletrocardiográficas. O uso de betabloqueadores não foi associado a taxas de recorrência.

Conclusões:

Sexo feminino, tempo desde o primeiro episódio da síndrome, baixo IMC e obstrução ventricular foram relatados como possíveis preditores de recorrência da STT.

The prognostic value of dispersion of repolarization in stress cardiomyopathy

INTRODUCTION

Although abnormalities of ventricular repolarization are a hallmark of SC, their clinical impact on management remains to be determined. This study sought to evaluate the prognostic value of dispersion of repolarization in stress cardiomyopathy (SC) with regards to major cardiac events (MCE), recovery time, and recurrence.

METHODS

This study analyzed data from258 patients with SC, from January 2009 to January 2018. Standard 12 lead ECG recordings during the acute, subacute, and recovery phases were collected for each eligible patient. Logistic regression was used to identify independent predictors of MCE, a composite of 30 day all-cause mortality, cardiogenic shock, life-threatening ventricular arrhythmias, and stroke.

RESULTS

Among the 101 eligible patients (80.2% females, mean age 45.8 ± 11.5 years) in the study cohort, MCE occurred in 16 patients (15.8%). Cox regression analysis identified two independent predictors of MCE: increased ΔQT dispersion ≥ 40 ms (HR 1.31, 95% CI 1.05-9.77, p = 0.029) and increased Δnegative T wave amplitude dispersion ≤ -2.0 mV (HR 1.25, 95% CI 1.11-11.93, p = 0.018) during the subacute phase. The final regression model had good accuracy (sensitivity 81.3%, specificity 96.5%) and discriminative power (AUC 0.89, 95% CI 0.83-0.95). Kaplan-Meier analysis revealed that there was increasing MCE in patients with zero, one, or two predictors (log rank p < 0.001). In addition, patients with increased dispersion also had a significantly longer time to achieve complete recovery (21.4 ± 6.8 vs. 8.5 ± 4.3 days, p = 0.012) and a higher incidence of recurrence (31.3% vs. 2.4%, p = 0.011) of SC.

CONCLUSION

Evaluation of dynamic changes of dispersion of repolarization is a simple bed-side tool with high predictive accuracy for prognostication of short term adverse outcomes, delayed recovery, and recurrence in patients with SC.

Incidence and Clinical Impact of Recurrent Takotsubo Syndrome: Results From the GEIST Registry

Background

Current literature only reports variable information from single‐center studies on the recurrence rate, the complications, and the outcome of patients with Takotsubo syndrome (TTS) experiencing recurrent TTS. Therefore, a detailed description of clinical characteristics, predictors, and the prognostic impact of patients with TTS and recurrences in a multicenter registry is needed.

Methods and Results

We analyzed 749 patients with TTS from 9 European centers being part of the international, multicenter GEIST (German Italian Stress Cardiomyopathy) Registry. Patients were divided into the recurrence group and the nonrecurrence group. The recurrence rate at a median follow‐up of 830 days (interquartile range, 118–1701 days) was 4%. Most recurrences were documented in the first 5 years after the index TTS episode. Up to 2 TTS recurrences were documented in 2 of 30 patients (6%). A variable ballooning pattern (n=6, 0.8%) with, in particular, involvement of the right ventricular occurred in 3 cases (0.4%) at the recurrence event. Except for the higher presence of arterial hypertension (86.7% versus 68.3%; P=0.03) in the recurrence group, no other baseline characteristics were different between groups. Observation of TTS complications during follow‐up, including stroke, thromboembolic events, in‐hospital death, and cardiogenic shock, revealed no significant differences between groups (P>0.05), except the higher presence of pulmonary edema in the recurrence group versus the nonrecurrence group (13.3% versus 4.9%; P=0.04).

Conclusions

The incidence of TTS recurrence is estimated to be 4% in this multicenter TTS registry. A variable TTS pattern at recurrence is common in up to 20% of recurrence cases.

Atypical Takotsubo Cardiomyopathy Secondary to Combination of Chemo-Immunotherapy in a Patient With Non-Small Cell Lung Cancer

Takotsubo cardiomyopathy (TC) also known as broken heart syndrome or stress-induced cardiomyopathy is a relatively rare and transient form of cardiomyopathy. It usually mimics myocardial infarction in terms of clinical and electrocardiographic presentation, but coronary angiography usually does not reveal any evidence of coronary artery occlusion. Even though many underlying causes including emotional, physical or physiological stress have been identified, the exact pathogenesis remains uncertain. Few of anticancer therapies have been reported as an emerging cause of TC; however, no strong evidence of immunotherapy causing cardiomyopathy. We here present a very rare case of atypical TC in a 57-year-old female with advanced stage non-small cell lung cancer who underwent combined cytotoxic chemotherapy and immunotherapy with carboplatin, pemetrexed and pembrolizumab.

Takotsubo syndrome

Takotsubo syndrome is an acute cardiomyopathy that mimics acute coronary syndrome and is characterized by acute heart failure with reversible ventricular motion abnormalities, in the absence of justifying coronary artery disease. This document offers an exhaustive review of various proposed hypotheses that attempt to explain the pathophysiology of this disease and provides an updated review of the different classifications that have emerged in recent years. In addition, we describe the main clinical characteristics of these patients, the diagnostic tests that must be performed and the most appropriate treatment.

Perioperative takotsubo cardiomyopathy: Implications for anesthesiologist

Takotsubo cardiomyopathy (TCM) is characterized by transient ventricular dysfunction in the absence of obstructive coronary artery disease that may be triggered by an acute medical illness or intense physical or emotional stress. TCM is often confused with acute myocardial infarction given the similar electrocardiographic changes, cardiac enzymes, hemodynamic perturbations, and myocardial wall motion abnormalities. In the perioperative setting, the clinical picture may be more confusing because of the effect of anesthesia as well as hemodynamic changes related to the surgery itself. However, awareness of various other diagnostic modalities may enable clinicians to distinguish between the two, more systematically and with greater certainty. Despite the large body of literature, there still seems to be an overall paucity in our understanding of the etiopathogenesis, clinical characteristics, natural history, and management of this syndrome, especially in the perioperative setting. This narrative review seeks to present and synthesize the most recent literature on TCM and to identify gaps in current knowledge which can become the basis for future research.

Psychiatric conditions in patients presenting with Takotsubo syndrome: A systematic review and synthesis of case studies

OBJECTIVES

The purpose of this systematic review was to describe psychiatric presentations observed among Takotsubo syndrome (TS) patients, how psychiatric conditions and associated treatments impact TS events, and how psychiatric conditions are managed alongside TS medical treatment and follow-up.

METHODS

We searched MEDLINE, Cochrane Database of Systematic Reviews, Embase, PsycInfo, CINAHL, and Web of Science between 1990 and 2019 for case reports of TS with comorbid psychiatric conditions, behaviors, or substance use.

RESULTS

Of 2403 records, we included 243 records comprising 252 total cases. Common psychiatric conditions included depression (n = 98; 39%), anxiety (n = 44, 17%), alcohol use (n = 35, 14%), suicidality (n = 30, 12%), and severe mental illness (n = 25, 10%). Psychiatric conditions were frequently associated with triggering TS events (61%). Less than one-third of cases reported providing psychiatric care during hospitalization (n = 80, 32%). Only 33 cases (13%) described psychiatric functioning at follow-up. All case studies were assessed to be of low quality; patterns of reporting bias were observed.

CONCLUSIONS

Despite heterogeneous psychiatric presentations among TS patients, psychiatric treatment was rarely incorporated into the medical care or addressed at follow-up. This gap may be better attended to by integrating psychiatrists and psychologists into the multidisciplinary treatment team.

PROSPERO REGISTRATION NUMBER

CRD42019119998.

Takotsubo syndrome: diagnostic work-up and clues into differential diagnosis

PURPOSE OF REVIEW

Takotsubo syndrome represents an increasingly recognized clinical entity characterized by a reversible acute myocardial dysfunction, often triggered by an emotional or physical stress, and independent of an underlying epicardial coronary artery disease. The diagnosis is often challenging because of the nonspecific clinical presentation and the inconclusive noninvasive diagnostic imaging.

RECENT FINDINGS

The present review provides a brief overview of Takotsubo syndrome clinical presentation and guides the clinician through the diagnostic work-up of Takotsubo syndrome, highlighting clues into differential diagnosis. A review of clinical management is also provided.

SUMMARY

Despite increasing awareness and recognition, the diagnosis of Takotsubo syndrome remains challenging and Takotsubo syndrome is often underdiagnosed or misdiagnosed. The prompt recognition of Takotsubo syndrome portends relevant prognostic and therapeutic implications.

Stress (Takotsubo) Cardiomyopathy: A Review of Its Pathophysiology, Manifestations, and Factors That Affect Prognosis

Stress (Takotsubo) cardiomyopathy (SC) is becoming an increasingly recognized syndrome, previously underdiagnosed due to its similar presentation to acute coronary syndrome (ACS). With advancements in imaging and diagnostic tools, our ability to recognize, diagnose and subsequently manage SC has advanced as well. Multiple diagnostic criteria have been created for the diagnosis of SC. While the diagnosis of SC does not always require imaging, advanced imaging can aid in the diagnosis of SC in unclear cases. However, due to the severity of ACS and the consequences of missing that diagnosis, SC is still typically a diagnosis of exclusion once ACS has been ruled out on cardiac catheterization. Our understanding of the pathogenesis of SC is still evolving. While catecholamine surges are widely believed to be the precipitating cause of SC, the exact mechanism for how catecholamine surges lead to ventricular dysfunction is still being debated. Understanding the mechanism behind ventricular dysfunction in SC can potentially provide the basis for treatment. Different stressors may lead to different variants of cardiomyopathy, with different portions of the ventricles affected. Treatment of SC is largely supportive and therefore should be tailored to the patient's individual needs based on the severity of presentation. Both the underlying stressor and the variant of SC affect time to recovery and mortality. Many patient factors can impact prognosis as well. Even after initial hospital discharge for SC, long-term risks do exist, including the risk for recurrent SC. Only angiotensin-converting enzyme inhibitors have been shown to reduce the recurrence of SC.

Antecedent cancer in Takotsubo syndrome predicts both cardiovascular and long-term mortality

Background

Takotsubo syndrome (TTS), primarily an acute myocardial inflammatory condition engendered by catecholamine exposure, is associated with similar long-term mortality rates to those of patients with acute myocardial infarction. However, there is increasing evidence of a nexus between TTS and underlying malignancies:- many patients have antecedent cancer (A/Ca), while incremental risk of late cancer-related death has also been reported.

Purpose

To evaluate potential interactions between A/Ca among TTS patients and both early and late clinical course.

Methods

Three hundred forty-six consecutive TTS patients [aged 69 ± 13 (SD) years, males: 8.2%] were prospectively followed up for a median duration of 4.1 (IQR 2.2–6.4) years. Associations between A/Ca and severity of acute attacks, in-hospital complications and long-term death rates were sought utilising univariate analyses followed by multiple logistic regression analysis.

Results

A/Ca (present in 16.8% of patients) was associated with (i) greater elevation of hs-CRP and NT-proBNP concentrations (p = 0.01 and 0.04, respectively), (ii) more complicated in-hospital clinical course, with major adverse cardiac events (MACE) in 30.9% of patients, compared to 18.2% in non-A/Ca patients (p = 0.04). Long-term all-cause mortality rate was also greater [hazard ratio (HR) = 2.4, p = 0.0001] in A/Ca patients, with an excess cardiovascular (CVS) fatality rate (HR = 3.1, p = 0.001). On multivariate analysis, male gender, peak plasma concentrations of normetanephrine and hs-CRP, early arrhythmias and development of shock, but not A/Ca per se, were all independently associated with increased long-term mortality rate. Furthermore, patients discharged on β-adrenoceptor antagonists (βBl) or angiotensin converting enzyme inhibitors/ angiotensin receptor blockers (ACEi/ARB) had lower long-term mortality rates (β = − 0.2, p = 0.01; β = − 0.14, p = 0.05, respectively).

Conclusions

(1) A/Ca is associated with greater clinical severity of initial TTS attacks and substantially greater long-term CVS-related as well as all-cause mortality.

(2) Post-discharge therapy with either βBl or ACEi/ARB is associated with reductions in long-term mortality rates.

Overall, the current data suggest operation of substantial interactions between neoplasia and TTS, both at the level of pathogenesis and of outcomes.

Comparison of the first episode with the first recurrent episode of takotsubo syndrome in 128 patients from the world literature: Pathophysiologic connotations

BACKGROUND

The pathophysiology of takotsubo syndrome (TTS) and its recurrence (REC-TTS) is still elusive. Various ventriculographic "ballooning" patterns in response to a variety of triggers are observed in patients with REC-TTS. Although patients with and without REC-TTS have been previously compared, no comparison of patients' 1st TTS episode (1stTTS) with the 1st REC-TTS episode (1stREC-TTS) has been attempted.

METHODS

All patients with ≥1 REC-TTS episodes with patient-based data (45 variables) from the world literature, retrieved via PubMed, were meta-analyzed, and the patients' 1st REC-TTS and stREC-TTS were compared.

RESULTS

The time interval between the 1stTTS and 1stREC-TTS of the meta-analyzed 128 patients, 117 (91.4%) female, was 30.4 ± 36.1 months, with 47 (36.7%) patients having a neurological and/or psychiatric comorbidity(ies). Among 113 patients with paired 1stTTS and 1stREC-TTS data on the ventriculographic "ballooning" appearance, 101 (78.9%) had a different variant during the 1stTTS as compared with the 1stREC-TTS. Six patients (4.7%) died during hospitalization. Thirty patients (23.4%) were taking a β-blocker prior to their 1strTTS. Among 19 variables compared between the 1st TTS and 1st REC-TTS episodes, only mean age (by 2.5 years) and use of β-blockers were statistically significantly different. The precipitating triggers, and the in-hospital adverse events were similar in the 1st TTS and 1st REC-TTS episodes.

CONCLUSIONS

A comparison of the 1st TTS and 1st REC-TTS episodes of patients with REC-TTS, revealed large variation in the ventriculographic "ballooning" patterns, similarity in the TTS triggers, and no difference in the in-hospital adverse events. There was no protective effect for imparted by β-blockers in REC-TTS.

The N-AcetylCysteine and RAMipril in Takotsubo Syndrome Trial (NACRAM): Rationale and design of a randomised controlled trial of sequential N-Acetylcysteine and ramipril for the management of Takotsubo Syndrome

BACKGROUND

Takotsubo Syndrome(TTS), contrary to historical reports, is now increasingly recognised to be associated with substantial mortality and morbidity, both in the short- and long-term. Although TTS is often precipitated by a catecholamine "pulse", in-hospital hypotension is a common occurrence, increasing the risk of mortality. Furthermore, despite the transient catecholamine stimulus, there is increasing evidence that there are significant long term sequelae, including persistently impaired left ventricular(LV) systolic dysfunction, myocardial oedema with fibrosis, as well as persistent impairment of quality of life. A definitive therapeutic option to limit the extent of initial myocardial injury, and to accelerate recovery in TTS is therefore justified. However to date, there has been a lack of prospective studies in this area.

DESIGN AND RATIONALE

NACRAM is a multi-centre, randomised, placebo-controlled trial, sequentially testing early use of intravenous N-acetylcysteine(NAC), followed by/or oral ramipril for 12 weeks. The rationale for utilising these agents is related to their effects on limiting nitrosative stress and expression of the inflammasome activator thioredoxin interacting protein(TXNIP); both processes fundamental to the pathogenesis of TTS.

END POINTS

NACRAM is assessing resolution of myocardial oedema on cardiac magnetic resonance imaging(CMR), improvements in LV systolic function as measured by global longitudinal strain(GLS) on echocardiography, quality of life, and inflammatory markers.

DISCUSSION

To the best of our knowledge, NACRAM will be the first prospective study to help definitively evaluate a therapeutic option in acute attacks of TTS.

The Great Myocardial Mimic - Takotsubo Syndrome

Takotsubo syndrome has been traditionally considered a reversible form of acute heart failure triggered by an emotional or physical stressor, mainly occurring in women of post-menopausal age and often mimicking an acute coronary syndrome. While its pathophysiology is still incompletely understood, sympathetic overstimulation is known to play a central role in the disease. The classical hallmark of the condition was the presence of wall motion abnormalities limited to the apical segments of the ventricle, leading to the so-called apical ballooning, but different patterns of wall motion abnormalities are nowadays recognised. Different definitions and diagnostic criteria for takotsubo syndrome were proposed during the last decades, reflecting the heterogeneity of the condition and the gaps in the thorough understanding of the disease. While initially it was believed to be a benign entity, takotsubo syndrome has in fact similar morbidity and mortality with acute coronary syndromes, both on short- and long-term, highlighting the importance of proper risk stratification. Many questions still remain unanswered concerning the pathophysiology of the syndrome and the optimal therapeutic strategy for these patients.

Recurrent takotsubo syndrome with worsening of left ventricular outflow obstruction during haemodialysis: a case report

Background

The recurrence rate of takotsubo syndrome (TS) has been reported as 1.8% per patient-year while left ventricular outflow tract (LVOT) obstruction is comorbid in 10–25% of all instances of TS. The clinical course of recurrent TS with associated LVOT while on haemodialysis has rarely been reported.

Case summary

This case report involves a 60-year-old female patient receiving regular haemodialysis who was admitted for chest pain during ballroom dancing. Four years prior, she had suffered TS, and fully recovered after the hospitalization. An emergent coronary angiogram done during the second hospitalization showed no significant stenosis, and left ventriculography demonstrated mid-apical akinesia and basal hyperkinesia. Based on these findings, we diagnosed the recurrence of TS. Later in the admission, chest pain reappeared with the start of haemodialysis. A transthoracic echocardiogram demonstrated mean pressure gradient (PG) of LVOT was 58 mmHg, with systolic anterior motion of the mitral valve and basal-wall hyperkinesia. The main aetiology for her symptoms was considered as an exacerbation of LVOT obstruction due to removing intravascular volume by haemodialysis. After starting landiolol at 3 μg/kg/min, PG of LVOT and symptoms gradually improved with uptitration of landiolol. Finally, her chest pain resolved when mean PG of LVOT was down to 38 mmHg using 10 μg/kg/min of landiolol.

Discussion

To our knowledge, this is the first report of a recurrent TS case comorbid with LVOT obstruction while on regular haemodialysis. Landiolol, the ultrashort-acting beta-blocker, may be a promising therapeutic option for rapid recovery of increased PG due to LVOT obstruction.

A Review of Catecholamine Associated Cardiomyopathies and Channelopathies

Conditions associated with states of catecholamine toxicity are pheochromocytoma, paraganglioma, Takotsubo’s cardiomyopathy, and catecholaminergic polymorphic ventricular tachycardia. This article defines these conditions along with relevant diagnostic and prognostic factors. The role of catecholamines in these conditions are compared and contrasted. Emphasis is given to the role of endothelial dysfunction as a possible etiologic factor in cardiomyopathy associated with excess catecholamines.