Pathophysiology of Takotsubo Syndrome

The Safety and Strategies for Reinitiating Electroconvulsive Therapy After ECT-Induced Takotsubo Cardiomyopathy: A Case Report and Systematic Review

OBJECTIVES

Takotsubo cardiomyopathy (TCM) is a life-threatening complication of electroconvulsive therapy (ECT). We report the case of a 66-year-old woman who was rechallenged with ECT after ECT-induced TCM. Moreover, we have made a systematic review to assess the safety of and strategies for reinitiating ECT after TCM.

METHODS

We searched for published reports on ECT-induced TCM since 1990 in MEDLINE (PubMed), Scopus, Cochrane Library, ICHUSHI, and CiNii Research.

RESULTS

A total of 24 ECT-induced TCM cases were identified. Patients who developed ECT-induced TCM were predominantly middle-aged and older women. There was no specific trend in anesthetic agents used. Seventeen (70.8%) cases developed TCM by the third session in the acute ECT course. Eight (33.3%) cases developed ECT-induced TCM despite the use of β-blockers. Ten (41.7%) cases developed cardiogenic shock or abnormal vital signs related to cardiogenic shock. All cases recovered from TCM. Eight (33.3%) cases tried to receive ECT retrial. The duration until ECT retrial was between 3 weeks and 9 months. The most common preventive measures during ECT retrial were related to β-blockers; however, the type, dose, and route of administration of β-blockers varied. In all cases, ECT could be reperformed without TCM recurrence.

CONCLUSIONS

Electroconvulsive therapy-induced TCM is more likely to cause cardiogenic shock than nonperioperative cases; nevertheless, it has good prognosis. Cautious reinitiation of ECT after TCM recovery is possible. Further studies are required to determine preventive measures for ECT-induced TCM.

Case report: Anxiety and depression as initial symptoms in a patient with acute hypoxia and patent foramen ovale

The prevalence of patent foramen ovale (PFO) is 15-35% among adults. The role of right-to-left shunting through the PFO, anxiety, depression, and hypoxemia in the systemic circulation remains poorly understood. Herein, we present the case of a 52-year-old woman with no heart or lung disease, who was admitted due to anxiety for 5 months and had symptom exacerbation with dizziness for 4 days and presented with cyanosis. She was noted to have acute hypoxemia, with an oxygen saturation of 94.48% on room air, and arterial blood gas showed an oxygen tension of 65.64 mmHg. Agitated saline contrast echocardiography showed right-to-left shunting due to PFO. Arteriovenous fistula, pneumonia, pulmonary embolism, pulmonary hypertension, congestion peripheral cyanosis, ischemic peripheral cyanosis, and methemoglobin were excluded. Additionally, the patient improved by taking Paroxetine, Oxazepam, and Olanzapine. Her oxygen tension returned to 90.42 mmHg, and her symptoms resolved. In the case of severe anxiety and depression, right-to-left shunting through the PFO may cause acute systemic hypoxemia via a flow-driven mechanism, occasionally manifesting as cyanosis. When anxiety improved, hypoxia also improved. Thus, the treatment of anxiety and depression seems effective in improving hypoxemia. Notably, this is a rare report, and we hope to draw the attention of psychosomatic specialists, psychiatrists, and clinicians to seek the relationship between anxiety appearing as acute stress and PFO. This may be a new therapeutic method for treating severe anxiety disorder.

Takotsubo Cardiomyopathy Associated with Acute COVID-19 Pneumonia

Cardiogenic shock carries a high burden of morbidity and mortality because of inadequate tissue perfusion leading to end-stage multi-organ damage. The initial work-up includes a pertinent and thorough history and physical examination to identify possible cardiac and noncardiac etiologies. The following case describes a patient presenting with symptomatic acute COVID-19 (SARS-CoV-2) pneumonia with initial findings consistent with cardiogenic shock. SARS-CoV-2 pneumonia has been associated with multiple cardiac manifestations including myocarditis, heart failure, myocardial infarction, and Takotsubo cardiomyopathy. This patient was treated with conservative medical management and had complete clinical recovery and normal cardiac angiography weeks after their initial presentation. This clinical scenario highlights the significance of a broad differential and extensive work-up when faced with a patient presenting with cardiogenic shock.

Topographical Association Between Left Ventricular Strain and Brain Lesions in Patients With Acute Ischemic Stroke and Normal Cardiac Function

Background Although it is well known that the disordered brain provokes cardiac autonomic dysfunction, the detailed location of brain lesions related to cardiac function warrants further investigation. We aimed to elucidate the brain lesions topographically associated with left ventricular (LV) systolic function measured by myocardial strain in patients with acute ischemic stroke without preexisting primary cardiac dysfunction by using support vector regression lesion-symptom mapping. Methods and Results Subjects were those with LV ejection fraction of 50% or more among patients with acute ischemic stroke registered in the Samsung Medical Center stroke registry between 2016 and 2017. To evaluate LV systolic performance and contractility, we measured LV ejection fraction and LV global and regional longitudinal strain using 2-dimensional speckle-tracking echocardiography. The association between stroke lesion location and cardiac strain was assessed using support vector regression lesion-symptom mapping. Of a total of 776 patients, 286 subjects (mean age of 67.0 years, 65.4% men) were finally enrolled in this study. The mean global longitudinal strain was -17.0±3.4%, and the mean LV ejection fraction was 64.7±5.7%. The support vector regression lesion-symptom mapping analysis revealed that the right insula and peri-insular regions and left parietal cortex were associated with impaired LV global longitudinal strain in patients with acute ischemic stroke. In addition, impaired regional longitudinal strain showed topographical associations with these regions. Conclusions This study suggests that brain lesions in the right insula and peri-insular regions and left parietal cortex are topographically associated with impaired LV strain in patients with acute ischemic stroke without preexisting cardiac dysfunction.

Severe and Atypical Presentation of Takotsubo Cardiomyopathy in a Pediatric Patient after a Serious Crash Injury-Case Report and Literature Review

Takotsubo cardiomyopathy is an uncommon clinical entity in children, resulting in severe but sometimes reversible systolic dysfunction of the left ventricle. This condition is triggered by multiple emotional or physical stressors, while neurogenic stress cardiomyopathy after brain injuries has become increasingly recognized in children over the past few years. We report the case of an 11-year-old child with an atypical clinical presentation after a serious car crash accident. An initial computed tomography scan revealed an acute epidural hematoma, which was immediately treated by an emergency craniotomy. During the patient's following pediatric intensive care unit hospitalization, severe hemodynamic instability was observed, leading to gradually higher doses of vasopressors for circulatory support. On echocardiography, the patient had signs of severe cardiac contractility compromise, with characteristic pattern of regional wall motion abnormalities of the left ventricle, which, in combination with seriously elevated cardiac enzymes, electrocardiographic (ECG) abnormalities and continuous thermodilution hemodynamic monitoring (PICCO) findings, led to intensification of inotropic support and to the diagnosis of takotsubo cardiomyopathy. Despite supportive measures, the patient developed multiorgan failure and succumbed to their serious illness. For this atypical case, extracorporeal membrane oxygenation (ECMO) was addressed as an option for the seriously failing heart, but due to the extremely high risk of intracranial bleeding, it could not be used for this patient's treatment. In conclusion, Takotsubo cardiomyopathy should be suspected in pediatric cases of cardiac dysfunction after serious injuries or stress conditions.

12,13-diHOME and noradrenaline are associated with the occurrence of acute myocardial infarction in patients with type 2 diabetes mellitus

BACKGROUND

Acute myocardial infarction (AMI) is the most prevalent cause of mortality and morbidity in patients with type 2 diabetes mellitus (T2DM). However, strict blood glucose control does not always prevent the development and progression of AMI. Therefore, the present study aimed to explore potential new biomarkers associated with the occurrence of AMI in T2DM patients.

METHODS

A total of 82 participants were recruited, including the control group (n = 28), T2DM without AMI group (T2DM, n = 30) and T2DM with initial AMI group (T2DM + AMI, n = 24). The untargeted metabolomics using liquid chromatography-mass spectrometry (LC-MS) analysis was performed to evaluate the changes in serum metabolites. Then, candidate metabolites were determined using ELISA method in the validation study (n = 126/T2DM group, n = 122/T2DM + AMI group).

RESULTS

The results showed that 146 differential serum metabolites were identified among the control, T2DM and T2DM + AMI, Moreover, 16 differentially-expressed metabolites were significantly altered in T2DM + AMI compared to T2DM. Amino acid and lipid pathways were the major involved pathways. Furthermore, three candidate differential metabolites, 12,13-dihydroxy-9Z-octadecenoic acid (12,13-diHOME), noradrenaline (NE) and estrone sulfate (ES), were selected for validation study. Serum levels of 12,13-diHOME and NE in T2DM + AMI were significantly higher than those in T2DM. Multivariate logistic analyses showed that 12,13-diHOME (OR, 1.491; 95% CI 1.230-1.807, P < 0.001) and NE (OR, 8.636; 95% CI 2.303-32.392, P = 0.001) were independent risk factors for AMI occurrence in T2T2DM patients. The area under receiver operating characteristic (ROC) curve (AUC) were 0.757 (95% CI 0.697-0.817, P < 0.001) and 0.711(95% CI 0.648-0.775, P < 0.001), respectively. The combination of both significantly improved the AUC to 0.816 (95% CI 0.763-0.869, P < 0.001).

CONCLUSIONS

12,13-diHOME and NE may lead to understanding the possible metabolic alterations associated with AMI onset in T2DM population and serve as promising risk factors and therapeutic targets.

Stroke-heart syndrome: A case report and mini literature review

Despite the fact that cardiac troponin (cTn) elevation is commonly seen in the acute phase of ischemic stroke, investigating its etiology represents a challenge for healthcare practitioners. Therefore, we describe the case of an 86-year-old woman with dyspnea and cTn-elevation within the first days following acute ischemic stroke and discuss potential differential diagnoses and diagnostic dilemmas.

Takotsubo syndrome is a coronary microvascular disease: experimental evidence

BACKGROUND AND AIMS

Takotsubo syndrome (TTS) is a conundrum without consensus about the cause. In a murine model of coronary microvascular dysfunction (CMD), abnormalities in myocardial perfusion played a key role in the development of TTS.

METHODS AND RESULTS

Vascular Kv1.5 channels connect coronary blood flow to myocardial metabolism and their deletion mimics the phenotype of CMD. To determine if TTS is related to CMD, wild-type (WT), Kv1.5-/-, and TgKv1.5-/- (Kv1.5-/- with smooth muscle-specific expression Kv1.5 channels) mice were studied following transaortic constriction (TAC). Measurements of left ventricular (LV) fractional shortening (FS) in base and apex, and myocardial blood flow (MBF) were completed with standard and contrast echocardiography. Ribonucleic Acid deep sequencing was performed on LV apex and base from WT and Kv1.5-/- (control and TAC). Changes in gene expression were confirmed by real-time-polymerase chain reaction. MBF was increased with chromonar or by smooth muscle expression of Kv1.5 channels in the TgKv1.5-/-. TAC-induced systolic apical ballooning in Kv1.5-/-, shown as negative FS (P < 0.05 vs. base), which was not observed in WT, Kv1.5-/- with chromonar, or TgKv1.5-/-. Following TAC in Kv1.5-/-, MBF was lower in LV apex than in base. Increasing MBF with either chromonar or in TgKv1.5-/- normalized perfusion and function between LV apex and base (P = NS). Some genetic changes during TTS were reversed by chromonar, suggesting these were independent of TAC and more related to TTS.

CONCLUSION

Abnormalities in flow regulation between the LV apex and base cause TTS. When perfusion is normalized between the two regions, normal ventricular function is restored.

A Case of Posterior Reversible Encephalopathy Due to Takotsubo Cardiomyopathy Triggered by Aerophobia

A 37-year-old woman, previously known to have severe airplane phobia, develops panic disorder-like symptoms in the second hour of the flight. After a while, panic disorder was accompanied by chest pain and syncope. An ECG showed no abnormalities. Transthoracic echocardiogram demonstrated decreased left ventricular ejection fraction (EF: 30), large apical akinesis, and characteristic regional wall motion abnormalities involving the middle and apical segments of the left ventricle. Findings were consistent with Takotsubo cardiomyopathy. But in the emergency department, Brain Diffusion MRI showed cortical and subcortical vasogenic edema in the posterior regions, predominantly on the left, bilaterally, compatible with posterior reversible encephalopathy. This case highlights the Takotsubo cardiomyopathy-related posterior reversible encephalopathy syndrome (PRES) syndrome and managing the disease.

Multicenter retrospective database evaluation of Takotsubo syndrome in subjects undergoing catheter ablation for atrial fibrillation

Background

Intracardiac catheter ablation for atrial fibrillation with pulmonary vein isolation may result in Takotsubo syndrome (TS), but the frequency, predisposing factors (age, sex, mental health disorders), and outcomes are currently unknown. This study sought to assess the frequency, predisposing factors, and outcomes of subjects who underwent intracardiac catheter ablation for atrial fibrillation with pulmonary vein isolation and were diagnosed with TS.

Methods

This was a retrospective observational cohort study utilizing TriNetX® electronic health record (EHR) data. We included subjects aged older than 18 years who underwent intracardiac catheter ablation for atrial fibrillation with pulmonary vein isolation. The study population was divided into two groups (no TS diagnostic code presence and TS diagnostic code presence). We analyzed the distributions of age, sex, race, diagnostic codes, common terminology procedures (CPT), and vasoactive medication codes and examined mortality rate within 30 days.

Results

We included 69,116 subjects. Of these, 27 (0.04%) had a TS diagnostic code, the cohort was comprised mostly of females [17 (63.0%)], and 1 (3.7%) death within 30 days was reported. There were no significant differences in age and frequency of mental health disorders between those patients in TS and non-TS cohorts. Adjusting for age, sex, race, ethnicity, patient regionality, and mental health disorder diagnostic code, those patients who developed TS had a significantly higher odds of dying in 30 days after catheter ablation compared to those without TS (OR = 15.97, 95% CI: 2.10-121.55, p = .007).

Conclusions

Approximately 0.04% of subjects who underwent intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation had a subsequent diagnostic code of TS. Further study is needed to determine whether there are predisposing factors associated with the development of TS in subjects who undergo catheter ablation of atrial fibrillation by pulmonary vein isolation.

Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA): Focus on Coronary Microvascular Dysfunction and Genetic Susceptibility

Among the most common causes of death worldwide, ischemic heart disease (IHD) is recognized to rank first. Even if atherosclerotic disease of the epicardial arteries is known as the leading cause of IHD, the presence of myocardial infarction with non-obstructive coronary artery disease (MINOCA) is increasingly recognized. Notwithstanding the increasing interest, MINOCA remains a puzzling clinical entity that can be classified by distinguishing different underlying mechanisms, which can be divided into atherosclerotic and non-atherosclerotic. In particular, coronary microvascular dysfunction (CMD), classifiable in non-atherosclerotic mechanisms, is a leading factor for the pathophysiology and prognosis of patients with MINOCA. Genetic susceptibility may have a role in primum movens in CMD. However, few results have been obtained for understanding the genetic mechanisms underlying CMD. Future studies are essential in order to find a deeper understanding of the role of multiple genetic variants in the genesis of microcirculation dysfunction. Progress in research would allow early identification of high-risk patients and the development of pharmacological, patient-tailored strategies. The aim of this review is to revise the pathophysiology and underlying mechanisms of MINOCA, focusing on CMD and actual knowledge about genetic predisposition to it.

Pathophysiological effects of SARS-CoV-2 infection on the cardiovascular system and its clinical manifestations-a mini review

Coronavirus disease 2019 (COVID-19) is a viral infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 may have a mild presentation, with few symptoms, or progress to a severe condition, characterized by generalized inflammation, systemic microvascular involvement, coagulopathy, and pulmonary and cardiovascular complications. Men present with more severe symptoms than women, especially men who are older and who present with comorbidities such as hypertension, diabetes mellitus, and a history of atherosclerotic diseases. Owing to its association with endothelial dysfunction, inflammation, thrombosis, and microvascular obstruction, SARS-CoV-2 infection can cause lesions in several organs, including the myocardium and the coronary arterial bed, which can result in clinical manifestations involving the cardiovascular system. In this mini review, we summarize the effects of SARS-CoV-2 infection on the cardiovascular system in both children and adults and characterize the various clinical manifestations associated with this disease.

Takotsubo syndrome: getting closer to its causes

Takotsubo syndrome (TTS) accounts for between 1 and 4% of cases presenting clinically as an acute coronary syndrome. It typically presents as a transient cardiac phenotype of left ventricular dysfunction with spontaneous recovery. More dramatic presentations may include cardiogenic shock or cardiac arrest. Despite progress in the understanding of the condition since its first description in 1990, considerable questions remain into understanding underlying pathomechanisms. In this review article, we describe the current published data on potential underlying mechanisms associated with the onset of TTS including sympathetic nervous system over-stimulation, structural and functional alterations in the central nervous system, catecholamine secretion, alterations in the balance and distribution of adrenergic receptors, the additive impact of hormones including oestrogen, epicardial coronary or microvascular spasm, endothelial dysfunction, and genetics as potentially contributing to the cascade of events leading to the onset. These pathomechanisms provide suggestions for novel potential therapeutic strategies in patients with TTS including the role of cognitive behavioural therapy, beta-blockers, and endothelin-A antagonists. The underlying mechanism of TTS remains elusive. In reality, physical or emotional stressors likely trigger through the amygdala and hippocampus a central neurohumoral activation with the local and systemic secretion of excess catecholamine and other neurohormones, which exert its effect on the myocardium through a metabolic switch, altered cellular signalling, and endothelial dysfunction. These complex pathways exert a regional activation in the myocardium through the altered distribution of adrenoceptors and density of autonomic innervation as a protective mechanism from myocardial apoptosis. More research is needed to understand how these different complex mechanisms interact with each other to bring on the TTS phenotype.

Cardiac tamponade-mediated generalized coronary vasospasm presenting as an inferior ST-segment elevation myocardial infarction: a case report

Background

Coronary vasospasm is a rare cause of ST-segment elevation myocardial infarction (STEMI) and can be precipitated by numerous inciting factors including endogenous catecholamines. Differentiating coronary vasospasm from an acute atherothrombotic event is diagnostically challenging and requires a careful clinical history combined with electrocardiographic and angiographic abnormalities to make the diagnosis and guide therapy.

Case Summary

We report a case of cardiogenic shock secondary to cardiac tamponade leading to an endogenous catecholamine surge resulting in profound arterial vasospasm and STEMI. The patient presented with chest pain and inferior ST segment elevations prompting emergent coronary angiography, demonstrating subtotal occlusion of the right coronary artery, severe proximal left anterior descending coronary artery stenosis, and diffusely stenosed aortoiliac vessels. Emergent transthoracic echocardiogram revealed a large pericardial effusion and hemodynamics consistent with cardiac tamponade. Pericardiocentesis resulted in dramatic hemodynamic improvement with immediate normalization of ST segments. Repeat coronary angiography performed one day later showed no angiographically significant coronary or peripheral arterial stenosis.

Discussion

This is the first reported case of simultaneous coronary and peripheral arterial vasospasm presenting as inferior STEMI caused by endogenous catecholamines from cardiac tamponade. Several clues suggest coronary vasospasm including the discordant electrocardiography (ECG) and coronary angiographic findings as well as diffusely stenosed aortoiliac vessels. Diffuse vasospasm was confirmed when repeat angiography performed after pericardiocentesis demonstrated angiographic resolution of coronary and peripheral arterial stenosis. Though rare, circulating endogenous catecholamines resulting in diffuse coronary vasospasm may present as STEMI and should be considered based on the clinical history, ECG findings, and coronary angiography.

The role of temporary mechanical circulatory support in de novo heart failure syndromes with cardiogenic shock: A contemporary review

Cardiogenic shock (CS) is a complex clinical syndrome with a high mortality rate. It can occur to due to multiple etiologies of cardiovascular disease and is phenotypically heterogeneous. Acute myocardial infarction-related CS (AMI-CS) has historically been the most prevalent cause, and thus, research and guidance have focused primarily on this. Recent data suggest that the burden of non-ischemic CS is increasing in the population of patents requiring intensive care admission. There is, however, a paucity of data and guidelines to inform the management of these patients who fall into two broad groups: those with existing heart failure and CS and those with no known history of heart failure who present with "de novo" CS. The use of temporary mechanical circulatory support (MCS) has expanded across all etiologies, despite its high cost, resource intensity, complication rates, and lack of high-quality outcome data. Herein, we discuss the currently available evidence on the role of MCS in the management of patients with de novo CS to include fulminant myocarditis, right ventricular (RV) failure, Takotsubo syndrome, post-partum cardiomyopathy, and CS due to valve lesions and other cardiomyopathies.

Sex Difference in Clinical and Management Outcomes in Patients With Takotsubo Syndrome: A Systematic Review and Meta-Analysis

Takotsubo syndrome (TTS) is being increasingly recognized globally with a female sex predilection. However, sex-related differences in clinical outcomes are yet to be identified. Therefore, we aim to investigate the sex differences in clinical outcomes in patients with TTS. We included cohort studies retrieved from the Web of Science, SCOPUS, EMBASE, PubMed, and Cochrane until September 14, 2022. The risk ratio (RR) for dichotomous outcomes with the corresponding 95% confidence interval (CI) was used. The study protocol was registered in PROSPERO with ID: CRD42022363349. Thirteen retrospective cohort studies, with a total of 104,410 patients were included. Men had a higher risk of in-hospital mortality (RR: 2.42 with 95% CI [1.53, 3.83], P = 0.0002), long-term mortality (RR: 1.59 with 95% CI [1.40, 1.80], P = 0.00001), cardiogenic shock (RR: 1.65 with 95% CI [1.52, 1.79], P = 0.00001), arrhythmia (RR: 1.70 with 95% CI [1.56, 1.86], P = 0.00001), and acute kidney injury (RR: 1.71 with 95% CI [1.50, 1.96]. P = 0.00001), as compared with women. However, no significant difference was observed in stroke (RR: 1.22 with 95% CI [0.78, 1.89], P = 0.39), left ventricular thrombus (RR: 0.96 with 95% CI [0.40, 2.33], P = 0.93), and TTS recurrence (RR: 1.11 with 95% CI [0.68, 1.82], P = 0.67) between men and women. Despite women having a higher incidence of TTS, men have higher morbidity and mortality rates. Hence, further studies are necessary to identify the pathophysiological factors of this sex difference in clinical outcomes, including hormonal and psychological variables.

The potential role of SARS‐CoV‐2 infection in acute coronary syndrome and type 2 myocardial infarction (T2MI): Intertwining spread

Coronavirus disease 2019 (COVID‐19) is a novel pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). It has been shown that SARS‐CoV‐2 infection‐induced inflammatory and oxidative stress and associated endothelial dysfunction may lead to the development of acute coronary syndrome (ACS). Therefore, this review aimed to ascertain the link between severe SARS‐CoV‐2 infection and ACS. ACS is a spectrum of acute myocardial ischemia due to a sudden decrease in coronary blood flow, ranging from unstable angina to myocardial infarction (MI). Primary or type 1 MI (T1MI) is mainly caused by coronary plaque rupture and/or erosion with subsequent occlusive thrombosis. Secondary or type 2 MI (T2MI) is due to cardiac and systemic disorders without acute coronary atherothrombotic disruption. Acute SARS‐CoV‐2 infection is linked with the development of nonobstructive coronary disorders such as coronary vasospasm, dilated cardiomyopathy, myocardial fibrosis, and myocarditis. Furthermore, SARS‐CoV‐2 infection is associated with systemic inflammation that might affect coronary atherosclerotic plaque stability through augmentation of cardiac preload and afterload. Nevertheless, major coronary vessels with atherosclerotic plaques develop minor inflammation during COVID‐19 since coronary arteries are not initially and primarily targeted by SARS‐CoV‐2 due to low expression of angiotensin‐converting enzyme 2 in coronary vessels. In conclusion, SARS‐CoV‐2 infection through hypercytokinemia, direct cardiomyocyte injury, and dysregulation of the renin‐angiotensin system may aggravate underlying ACS or cause new‐onset T2MI. As well, arrhythmias induced by anti‐COVID‐19 medications could worsen underlying ACS.

Current evidence of COVID-19 vaccination-related cardiovascular events

Currently, the world is recovering from the shock of the coronavirus disease 2019 (COVID-19) pandemic; however, this situation is still fragile. Health authorities recommend administering COVID-19 vaccines as the safest and most reliable tool for eliminating COVID-19. Subsequent to the extensive administration of the COVID-19 vaccines, a series of cardiovascular adverse effects have been reported. This comprehensive review aimed to provide an update on the etiology, pathophysiology, clinical features, and management of the cardiovascular adverse events associated with COVID-19 vaccines, including myocarditis, pericarditis, thrombosis with thrombocytopenia syndrome, myocardial infarction, cardiac arrhythmias, hypertension, and stress-induced cardiomyopathy. The benefits of COVID-19 vaccination far outweigh the reported adverse events. It would be clinically important to provide diagnostic scoring systems to differentiate COVID-19-related cardiovascular adverse events from other causes and develop therapeutic approaches for their management. Further evaluation of cardiovascular adverse events of the COVID-19 vaccines is crucial for implementing vaccination programs and developing safer and more reliable vaccines.

Can Breaking Heroin Addiction Lead to a Broken Heart? A Case of Reverse Takotsubo Cardiomyopathy in a Patient With Heroin Withdrawal

Reverse takotsubo cardiomyopathy is triggered by emotional or physical stress and has a presentation similar to that of acute coronary syndrome. A 39-year-old woman with a history of heroin use disorder presented with intractable nausea, vomiting, and diarrhea. She was diagnosed with heroin withdrawal and started on buprenorphine-naloxone. On day 2 of her hospitalization, she developed chest heaviness and had an elevated troponin I level of 3.2 ng/mL (reference range, 0.015-0.045 ng/mL); electrocardiography showed new T-wave inversions in the anterior and inferior leads. Emergent coronary angiography showed patent coronary arteries, and left ventriculography showed basal hypokinesis and apical hyperkinesis, consistent with reverse takotsubo cardiomyopathy secondary to heroin withdrawal. She was started on antihypertensive agents, and her buprenorphine-naloxone dose was increased. At her 3-month follow-up visit, she reported no symptoms consistent with angina or heart failure. This appears to be the first report of heroin withdrawal causing reverse takotsubo cardiomyopathy. Awareness of this association can lead to earlier recognition and treatment of reverse takotsubo cardiomyopathy.

Long-term prognostic impact of beta-blockers in patients with Takotsubo syndrome: Results from the RETAKO Registry

BACKGROUND

No evidence-based therapy has yet been established for Takotsubo syndrome (TTS). Given the putative harmful effects of catecholamines in patients with TTS, beta-blockers may potentially decrease the intensity of the detrimental cardiac effects in those patients.

OBJECTIVE

The purpose of this study was to assess the impact of beta-blocker therapy on long-term mortality and TTS recurrence.

METHODS

The cohort study used the national Spanish Registry on TakoTsubo Syndrome (RETAKO). A total of 970 TTS post-discharge survivors, without pheochromocytoma, left ventricular outflow tract obstruction, sustained ventricular arrhythmias, and significant bradyarrhythmias, between January 1, 2003, and July 31, 2018, were assessed. Cox regression analysis and inverse probability weighting (IPW) propensity score analysis were used to evaluate the association between beta-blocker therapy and survival free of TTS recurrence.

RESULTS

From 970 TTS patients, 582 (60.0%) received beta-blockers. During a mean follow-up of 2.5±3.3 years, there were 87 deaths (3.6 per 100 patients/year) and 29 TTS recurrences (1.2 per 100 patient/year). There was no significant difference in follow-up mortality or TTS recurrence in unadjusted and adjusted Cox analysis (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.59-1.27, and 0.95, 95% CI 0.57-1.13, respectively). After weighting and adjusting by IPW, differences in one-year survival free of TTS recurrence between patients treated and untreated with beta-blockers were not found (average treatment effect -0.01, 95% CI -0.07 to 0.04; p=0.621).

CONCLUSIONS

In this observational nationwide study from Spain, there was no significant association between beta-blocker therapy and follow-up survival free of TTS recurrence.

Temporal electrocardiographic changes in anterior ST elevation myocardial infarction versus the Takotsubo syndrome

Background

Electrocardiography (ECG) on admission is similar in ST elevation myocardial infarction (STEMI) and Takotsubo syndrome (TTS). ECG on admission has been extensively investigated and compared between STEMI and TTS, however, only a few studies have compared temporal ECG. Our aim was to compare ECG in anterior STEMI versus female TTS from admission to day 30.

Methods

Adult patients with anterior STEMI or TTS treated at Sahlgrenska University Hospital (Gothenburg, Sweden) from December 2019 to June 2022 were prospectively enrolled. Baseline characteristics, clinical variables and ECGs from admission to day 30 were analyzed. Using a mixed effects model, we compared temporal ECG between female patients with anterior STEMI or TTS, as well as between female and male patients with anterior STEMI.

Results

A total of 101 anterior STEMI patients (31 female, 70 male) and 34 TTS patients (29 female, 5 male) were included. The temporal pattern of T wave inversion was similar between female anterior STEMI and female TTS, as well as between female and male anterior STEMI. ST elevation was more common, whereas QT prolongation was less common, in anterior STEMI compared with TTS. Q wave pathology was more similar between female anterior STEMI and female TTS than between female and male anterior STEMI.

Conclusions

The pattern of T wave inversion and Q wave pathology from admission to day 30 was similar in female patients with anterior STEMI and female patients with TTS. Temporal ECG in female patients with TTS may be interpreted as following a "transient ischemic" pattern.

Metoprolol Improves Left Ventricular Longitudinal Strain at Rest and during Exercise in Obstructive Hypertrophic Cardiomyopathy

BACKGROUND

Patients with obstructive hypertrophic cardiomyopathy (HCM) often experience symptoms of heart failure upon exertion despite having normal left ventricular (LV) ejection fractions. Longitudinal strain (LS) may be a more sensitive marker of systolic dysfunction in patients with LV hypertrophy. The aims of this study were to characterize LV segmental LS and global LS (GLS) at rest and during exercise and to assess if first-line treatment with β-blockers improves LV systolic performance.

METHODS

Twenty-nine patients with obstructive HCM and New York Heart Association functional class ≥ II symptoms were enrolled in a double-blind, placebo-controlled, randomized crossover trial. Patients received metoprolol 150 mg or placebo for two consecutive 2-week periods in random order. Echocardiographic assessment with speckle-tracking-derived LS was performed at rest and during peak exercise at the end of each treatment period.

RESULTS

During placebo treatment, resting values of segmental LS showed an apical-basal difference of -10.3% (95% CI, -12.7% to -7.8%; P < .0001), with a severely abnormal value of the basal segment of -9.3 ± 4.2%. Treatment with metoprolol was associated with more negative LS values of the apical segment (-2.8%; 95% CI, -4.2% to -1.3%; P < .001) and the mid segment (-1.1%; 95% CI, -2.0% to -0.3%; P = .007). During peak exercise there was a deterioration in LV GLS, but treatment with metoprolol was associated with more negative peak exercise LV GLS (-1.3 %; 95% CI, -2.6% to -0.1%; P = .03).

CONCLUSIONS

Systolic performance assessed by LV GLS showed impaired values at rest and during exercise, with severely depressed values of the basal and mid segments. Treatment with metoprolol improved LV GLS upon exercise, indicating a beneficial effect of β-blocker treatment on LV systolic function.

Sex Differences in Stress-Induced (Takotsubo) Cardiomyopathy

Background

Takotsubo cardiomyopathy (TC) affects predominantly women. Prior studies have suggested that men might have worse short-term outcomes, but limited data are available regarding long-term outcomes. We hypothesized that men, compared to women, with TC have worse short- and long-term outcomes.

Methods

A retrospective study of patients diagnosed with TC between 2005 and 2018 in the Veteran Affairs system was performed. Primary outcomes were in-hospital death, 30-day risk of stroke, death, and long-term mortality.

Results

A total of 641 patients were included (444 men [69%]; 197 women [31%]). Men had a higher median age (65 vs 60 years; P < 0.001), and women were more likely to present with chest pain (68.7% vs 44.1%; P < 0.001). Physical triggers were more common in men (68.7% vs 44.1%, P < 0.001). Men had a higher in-hospital mortality rate (8.1% vs 1%; P < 0.001). On multivariable regression analysis, female sex was an independent predictor for improved in-hospital mortality, compared to men (odds ratio 0.25, 95% confidence interval 0.06-1.10; P = 0.04). On 30-day follow-up, no difference occurred in a combined outcome of stroke and death (3.9% vs 1.5%; P = 0.12). On long-term follow-up (3.7 ± 3.1 years), female sex was identified as an independent predictor of lower mortality (hazard ratio 0.71, 95% CI 0.51-0.97; P = 0.032). Women were more likely to have TC recurrence (3.6% vs 1.1%; P = 0.04).

Conclusions

In our study with a predominantly male population, men had less-favourable short- and long-term outcomes after TC, compared to those of women.

Takotsubo Syndrome and Sudden Cardiac Death

Takotsubo syndrome (TTS), triggered by intense emotional or physical stress, occurring most commonly in post-menopausal women, presents as an ST-elevation myocardial infarction (MI). Cardiovascular complications occur in almost half the patients with TTS, and the inpatient mortality is comparable to MI (4-5%) owing to cardiogenic shock, myocardial rupture, or life-threatening arrhythmias. Thus, its prognosis is not as benign as previously thought, as it may cause mechanical complications (cardiac rupture) and potentially lethal arrhythmias and sudden cardiac death (SCD). Similar to MI, some patients may perish before reaching the hospital due to out-of-hospital cardiac arrest; this may lead to underestimation of the actual SCD risk. Furthermore, after discharge, some patients may develop late SCD and/or TTS recurrence that may result in SCD. There are risk factors for SCD in TTS patients, such as severe/persistent QT-interval prolongation inciting torsade-de-pointes, other ECG abnormalities (diffuse giant negative T-waves, widened QRS-complex), bradyarrhythmias, comorbidities, concurrent obstructive coronary artery disease or vasospasm, male gender, older age, severe left ventricular dysfunction, and use of sympathomimetic drugs. All these issues are herein reviewed, case reports/series and data from large cohort studies and meta-analyses are analyzed, risk factors are tabulated, and proarrhythmic effects and management strategies are discussed and pictorially illustrated.

Takotsubo cardiomyopathy following envenomation: An updated review

BACKGROUND

Takotsubo cardiomyopathy (TTC) can be diagnosed in patients presenting with clinical features of acute coronary syndrome (ACS) by using Mayo clinic criteria. Multiple precipitators have been attributed to causing TTC. Rarely it has been reported to occur following an acute envenomation.

AIM

This review describes the various patterns, mechanisms, and outcomes of envenomation induced TTC.

METHODS

In this review, we included all studies on “TTC” and “envenomation “published in the various databases before June 2022. To be included in the review articles had to have a distinct diagnosis of TTC and an envenomation

RESULTS

A total of 20 patients with envenomation induced TTC were identified. Most episodes of envenomation induced TTC were reported following a bee sting, scorpion sting, and snake envenomation. Fear and anxiety related to the sting, direct catecholamine toxicity and administration of exogenous beta-adrenergic agents have been commonly postulated to precipitate TTC in these patients. 95% of these patients presented with a clinical picture of ACS. Most of these patients also fulfill at least 3 out of 4 criteria of Mayo clinic criteria for TTC. Echocardiographic evidence of Apical TTC was noted in 72% of patients. 94% of these patients had clinical improvement following optimal management and 35% of these patients were treated with guideline directed medications for heart failure.

CONCLUSION

Envenomation following multiple insect stings and reptile bites can precipitate TTC. Most reported envenomation related TTC has been due to bee stings and scorpion bites. Common mechanisms causing TTC were fear, anxiety, and stress of envenomation. Most of these patients present with clinical presentation of ACS, ST elevation, and elevated troponin. The most common type of TTC in these patients is Apical, which improved following medical management.

Ischemia with no obstructive coronary artery disease (INOCA): A patient self-report quality of life survey from INOCA international

BACKGROUND

There is limited information available regarding evidence of ischemia with no obstructive coronary arteries (INOCA) and quality of life.

PURPOSE

To determine associations between INOCA and self-reported physical, social, and mental health.

METHODS

We conducted a survey of all members (n = 1579) of the INOCA International patient support group. Current self-reported diagnosis and health measures were collected. Functional capacity was retrospectively estimated using the Duke Activity Status Index (DASI), assessing levels of activities performed prior and after symptom onset.

RESULTS

A total of 297 (20.8% response rate, 91% women) reported symptoms of chest pain, pressure, or discomfort in 92.9%. Overall, 34.4% were living with symptoms for ≥3 years before an INOCA diagnosis, and 77.8% were told their symptoms were not cardiac. Estimated functional capacity was higher prior to compared to after symptom onset (8.6 ± 1.8 METs vs 5.6 ± 1.8 METs; P < 0.0001). Most respondents reported an adverse impact of symptoms on their home life (80.5%), social life (80.1%), mental health (70.4%), outlook on life (69.7%), sex life (55.9%), and their partner/spouse relationship (53.9%), while approximately three-quarters reduced their work hours or stopped work completely, 47.5% retired early, and 38.4% applied for disability.

CONCLUSIONS

INOCA symptoms are associated with adverse physical, mental and social health quality of life. Increased patient awareness, physician recognition and diagnosis, and clinical trials are needed to develop evidence-based guidelines for this increasingly recognized cardiovascular disorder.

Myocardial stunning secondary to erroneous administration of intravenous epinephrine

Epinephrine is a commonly used medication for emergent conditions, such as anaphylaxis, respiratory distress, and shock. However, its versatility can also lead to iatrogenic errors in dosages, concentrations, and routes of administration. In this case, a 47-year-old female experiencing anaphylaxis received an intravenous dose of 0.3 mg (1:1000) epinephrine formulated for intramuscular injection, resulting in cardiac arrest and acute heart failure due to myocardial stunning, as diagnosed by echocardiography. Management included invasive ventilation and hemodynamic support until cardiac function recovered. This case highlights the potential dangers of epinephrine overdose, and to our knowledge, is the first reported case of iatrogenic epinephrine-induced Takotsubo cardiomyopathy in a rural area. In addition, we review the literature on iatrogenic epinephrine toxicity-associated cardiomyopathy and the epidemiology of epinephrine errors. Safety measures must be considered for improving communication in emergencies, increasing awareness via training, and changing epinephrine's antiquated packaging design.

ST-Segment Elevation Myocardial Infarction on the Line: Inadvertent Arterial Infusion of Vasopressors Causing Acute Myocardial Infarction

Central venous catheters (CVCs), regarded as lines of life, are helpful in hemodynamic monitoring and delivering medications to patients. However, there are several complications that can result from the placement of CVCs. This includes accidental arterial puncture, which has a temporal association with hemorrhage, hematoma, and stroke. Infusion of vasopressors through such a mispositioned arterial CVC further increases the risk of these complications with potential end-organ ischemia. Here, we discuss the case of a 76-year-old woman who developed a myocardial infarction, heart failure, and subarachnoid hemorrhage following the arterial infusion of vasopressors through a malpositioned CVC.

The Heart Is at Risk: Understanding Stroke-Heart-Brain Interactions with Focus on Neurogenic Stress Cardiomyopathy-A Review

In recent years, it has been convincingly demonstrated that acute brain injury may cause severe cardiac complications-such as neurogenic stress cardiomyopathy (NSC), a specific form of takotsubo cardiomyopathy. The pathophysiology of these brain-heart interactions is complex and involves sympathetic hyperactivity, activation of the hypothalamic-pituitary-adrenal axis, as well as immune and inflammatory pathways. There have been great strides in our understanding of the axis from the brain to the heart in patients with isolated acute brain injury and more specifically in patients with stroke. On the other hand, in patients with NSC, research has mainly focused on hemodynamic dysfunction due to arrhythmias, regional wall motion abnormality, or left ventricular hypokinesia that leads to impaired cerebral perfusion pressure. Comparatively little is known about the underlying secondary and delayed cerebral complications. The aim of the present review is to describe the stroke-heart-brain axis and highlight the main pathophysiological mechanisms leading to secondary and delayed cerebral injury in patients with concurrent hemorrhagic or ischemic stroke and NSC as well as to identify further areas of research that could potentially improve outcomes in this specific patient population.

Cardiovascular Disease in Women: What the Radiologist Needs to Know

BACKGROUND

 Sex-specific disparities are well documented for cardiovascular disease (CVD). There are differences in physiology and pathophysiology, pain perception, spectrum of disease, risk, therapeutic aspects, prognosis, and outcome. CVD represents a broad spectrum of disorders. This review focuses on cardiovascular and cardiac pathology.

METHOD

 This review summarizes the current state of the literature on cardiovascular disease in women from a radiological viewpoint. It aims to provide a deeper understanding of these differences and thereby alerts the reader to the potential of CT and MRI for diagnosing CVD in women. Special attention is paid to disparities in the underlying physiological and pathophysiological processes, clinical presentation, and the quality of care to provide a deep understanding of the topic. Cardiovascular and cardiac pathologies with a sex-specific pattern of disease are presented and typical CT and MRI findings are arranged and illustrated with imaging findings.

RESULTS AND CONCLUSION

 Sex-specific differences are not only sex hormonal in nature but are rooted in the epigenome and encompass a multitude of physiological systems. In fact, cardiovascular disease shows sex-specific characteristics spanning from incidence to clinical presentation, course of disease, and prognosis. This is of significance regarding pretest probabilities, the power of tests, imaging strategies, and interpretation of imaging results. Key sex-specific issues encompass obstructive and non-obstructive coronary artery disease (CAD), microvascular angina, myocardial infarction with non-obstructive CAD, and coronary artery dissection. Sex-specific patterns are also noted in myocardial disease and heart failure such as pregnancy-related heart disease, Takotsubo syndrome, and anthracycline-induced cardiotoxicity.

KEY POINTS

  · Cardiovascular diseases have sex-specific characteristics.. · Imaging strategies and interpretation of imaging results should be adjusted for women.. · Imaging helps in the improvement of the sex-specific management of cardiovascular disease..

Unraveling Pathophysiology of Takotsubo Syndrome: The Emerging Role of the Oxidative Stress's Systemic Status

Takotsubo Syndrome (TTS) is usually triggered by emotional or physical stressors, thus suggesting that an increased sympathetic activity, leading to myocardial perfusion abnormalities and ventricular dysfunction, plays a major pathogenetic role. However, it remains to be elucidated why severe emotional and physical stress might trigger TTS in certain individuals but not others. Clinical research has been focused mainly on mechanisms underlying the activation of the sympathetic nervous system and the occurrence of myocardial ischemia in TTS. However, scientific evidence shows that additional factors might play a pathophysiologic role in the condition's occurrence. In this regard, a significant contribution arrived from metabolomics studies that followed the systemic response to TTS. Specifically, preliminary data clearly show that there is an interplay between inflammation, genetics, and oxidative status which might explain susceptibility to the condition. This review aims to sum up the established pathogenetic factors underlying TTS and to appraise emerging mechanisms, with particular emphasis on oxidative status, which might better explain susceptibility to the condition.

Cardiac MRI in patients with COVID-19 infection

Objective

COVID-19 infection is a systemic disease with various cardiovascular symptoms and complications. Cardiac MRI with late gadolinium enhancement is the modality of choice for the assessment of myocardial involvement. T1 and T2 mapping can increase diagnostic accuracy and improve further management. Our study aimed to evaluate the different aspects of myocardial damage in cases of COVID-19 infection using cardiac MRI.

Methods

This descriptive retrospective study included 86 cases, with a history of COVID-19 infection confirmed by positive RT-PCR, who met the inclusion criteria. Patients had progressive chest pain or dyspnoea with a suspected underlying cardiac cause, either by an abnormal electrocardiogram or elevated troponin levels. Cardiac MRI was performed with late contrast-enhanced (LGE) imaging, followed by T1 and T2 mapping.

Results

Twenty-four patients have elevated hsTnT with a median hsTnT value of 133 ng/L (IQR: 102 to 159 ng/L); normal value < 14 ng/L. Other sixty-two patients showed elevated hsTnI with a median hsTnI value of 1637 ng/L (IQR: 1340 to 2540 ng/L); normal value < 40 ng/L. CMR showed 52 patients with acute myocarditis, 23 with Takotsubo cardiomyopathy, and 11 with myocardial infarction. Invasive coronary angiography was performed only in selected patients.

Conclusion

Different COVID-19-related cardiac injuries may cause similar clinical symptoms. Cardiac MRI is the modality of choice to differentiate between the different types of myocardial injury such as Takotsubo cardiomyopathy and infection-related cardiomyopathy or even acute coronary syndrome secondary to vasculitis or oxygen-demand mismatch.

Key Points

• It is essential to detect early COVID-related cardiac injury using different cardiac biomarkers and cardiac imaging, as it has a significant impact on patient management and outcome.

• Cardiac MRI is the modality of choice to differentiate between the different aspects of COVID-related myocardial injury.

The Role of Stress in Stable Patients with Takotsubo Syndrome-Does the Trigger Matter?

BACKGROUND

Takotsubo syndrome (TTS) is a unique type of reversible cardiomyopathy that predominantly affects elderly women. The role of physical and emotional stress in the pathophysiology of TTS is well established. However, the association between preceding emotional triggers and clinical outcomes in stable patients has not yet been fully investigated. We aimed to investigate the association between emotional triggers before symptom onset and clinical outcomes in stable patients with TTS.

METHODS

This is a retrospective cohort study based on the data of patients with ICD-9 discharge diagnosis of TTS between 2017 and 2022. Patients were divided into two groups: with and without obvious emotional trigger before symptom onset. Demographic, laboratory, echocardiographic, and clinical outcomes were obtained and compared between the two groups.

RESULTS

We included 86 patients (93% were women, mean age 68.8 ± 12.3 years). Of them, 64 (74.4%) reported an emotional trigger before symptom onset. Patients with a previous emotional trigger had a longer hospital stay (4.3 + 2.0 days vs. 3.0 + 1.4, p = 0.002) with no difference in in-hospital complications (32.8% vs. 13.6%, p = 0.069), with no difference in 30-day mortality, readmissions, or recurrence rate between the groups.

CONCLUSIONS

Patients with TTS related to an emotional trigger may represent a different population from patients without a preceding trigger by having more symptomatic disease and longer hospital stay, yet with no difference in the 30-day outcomes.

Incremental prognostic value of global longitudinal strain to the coronary microvascular resistances in Takotsubo patients

BACKGROUND

Global longitudinal strain (GLS) allows an accurate assessment of left ventricular function with prognostic value. We aimed to evaluate whether the assessment of GLS in the acute phase of Takotsubo syndrome (TTS) provides incremental prognostic value to the degree of impaired microvascular resistance (MR) in TTS patients at 1-year follow-up.

METHODS

We recruited patients admitted for TTS who underwent cardiac angiography and echocardiography from January 2017 to June 2020. Left anterior descending coronary artery non-hyperaemic angiography-derived index of microcirculatory resistance (LAD NH-IMRangio) was calculated. NT-proBNP, high-sensitive cardiac troponin T (hs-cTnT), left ventricular ejection fraction (LVEF) and GLS were measured at admission. Major adverse cardiac events (MACE) were defined as the composite of cardiovascular death, repeat hospitalizations for heart failure (HF) and acute myocardial infarctions.

RESULTS

67 patients had both GLS and NH-IMRangio available and were included in the study. Median age was 75.2 years and 88% were women. Rate of MACE at 1-year was 13.4%. Kaplan-Meier curves showed higher rates of MACE at 1-year in patients with both higher LAD NH-IMRangio and GLS values compared with those with higher LAD NH-IMRangio and lower GLS values (33.3% vs. 11.1%; p = 0.049). NT-proBNP levels at admission and the recovery of LVEF were correlated with GLS values while MR and hs-cTnT were not.

CONCLUSION

GLS provides incremental prognostic value to the degree of impaired MR in TTS patients. The combination of a poorer GLS with a higher degree of impaired MR was associated with a higher rate of MACE in these patients.

Takotsubo Cardiomyopathy and β-Blocker Poisoning: A Case Report

β-blocker poisoning is frequently observed because of its primary use for the treatment of cardiovascular diseases. The management of β-blocker toxicity is dependent on the cardiovascular response and the severity of presentation. The present study describes the case of a patient with combined drug intoxication, β-blocker, digoxin, benzodiazepines, acetaminophen and opiates in a suicidal attempt. A 63-year-old female was found somnolent and in a confused state at her residence following intentional poly-drug ingestion. Upon presentation, she was found to be hemodynamically unstable and was thus treated with vasopressors. The toxicological screening performed upon presentation was positive for polydrug ingestion. On day 3, the patient developed chest pain and ST-segment elevation in anterior leads, while transthoracic echocardiographic assessment disclosed a non-dilated left ventricle with moderate dysfunction and akinesia of the apex. Coronary angiogram revealed normal coronary arteries and, subsequently, the diagnosis of Takotsubo cardiomyopathy (TTC) was suspected. Supportive treatment was initiated with favorable evolution and left ventricular ejection fraction normalization. The management of hemodynamic instability with vasopressors should be judiciously administered in the treatment of β-blocker poisoning, in view of the adverse effects on cardiac functions, including stress cardiomyopathy.

Takotsubo Cardiomyopathy in the Setting of Myxedema Coma

Myxedema coma and its treatment are potent physical stressors that likely predispose patients to develop Takotsubo cardiomyopathy (TCM). We postulate a multifactorial pathophysiology for TCM that includes a mechanism involving catecholamine-induced potentiation of cardiac adrenoreceptors during thyroid hormone replacement in the setting of severe hypothyroidism. Furthermore, TCM can be difficult to anticipate when presenting as a complication of another diagnosis. In this case report, we aim to improve awareness of TCM as a consequence of extreme hypothyroid states.

Takotsubo syndrome: A current review of presentation, diagnosis, and management

Takotsubo syndrome is a syndrome of acute heart failure due to left ventricular systolic dysfunction that is associated with increased cardiovascular morbidity and mortality. It occurs in both sexes and at all ages, but predominates in post-menopausal women for reasons that are unclear. In a patient who presents with cardiac symptoms, electrocardiographic changes, and/or biomarker elevation indicating myocardial stress (i.e. troponin elevation), this condition should be considered in the differential diagnosis. Cardiac imaging is critical for a timely diagnosis of this condition and has management implications. This syndrome can occur with or without underlying coronary artery disease, and while there are various characteristic myocardial patterns described on imaging, the most common one is left ventricular dysfunction due to apical stunning with basal hyperkinesis. In the acute phase, Takotsubo syndrome can lead to life-threatening sequelae, including cardiogenic shock, pulmonary edema, thromboembolism, and arrhythmias. Multiple pathophysiologic mechanisms are implicated, including an acute increase in left ventricular afterload in the setting of sympathetic activation with a catecholamine storm, multi-vessel coronary vasospasm, coronary endothelial microvascular dysfunction, and inflammation. In this review, we discuss the current knowledge surrounding presentation, diagnosis, and treatment of this under-diagnosed condition.

Metabolic remodeling in takotsubo syndrome

The heart requires a large and constant supply of energy that is mainly the result of an efficient metabolic machinery that converges on mitochondrial oxidative metabolism to maintain its continuous mechanical work. Perturbations in these metabolic processes may therefore affect energy generation and contractile function directly. Metabolism characteristics in takotsubo syndrome (TTS) reveals several metabolic alterations called metabolic remodeling, including the hyperactivity of sympathetic metabolism, derangements of substrate utilization, effector subcellular dysfunction and systemic metabolic disorders, ultimately contributing to the progression of the disease and the development of a persistent and long-term heart failure (HF) phenotype. In this review, we explore the current literature investigating the pathological metabolic alterations in TTS. Although the metabolic dysfunction in takotsubo hearts is initially recognized as a myocardial metabolic inflexibility, we suggest that the widespread alterations of systemic metabolism with complex interplay between the heart and peripheral tissues rather than just cardiometabolic disorders per se account for long-term maladaptive metabolic, functional and structural impairment under this condition. Therapeutic strategies with the recent evidence from small clinical and animal researches, especially for targeting substrate utilization and/or oxidative stress, might be promising tools to improve the outcome of patients with TTS beyond that achieved with traditional sympathetic inhibition and symptomatic therapies.

Recurrent Takotsubo syndrome: case report and literature review

Abstract Introduction: Takotsubo syndrome is a cardiomyopathy that can lead to severe myocardial involvement. It is characterized by the presence of signs and symptoms suggestive of ventricular dysfunction associated with an adrenergic discharge during a stressful event. This case report presents a literature review, as well as a comparison with other similar cases. Case presentation. A 56-year-old female with a previous episode of Takotsubo was admitted to the emergency department due to symptoms of acute coronary syndrome and a history of Takotsubo syndrome. Her electrocardiogram showed T-wave inversion in leads V1-V4 and a raise in troponins. Percutaneous coronary angiography revealed no coronary lesions, and an echocardiogram revealed segmental alterations compatible with Takotsubo syndrome, requiring medical therapy with beta-blockers and angiotensin-converting enzyme (ACE) inhibitors, with subsequent improvement in ventricular function. Conclusions. Recurrence in Takotsubo cardiomyopathy is a rare complication that should be suspected. The risk factors associated with recurrence are not known. Although therapy with ACE inhibitors and beta-blockers seems to have an impact on the recovery of ventricular function in patients with this condition, further studies are necessary to establish the best pharmacological treatment.

De novo ulcerative colitis and Takotsubo cardiomyopathy following sleeve gastrectomy

The increasing prevalence of severe obesity is a major public health concern. Bariatric surgery is an important treatment option for severe obesity due to its long-term sustained result. Multiple studies have shown that patients have an increased risk of developing inflammatory bowel disease following bariatric surgery. Takotsubo syndrome usually presents as acute left ventricular systolic dysfunction without corresponding obstructive coronary artery disease after an acute stress episode. We describe a unique case of a patient who developed de novo ulcerative colitis and takotsubo cardiomyopathy shortly after sleeve gastrectomy. The patient made a successful recovery due to prompt recognition and appropriate treatment.

Bibliometric and visual analysis of coronary microvascular dysfunction

Background

Coronary microvascular dysfunction (CMD) may play an important role in various cardiovascular diseases, including HFpEF and both obstructive and non-obstructive coronary artery disease (CAD). To date, there has been no bibliometric analysis to summarize this field. Here, we aim to conduct a bibliometric analysis of CMD to determine the current status and frontiers in this field.

Materials and methods

Publications about CMD were taken from the Web of Science Core Collection database (WOSCC). WOSCC's literature analysis wire, the VOSviewer 1.6.16, and CiteSpace 5.1.3 were used to conduct the analysis.

Results

A total of 785 publications containing 206 reviews and 579 articles are included in the sample. The leading authors are Iacopo Olivotto, Paolo G. Camici, and Carl J. Pepine. The most productive institutions are the University of Florence, Cedars Sinai Medical Center, and Harvard University. The most productive countries are the USA, Italy, and England. There are a total of 237 journals that contribute to this field, and the leading journals in our study were the International Journal of Cardiology, the European Heart Journal and the JACC. From 2012 to 2021, the top three most-cited articles focused on the association between HFpEF and CMD. The important keywords are heart failure, hypertrophic cardiomyopathy, chest pain, women, coronary flow reserve (CFR), endothelial dysfunction and prognostic value. "Positron emission tomography" shows the strongest burst strength, followed by "blow flow" and "artery." The keywords that started to burst from 2015 are particularly emphasized, including "heart failure," "coronary flow reserve," and "management."

Conclusion

Studies about CMD are relatively limited, and the largest contribution comes from the USA, Italy and England. More studies are needed, and publications from other countries should be enhanced. The main research hotspots in the CMD field include CMD in patients with HFpEF, sex differences, the new methods of diagnosis for CMD, and the effective treatment of CMD. Attention should be given to CMD in patients with HFpEF, and untangling the association between CMD and HFpEF could be helpful in the development of physiology-stratified treatment for patients with CMD and HFpEF.

Is Takotsubo cardiomyopathy still looking for its own nosological identity?

Despite several efforts to provide a proper nosological framework for Takotsubo cardiomyopathy (TCM), this remains an unresolved matter in clinical practice. Several clinical, pathophysiologic and histologic findings support the conceivable hypothesis that TCM could be defined as a unique pathologic entity, rather than a distinct subset of myocardial infarction with non-obstructive coronary arteries. Further investigations are needed in order to define TCM with the most appropriate disease taxonomy.