Stress Cardiomyopathy Diagnosis and Treatment: JACC State-of-the-Art Review

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.

Case report: Takotsubo syndrome induced by severe hypoglycemia

Background

Takotsubo syndrome (TTS) is a disorder frequently characterized by transient dysfunction of the apical portion of the left ventricle with hyperkinesis in other parts of the heart walls. TTS is also called stress cardiomyopathy because it is known to be triggered by emotional or physical stress. We report a case of TTS associated with severe hypoglycemia.

Case summary

An 85-year-old female patient with a history of non-insulin-dependent diabetes mellitus and hypertension presented to the emergency department with hypoglycemia-induced unconsciousness. The patient regained consciousness after an intravenous glucose injection. The patient complained of chest discomfort after the correction of hypoglycemia. Electrocardiography (ECG) revealed ST-segment elevation in leads V2-V5, therefore, ST-segment elevation myocardial infarction was highly suspected. Echocardiography showed impaired left ventricular systolic function with an ejection fraction of 40% accompanied by hypokinesis of the apex. Percutaneous coronary angiography showed 30% stenosis of the left anterior descending coronary artery. Left ventricular angiography revealed apical dyskinesia, which is typical of the classic apical ballooning shape of takotsubo. The patient was diagnosed with TTS and managed with pharmacological therapy, including antiplatelet (i.e., aspirin), lipid-lowering, anti-heart failure, and hypoglycemic drugs. The patient was successfully discharged in a stable condition.

Conclusion

This is a representative case of TTS caused by hypoglycemia. Due to the self-limiting nature of TTS, diagnoses can be missed among hypoglycemic patients. Thus, echocardiography is required for patients with hypoglycemia to ensure an accurate TTS diagnosis in the emergency department.

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.

Cardiotoxicity Induced by Immune Checkpoint Inhibitors: What a Cardio-Oncology Team Should Know and Do

Immune checkpoint inhibitors (ICIs) have revolutionized the therapeutic scenario for several malignancies. However, they can be responsible for immune-related adverse events (irAEs), involving several organs, with a pooled incidence ranging between 54% and 76%. The frequency of cardiovascular system involvement is <1%. Among the cardiovascular irAEs, myocarditis is the most common and the most dangerous but other, less common manifestations of ICI-related cardiotoxicity include pericardial disease, arrhythmias, Takotsubo-like syndrome, and acute myocardial infarction, all of which remain poorly explored. Both oncologists and cardiologists, as well as the patients, should be aware of the possible occurrence of one or more of these complications, which in some cases are fatal, in order to implement effective strategies of cardiac surveillance. In this review, we summarize the latest studies and recommendations on the pathogenesis, clinical manifestation, diagnosis, and management of ICI-related cardiotoxicity in order to realize a complete and updated overview on the main aspects of ICI-related cardiotoxicity, from surveillance to diagnosis to management, useful for both oncologists and cardiologists in their clinical practice. In particular, in the first part of the review, we realize a description of the pathogenetic mechanisms and risk factors of the main cardiovascular irAEs. Then, we focus on the management of ICI-related cardiotoxicity by analyzing five main points: (1) identifying and evaluating the type and severity of the cardiotoxicity; (2) deciding whether to withhold ICI therapy; (3) initiating steroid and immunosuppressive therapy; (4) starting conventional cardiac treatment; and (5) restarting ICI therapy. Finally, we discuss the existing evidence on surveillance for ICI-related cardiotoxicity and propose a surveillance strategy for both short- and long-term cardiotoxicity, according to the most recent guidelines.

Myocardial infarction with nonobstructive coronary arteries: the need for precision medicine

PURPOSE OF REVIEW

Myocardial infarction with nonobstructive coronary arteries (MINOCA) represents about 6-8% of all patients with myocardial infarction (MI), and several pathophysiological mechanisms showed to be involved in this heterogeneous clinical condition. Of note, MINOCA proved to be associated with a significant risk of mortality, angina burden and socioeconomic costs.

RECENT FINDINGS

Results from randomized clinical trials evaluating the clinical effectiveness of a comprehensive diagnostic algorithm, along with the acute and long-term management of patients with MINOCA, are pending.

SUMMARY

In this review article, we aim at providing an overview of the clinical features, diagnostic work-up and the therapeutic management of patients presenting with MINOCA, highlighting the recent acquisition along with the remaining important knowledge gaps in this field.

Cannabis and the heart: unchartered territory

Cannabis is one of the most commonly used illicit drugs. It is a psychoactive drug with tetrahydrocannabinol being the main active ingredient. With increasing decriminalization and legalization of marijuana use in the USA, it is essential to study its long-term effects on cardiovascular diseases, a leading cause of death in the USA. Cannabis can trigger acute myocardial infarction in otherwise healthy young individuals, affect atherogenesis, arrhythmia, develop Takotsubo cardiomyopathy and cannabis arteritis. The only definitive treatment for these pathologies is complete abstinence. In this review we focus on discussing the long-term effects of tetrahydrocannabinol on cardiovascular pathologies, its pathophysiology and a brief discussion on its clinical features and definitive management.

Takotsubo cardiomyopathy triggered by a single dose of flecainide in patient with focal atrial tachycardia

First described in 1990, Takotsubo cardiomyopathy (TC) is a medical condition defined by acute and transient left ventricular (LV) dysfunction with a diversity of wall-motion abnormalities. TC can be induced by emotional and physical stress, as well as direct administration of catecholamines or medications which can cause a catecholamine surge. Although recorded incidences of TC have been rising over the last decade (currently 15-30 cases per 100,000 per year), this is most likely due to increased awareness and recognition of the condition. Electrocardiogram (ECG), imaging modalities such as echocardiography, coronary computed tomography angiography, cardiac magnetic resonance, and coronary angiography are important tools in the diagnosis of TC. The in-hospital mortality rate for patients admitted with TC reaches 5%. In our report, we describe a case of TC in a 30-years old female with a medical history of episodes of focal atrial tachycardia (AT) after intravenous administration of a single, maximum dose of flecainide.

[MINOCA-myocardial infarction with nonobstructive coronary arteries]

BACKGROUND

Myocardial infarction with nonobstructive coronary arteries (MINOCA) accounts for 5-10% of all presentations of acute myocardial infarction.

OBJECTIVES

To outline the role of cardiovascular magnetic resonance (CMR) in patients with suspected MINOCA.

MATERIALS AND METHODS

Current guidelines for the use of CMR in suspected MINOCA are summarized. Clinical cases with typical CMR findings are presented.

RESULTS

In 2019, the American Heart Association published a revised definition of the term MINOCA, which was recently adopted in the European Society of Cardiology 2020 guidelines on acute coronary syndromes without persistent ST-segment elevation (NSTE-ACS). The guidelines indicate that a CMR is recommended (class 1B) in all MINOCA cases with no obvious cause.

CONCLUSION

The major strength of CMR imaging is to differentiate nonischemic from ischemic etiologies of myocardial injury. This makes CMR the most important noninvasive diagnostic tool for the differential diagnosis of patients with suspected MINOCA.

Takotsubo cardiomyopathy in a female presenting with status asthmaticus: a case report and review of literature

Background

Takotsubo cardiomyopathy (TCM) is a non-ischemic syndrome characterized by transient acute left ventricular dysfunction as evident on transthoracic echocardiography. It can often mimic myocardial ischemia and is characterized by the absence of angiographic evidence of obstructive coronary artery disease. Reports of Takotsubo syndrome in elderly with asthma exacerbations have been noted.

Case presentation

We describe a case of TCM in a 68-year-old female who presented with acute shortness of breath secondary to status asthmaticus. Her electrocardiogram showed ST segment elevations in multiple coronary artery distributions and mildly elevated troponin levels. Coronary angiography showed no significant stenosis of the coronary arteries with left ventriculography that showed systolic apical ballooning with a 10% ejection fraction, consistent with TCM.

Conclusions

Takotsubo syndrome should be considered in the differential diagnosis of patients presenting with status asthmaticus and elevated troponin levels on admission. Patients should be asked about the use of beta agonist prior to admission. A thorough literature review including a summary of 11 previously published case reports of TCM with acute asthma exacerbations has been presented.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43044-022-00310-9.

A Rare Case of Iatrogenic Inverted Stress Cardiomyopathy

We discuss a case of a 42-year-old female who was admitted for chronic intractable lower back pain requiring elective spinal surgery. Postoperatively, she experienced chest pressure and abdominal pain with a notable elevation in cardiac markers. A cardiac catheterization and left ventriculogram revealed normal coronary arteries and basal anterolateral hypokinesis, with the normal movement of the distal segment of the anterior wall. A rare variant of stress cardiomyopathy was diagnosed.

MINOCA: One Size Fits All? Probably Not—A Review of Etiology, Investigation, and Treatment

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous group of conditions that include both atherosclerotic (coronary plaque disruption) and non-atherosclerotic (spontaneous coronary artery dissection, coronary artery spasm, coronary artery embolism, coronary microvascular dysfunction, and supply–demand mismatch) causes resulting in myocardial damage that is not due to obstructive coronary artery disease. Failure to identify the underlying cause may result in inadequate and inappropriate therapy in these patients. The cornerstone of managing MINOCA patients is to identify the underlying mechanism to achieve the target treatment. Intravascular imaging is able to identify different morphologic features of coronary plaques, while cardiac magnetic resonance is the gold standard for detection of myocardial infarction in the setting of MINOCA. In this review, we summarize the relevant clinical issues, contemporary diagnosis, and treatment options of MINOCA.

Spontaneous subarachnoid haemorrhage

Subarachnoid haemorrhage (SAH) is the third most common subtype of stroke. Incidence has decreased over past decades, possibly in part related to lifestyle changes such as smoking cessation and management of hypertension. Approximately a quarter of patients with SAH die before hospital admission; overall outcomes are improved in those admitted to hospital, but with elevated risk of long-term neuropsychiatric sequelae such as depression. The disease continues to have a major public health impact as the mean age of onset is in the mid-fifties, leading to many years of reduced quality of life. The clinical presentation varies, but severe, sudden onset of headache is the most common symptom, variably associated with meningismus, transient or prolonged unconsciousness, and focal neurological deficits including cranial nerve palsies and paresis. Diagnosis is made by CT scan of the head possibly followed by lumbar puncture. Aneurysms are commonly the underlying vascular cause of spontaneous SAH and are diagnosed by angiography. Emergent therapeutic interventions are focused on decreasing the risk of rebleeding (ie, preventing hypertension and correcting coagulopathies) and, most crucially, early aneurysm treatment using coil embolisation or clipping. Management of the disease is best delivered in specialised intensive care units and high-volume centres by a multidisciplinary team. Increasingly, early brain injury presenting as global cerebral oedema is recognised as a potential treatment target but, currently, disease management is largely focused on addressing secondary complications such as hydrocephalus, delayed cerebral ischaemia related to microvascular dysfunction and large vessel vasospasm, and medical complications such as stunned myocardium and hospital acquired infections.

Neutrophile-Lymphocyte Ratio and Outcome in Takotsubo Syndrome

Background: Takotsubo syndrome (TTS) is an important type of acute heart failure with significant risk of acute complications and death. In this analysis we sought to identify predictors for in-hospital clinical outcome in TTS patients and present long-term outcomes. Methods: In this analysis from the Austrian national TTS registry, univariable and multivariable analyses were performed to identify significant predictors for severe in-hospital complications requiring immediate invasive treatment or leading to irreversible damage, such as cardiogenic shock, intubation, stroke, arrhythmias and death. Furthermore, the influence of independent predictors on long-term survival was evaluated. Results: A total of 338 patients (median age 72 years, 86.9% female) from six centers were included. Severe in-hospital complications occurred in 14.5% of patients. In multivariable analysis, high neutrophile-lymphocyte-ratio (NLR; OR 1.04 [95% CI 1.02−1.07], p = 0.009) and low LVEF (OR 0.92 [0.90−0.95] per %, p < 0.001) were significant predictors of severe in-hospital complications. Both the highest NLR tercile and the lowest LVEF tercile were significantly associated with reduced 5-year survival. Conclusions: Low LVEF and high NLR at admission were independently associated with increased in-hospital complications and reduced long-term survival in TTS patients. NLR is a new easy-to-measure tool to predict worse short- and long-term outcome after TTS.

Reverse Takutsubo Cardiomyopathy in a Patient with Phlegmasia Cerulea Dolens

Reverse takotsubo cardiomyopathy (rTTC) is a rare variant of takotsubo cardiomyopathy (TTC) which is characterized by reversible left ventricular (LV) dysfunction. Emotional and physical stress have been implicated in triggering TTC especially in postmenopausal women. TTC and its variants are becoming more recognized due to the widespread adoption of early coronary angiography in the setting of acute coronary syndromes. A man in his late 50s presented to the emergency department with left lower extremity pain, swelling, and cyanosis. Clinical assessment was consistent with phlegmasia cerulea dolens, with deep venous thrombosis detected by venous duplex ultrasound. During his admission, he developed clinical and EKG findings suggestive of acute coronary syndrome. Emergent coronary angiography and ventriculography revealed basal and midventricular hypokinesis with hyperdynamic left ventricular apex, depressed LV dysfunction without coronary artery obstruction diagnostic of reverse takotsubo cardiomyopathy. Venous thromboembolism is a rare finding but has been associated with takotsubo cardiomyopathy and should be considered in the appropriate setting.

Takotsubo syndrome in COVID-19: a case series study

BACKGROUND

Takotsubo syndrome is a clinical syndrome characterized by an acute and transient left ventricular systolic dysfunction related to an emotional or physical stressful event.

CASE PRESENTATION

During the Covid-19 pandemic, five cases of Takotsubo syndrome in hospitalized, mechanically ventilated patients due critical SARS-CoV-2 infection have been identified at our institution. Here we present the electrocardiographic, echocardiographic and angiographic characteristics of this case series. All cases were initially suspected by echocardiography performed due an abnormal electrocardiogram, troponin elevation or clinical deterioration.

CONCLUSION

A high index of suspicion should be sought to identify Takotsubo syndrome and other cardiac complications associated with SARS-CoV-2 infection.

Psychological Stress and Heart Disease: Fact or Folklore?

For at least a few centuries, if not millennia, psychological stress has been popularly believed to contribute to heart disease. Does psychological stress really contribute to heart disease? Are anecdotal, patient, and lay press reports that angina, heart attack, and even cardiac death are caused by stress based on fact, or are they just folklore? In this review, the study data supporting associations between stress and cardiovascular risk, as well as potential mechanisms by which psychological stress might contribute to heart disease and precipitate myocardial ischemia and infarction, are critically reviewed and summarized.

Spectrum of radionuclide perfusion study abnormalities in takotsubo cardiomyopathy

BACKGROUND

Takotsubo (stress) cardiomyopathy (TCM) is characterized by transient apical left ventricular dysfunction precipitated by emotional or physical stress. Its presentation makes it difficult to differentiate from an acute coronary syndrome. A suggestive echocardiogram plus normal coronary angiography most often are used for diagnosis. Radionuclide perfusion study (RPS) findings in TCM, including by positron emission tomography (PET), have been poorly characterized.

METHODS AND RESULTS

Intermountain Healthcare electronic medical records were searched from 2009 to 2019 for patients with a discharge diagnosis of TCM, stress CM, or takotsubo syndrome. 16 TCM patients with an RPS, including by PET in 8, were identified: 13 (81%) were women; age averaged 72 years (50-89 years); 14 had an identified stressor. TCM diagnosis was definite in 11 and probable/possible in 5. RPS was abnormal in 11, with 9 showing an apical perfusion deficit, whereas angiography in 14 showed normal coronaries in 12 and non-obstructive disease in 2. Echo ejection fraction averaged 41% (29%-60%); an apical wall motion abnormality was present in 14 (88%). Troponin elevations were noted in 14/15. The presenting ECG was abnormal is 14, frequently showing ST-T-wave abnormalities. 13 patients were discharged on a beta-blocker. Follow-up echo (in 12) showed recovered ejection fraction in 9 and recovered apical wall motion in 11.

CONCLUSIONS

Despite having normal or non-obstructive epicardial coronary arteries on angiography, TCM patients frequently present with apical wall motion abnormalities and matching RPS perfusion defects. These findings suggest microvascular abnormalities, whose pathophysiology, temporal course, and clinical implications should be the subject of further investigation.

Gender Differences in Takotsubo Syndrome

BACKGROUND

Male sex in takotsubo syndrome (TTS) has a low incidence and it is still not well characterized.

OBJECTIVES

The aim of the present study is to describe TTS sex differences.

METHODS

TTS patients enrolled in the international multicenter GEIST (GErman Italian Spanish Takotsubo) registry were analyzed. Comparisons between sexes were performed within the overall cohort and using an adjusted analysis with 1:1 propensity score matching for age, comorbidities, and kind of trigger.

RESULTS

In total, 286 (11%) of 2,492 TTS patients were men. Male patients were younger (age 69 ± 13 years vs 71 ± 11 years; P = 0.005), with higher prevalence of comorbid conditions (diabetes mellitus 25% vs 19%; P = 0.01; pulmonary diseases 21% vs 15%; P = 0.006; malignancies 25% vs 13%; P < 0.001) and physical trigger (55 vs 32% P < 0.01). Propensity-score matching yielded 207 patients from each group. After 1:1 propensity matching, male patients had higher rates of cardiogenic shock and in-hospital mortality (16% vs 6% and 8% vs 3%, respectively; both P < 0.05). Long-term mortality rate was 4.3% per patient-year (men 10%, women 3.8%). Survival analysis showed higher mortality rate in men during the acute phase in both cohorts (overall: P < 0.001; matched: P = 0.001); mortality rate after 60 days was higher in men in the overall (P = 0.002) but not in the matched cohort (P = 0.541). Within the overall population, male sex remained independently associated with both in-hospital (OR: 2.26; 95% CI: 1.16-4.40) and long-term mortality (HR: 1.83; 95% CI: 1.32-2.52).

CONCLUSIONS

Male TTS is featured by a distinct high-risk phenotype requiring close in-hospital monitoring and long-term follow-up.

Takotsubo cardiomyopathy in the setting of thyroid storm

A woman in her 50s with a background of chronic obstructive pulmonary disease secondary to smoking presented with intermittent chest tightness, dyspnoea and vomiting for 4 days. A presumed diagnosis of acute coronary syndrome (ACS) was made based on dynamic ischaemic ECG changes and elevation in high-sensitivity cardiac troponin T levels. She underwent emergent coronary angiography which demonstrated mild coronary artery disease with left ventriculography suggestive of mid-wall variant Takotsubo cardiomyopathy. Thyroid function tests performed to investigate sinus tachycardia were consistent with hyperthyroidism, and her thyroid-stimulating hormone receptor antibody was elevated. A diagnosis of thyroid storm was made in the setting of a newly diagnosed Graves’ disease and the patient was subsequently commenced on guideline-based therapy. This case demonstrates that Takotsubo cardiomyopathy, a mimic of ACS, is a possible complication of thyroid storm and therefore hyperthyroidism should be considered in the list of differentials in patients presenting with Takotsubo cardiomyopathy.

Arrhythmias and Their Electrophysiological Mechanisms in Takotsubo Syndrome: A Narrative Review

BACKGROUND

Takotsubo syndrome (TTS), an acute and usually reversible condition, is associated with both tachy- and bradyarrhythmias. Such arrhythmias can be life-threatening, e.g. ventricular tachycardia and fibrillation, and associated with cardiac arrest. Others, such as atrioventricular block, persist and require long-term device therapy. In this narrative review, we aim to provide a summary of the current literature on arrhythmias in TTS and their clinical sequelae.

METHODS

PubMed and Medline databases were searched with various permutations of TTS, arrhythmias and beta-adrenoceptors. After application of exclusion criteria and review, 84 articles were included.

RESULTS

Although there are no specific electrocardiograph (ECG) findings in TTS to differentiate it from ST-elevation myocardial infarction, suggestive patterns include small QRS amplitude, ST segment elevation without reciprocal ST depression and prolonged QT interval. Atrial tachyarrhythmias (incidence of 5-15%) are associated with a more unwell patient cohort. Ventricular arrhythmias (incidence 4-14%) are often associated with prolonged QT interval and are a cause of sudden death in TTS. Bradyarrhythmias are less common (incidence 1.3-2.5%), but have been reported with TTS, and usually persist beyond the acute phase.

CONCLUSIONS

Takotsubo syndrome, though considered primarily a disease of the myocardium, carries multiple arrhythmic manifestations that affect short- and long-term prognosis. The management of such arrhythmias represents a constantly evolving area of research.

Stress cardiomyopathy in critical care: A case series of 109 patients

BACKGROUND

Critically ill patients are at risk of developing stress cardiomyopathy (SC) but can be under-recognized.

AIM

To describe a case series of patients with SC admitted to critical care units.

METHODS

We conducted a retrospective observational study at a tertiary care teaching hospital. All adult (≥ 18 years old) patients admitted to the critical care units with stress cardiomyopathy over 5 years were included.

RESULTS

Of 24279 admissions to the critical care units [19139 to medical-surgical intensive care units (MSICUs) and 5140 in coronary care units (CCUs)], 109 patients with SC were identified. Sixty (55%) were admitted to the coronary care units (CCUs) and forty-nine (45%) to the medical-surgical units (MSICUs). The overall incidence of SC was 0.44%, incidence in CCU and MSICU was 1.16% and 0.25% respectively. Sixty-two (57%) had confirmed SC and underwent cardiac catheterization whereas 47 (43%) had clinical SC, and did not undergo cardiac catheterization. Forty-three (72%) patients in the CCUs were diagnosed with primary SC, whereas all (100%) patients in MSICUs developed secondary SC. Acute respiratory failure that required invasive mechanical ventilation and shock developed in twenty-nine (59%) MSICU patients. There were no statistically significant differences in intensive care unit (ICU) mortality, in-hospital mortality, use of inotropic or mechanical circulatory support based on type of unit or anatomical variant.

CONCLUSION

Stress cardiomyopathy can be under-recognized in the critical care setting. Intensivists should have a high index of suspicion for SC in patients who develop sudden or worsening unexplained hemodynamic instability, arrhythmias or respiratory failure in ICU.

Development and Validation of Predictive Model—HASBLAD Score—For Major Adverse Cardiovascular Events During Perioperative Period of Non-cardiac Surgery: A Single Center Experience in China

Background

Major adverse cardiovascular events (MACEs) represent a significant reason of morbidity and mortality in non-cardiac surgery during perioperative period. The prevention of perioperative MACEs has always been one of the hotspots in the research field. Current existing models have not been validated in Chinese population, and have become increasingly unable to adapt to current clinical needs.

Objectives

To establish and validate several simple bedside tools for predicting MACEs during perioperative period of non-cardiac surgery in Chinese hospitalized patients.

Design

We used a nested case-control study to establish our prediction models. A nomogram along with a risk score were developed using logistic regression analysis. An internal cohort was used to evaluate the performance of discrimination and calibration of these predictive models including the revised cardiac risk index (RCRI) score recommended by current guidelines.

Setting

Peking University Third Hospital between January 2010 and December 2020.

Patients

Two hundred and fifty three patients with MACEs and 1,012 patients without were included in the training set from January 2010 to December 2019 while 38,897 patients were included in the validation set from January 2020 and December 2020, of whom 112 patients had MACEs.

Main Outcome Measures

The MACEs included the composite outcomes of cardiac death, non-fatal myocardial infarction, non-fatal congestive cardiac failure or hemodynamically significant ventricular arrhythmia, and Takotsubo cardiomyopathy.

Results

Seven predictors, including Hemoglobin, CARDIAC diseases, Aspartate aminotransferase (AST), high Blood pressure, Leukocyte count, general Anesthesia, and Diabetes mellitus (HASBLAD), were selected in the final model. The nomogram and HASBLAD score all achieved satisfactory prediction performance in the training set (C statistic, 0.781 vs. 0.768) and the validation set (C statistic, 0.865 vs. 0.843). Good calibration was observed for the probability of MACEs in the training set and the validation set. The two predictive models both had excellent discrimination that performed better than RCRI in the validation set (C statistic, 0.660, P < 0.05 vs. nomogram and HASBLAD score).

Conclusion

The nomogram and HASBLAD score could be useful bedside tools for predicting perioperative MACEs of non-cardiac surgery in Chinese hospitalized patients.

Takotsubo cardiomyopathy after vaccination for coronavirus disease 2019 in a patient on maintenance hemodialysis

Coronavirus disease-2019 (COVID-19) has affected more than 220 million individuals since the global pandemic began. There is an urgent need for safe and effective vaccines, and vaccinations, such as mRNA vaccines, have been initiated worldwide. However, the adverse effects of these vaccines remain unclear. We herein present a case of an 80-year-old female on maintenance hemodialysis who developed takotsubo cardiomyopathy 4 days after receiving the first dose of the Pfizer-BioNTech COVID-19 vaccine. There was no obvious trigger for the onset of takotsubo cardiomyopathy other than the COVID-19 vaccination, which was the most significant event preceding her presentation. Echocardiograms obtained during her admission allowed us to monitor and show the recovery of left ventricular wall motion. We confirmed the diagnosis of takotsubo cardiomyopathy based on the findings, including transient left ventricular dysfunction, electrocardiographic abnormalities, an elevated troponin level, and the absence of occlusive coronary artery disease. In the present case, the vaccination may have triggered emotional or physical stress. Although difficulties are associated with proving the causal relationship in the present case, the temporal relationship between the vaccination and the onset of takotsubo cardiomyopathy is highly suggestive. The adverse effects associated with the vaccine are typical of COVID-19 vaccines administered to date, most of which are acceptable. Therefore, despite our experience of the present case, we still recommend the vaccination for COVID-19 because takotsubo cardiomyopathy induced by the COVID-19 vaccine is extremely rare and the prognosis of the patient was good. We herein present the first case of a patient on hemodialysis who developed takotsubo cardiomyopathy after receiving COVID-19 vaccination.

Outcomes in Takotsubo Syndrome Following Left Ventricular Ejection Fraction Improvement

Takotsubo syndrome (TTS) is evaluated by monitoring of left ventricular (LV) ejection fraction (LVEF); however, there are limited data to correlate echocardiographic findings with long-term outcomes. This study assessed clinical outcomes in patients with TTS and their association with echocardiographic parameters. Echocardiographic parameters at the time of diagnosis and on first follow-up were collected for 115 consecutive patients (58.5 ± 15.2 years, 74.8% women) diagnosed with TTS. The primary clinical end points were all-cause mortality and time to first readmission. Cox proportional hazard analysis was used to assess the association between echocardiographic parameters and clinical end points. Mean baseline LVEF and global longitudinal strain (GLS) were 37.1 ± 10.7% and -8.5 ± 3.4%, respectively. On follow-up echocardiogram at median of 14 days, LVEF and GLS improved to 58.7 ± 9.3% and -14.2 ± 4.0%, respectively. Most patients (83%) experienced normalization of LVEF (>50%), whereas only 20% had normalization of LV-GLS (<-18%). A total of 99 patients had clinical follow-up after the second echocardiogram with a median follow-up time of 1.3 years. Estimated Kaplan-Meier survival at 2 years was 80% (95% confidence interval 69% to 88%), and median time to readmission was 226 days. There was no significant association between any of the echocardiographic parameters (including LV end-diastolic diameter and baseline, follow-up, and differential LVEF and GLS) and our clinical end points. Zero deaths and only 10.4% of first readmissions were from cardiovascular causes. This suggests that although cardiology follow-up with repeat imaging is important after TTS, additional follow-up with noncardiology specialists is essential to improve outcomes.

Transplantation of umbilical cord blood-derived mesenchymal stem cells as therapy for adriamycin induced-cardiomyopathy

Umbilical cord blood-derived mesenchymal stem cells (UCBMSCs) have been reported to possess cardioprotective effects in diseases. However, its effects on cardiomyopathy remain unclear. This study aimed to the therapeutic effects of UCBMSC transplantation on adriamycin (ADR)-induced cardiomyopathy. UCBMSCs isolated from human UCB were identified by detecting surface markers (CD29, CD90, CD34, and CD45) using flow cytometry. The effect of UCBMSCs on left ventricular end-diastolic dimension (LVEDD), left ventricular systolic end-diastolic diameter (LVESD), left ventricular ejection fraction (LVEF), and left ventricular fraction shortening (LVFS) were determined by echocardiography. Histological changes were observed by HE and Masson staining. The serum levels of collagen-I (Col-I), brain natriuretic peptide (BNP), aspartate aminotransferase (AST), lactate dehydrogenase (LDH), creatine kinase (CK), CK-MB, interleukin (IL)-6, IL-10, and tumor necrosis factor alpha (TNF-α) were measured by corresponding kits. The protein levels of IL-6, IL-10, and TNF-α were measured by Western blotting. The isolated UCBMSCs manifested the positive expression of CD29 and CD90, and the negative expression of CD34 and CD45. UCBMSC transplantation significantly reduced LVEDD and LVESD, and increased LVEF and LVFS in ADR-induced cardiomyopathy model rats. Cardiac injury and high collagen deposition in model rats were alleviated by UCBMSC treatment. Moreover, UCBMSCs decreased the serum levels of Col-I, BNP, AST, LDH, CK, CK-MB, IL-6, IL-10, and TNF-α in model rats. Overall, UCBMSCs exert the therapeutic effects on ADR-induced cardiomyopathy through recovering the myocadiac function and alleviating the inflammatory response.

COVID-19 Induced Cardiomyopathy Successfully Treated with Tocilizumab

Background. Currently, the literature regarding the management of COVID-19 induced cardiomyopathy with reduced ejection fraction is limited. In this case report, we present the first documented case of COVID-19 induced myocardial stunning leading to severely reduced LV systolic function that was reversed by the administration of corticosteroids and tocilizumab. Case Summary. A 39-year-old female with well controlled systemic hypertension, tested positive for SARS-CoV-2 RNA and underwent self-isolation for 14 days. Patient presented to our facility a month later with one-week history of progressively worsening generalized body aches, chills, fever, watery diarrhea, nausea with associated mild dry nonproductive cough, shortness of breath and nonspecific chest pain. Initial labs demonstrated that she was COVID-19 positive, elevated troponin (4.295 ng/ml), and elevated BNP (2,291 pg/ml). Her initial Transthoracic echocardiography demonstrated an Left ventricular ejection fraction (LVEF) of 20-25% with apical akinesis. After administration of tocilizumab and corticosteroids, patient demonstrated interval improvement with LVEF improving to 50-55% within days. Her labs confirmed these findings with improved troponin (0.858 ng/ml) and BNP (209 pg/ml). Discussion. This case demonstrates that it can be safe and efficacious to use tocilizumab and corticosteroids in patients with COVID-19 induced cardiomyopathy. These finding suggest that cytokine storm is the predominant mechanism by which COVID-19 induced cardiomyopathy occurs. Additional studies are required to determine the role of corticosteroids and tocilizumab in management of this condition.

Takotsubo Syndrome in the Emergency Room - Diagnostic Challenges and Suggested Algorithm

Takotsubo syndrome is an important condition to consider among patients with acute chest pain in the emergency room. It often mimics acute coronary syndrome since chest pain and ECG changes are key features in both conditions. The hallmark of takotsubo syndrome is transient left ventricular dysfunction (characterized by apical ballooning) followed by complete echocardiographic recovery in most cases. Although most patients exhibit a benign course, lethal complications may occur. The use of hand-held point-of-care focused cardiac ultrasound may be helpful for early identification of takotsubo syndrome and distinguishing it from acute coronary syndrome and other cardiovascular emergencies. Emergency room physicians should be familiar with typical and atypical presentations of takotsubo syndrome and its key electrocardiographic changes. The approach in the emergency room should be based on a combination the clinical presentation, ECG, and handheld echocardiography device findings, rather than a single electrocardiographic algorithm.

Update of Takotsubo cardiomyopathy: Present experience and outlook for the future

Takotsubo cardiomyopathy (TTS) has become a recognised clinical entity since the Japanese scientist Sato first described it in 1990.

Despite an increasing number of confirmed cases, especially during the COVID-19 pandemic, its pathophysiology remains incompletely understood, and decision-making differs in the diagnosis and treatment. In addition, it is not evident whether a significant increase in TTS is due to better understanding among practitioners and widespread access to coronary angiography, or if it is a reflection of an actual increase in incidence.

We analysed a series of international research studies from 1990 to 2021. Beyond epidemiology and clinical presentation, we evaluated and summarised fundamental knowledge about various predisposing factors, with particular attention to the iatrogenic impact of certain drugs, namely antidepressants, chemotherapy, and antiarrhythmics.

Furthermore, we highlighted the main pathophysiological theories to date. In addition, based on published studies and clinical cases, we investigated the role of numerous diagnostic approaches in the differential diagnosis of TTS and identified predictors of TTS complications, such as cardiogenic shock, ventricular fibrillation, and left ventricular thrombi. Accordingly, we sought to propose a diagnostic algorithm and further treatment management of TTS under the presence of possible complications to help practitioners make more informed decisions, as the initial presentation continues to pose a challenge due to its close similarity to acute coronary syndrome with ST-elevation.

In conclusion, this article examines Takotsubo cardiomyopathy from different perspectives and, along with future systematic reviews and meta-analyses, can be of particular interest to practising cardiologists and researchers in developing clinical guidelines.

Cardioprotective Role of Estrogen in Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TC) is a rare, reversible cause of left ventricular wall motion abnormality (LVWMA) that mimics the presentation of acute myocardial infarction (AMI). TC is usually preceded by an emotional or physical stressor and appears to be more common in postmenopausal women. Various pathophysiological hypotheses of TC have been proposed, but the exact mechanism of action remains elusive. Elevated levels of catecholamines leading to cardiac dysfunction are the most prevalent hypothesis. The protective role of estrogen in the development of cardiomyopathies has been studied extensively. International Takotsubo Diagnostic Criteria (InterTAK) and Mayo clinic diagnostic criteria both have the stipulation stating prevalence of TC is higher in postmenopausal women which hints towards the protective role of estrogen in the development of TC. To review the protective role of estrogen in the mechanism of this novel pathology, we searched Pubmed and Google scholar for the relevant articles by using keywords such as: “takotsubo cardiomyopathy”, “apical ballooning”, “broken heart syndrome”, “stress cardiomyopathy”, “left ventricle wall motion abnormality”, “estrogen”, “estradiol” and “sex hormones”. Our research revealed that although the prevalence of TC is greater in postmenopausal women as compared to men, the prognosis is worse in men. It also revealed the involvement of multiple cellular pathways under the influence of estrogen that could explain the cardioprotective effect of estrogen. Most of the articles found were based on animal studies, thus, there is an emphasis on future human studies. However, we strongly suggest evaluating estrogen levels as part of the initial workup for any patient presenting with signs and symptoms of cardiac pathology.

Moving the Paradigm Forward for Prediction and Risk-Based Primary Prevention of Heart Failure in Special Populations

PURPOSE OF REVIEW

Heart failure (HF) treatment paradigms increasingly recognize the importance of primary prevention. This review explores factors that enhance HF risk, summarizes evidence supporting the pharmacologic primary prevention of HF, and notes barriers to the implementation of primary prevention of HF with a focus on female and sexual and gender minority patients.

RECENT FINDINGS

HF has pathophysiologic sex-specific distinctions, suggesting that sex-specific preventive strategies may be beneficial. Pharmacologic agents that have shown benefit in reducing the risk of HF address the pathobiology underpinning these sex-specific risk factors. The implementation of pharmacologic therapies for primary prevention of HF needs to consider a risk-based model. Current pharmacotherapies hold mechanistic promise for the primary prevention of HF in females and gender and sexual minorities, although research is needed to understand the specific populations most likely to benefit. There are significant systemic barriers to the equitable provision of HF primary prevention.

Prevalence and Impact of Atrial Fibrillation on Prognosis in Takotsubo Cardiomyopathy Patients

The purpose of this review is to describe the impact of atrial fibrillation (AF) on the cardiovascular outcomes and prognosis in patients with Takotsubo Cardiomyopathy (TTC). The pathophysiological basis of TTC is set on the release of catecholamines, occurring post an emotional or stressful event. The cardiovascular system of patients with TTC is affected by the high concentrations of catecholamines, creating the ideal background for the development of AF: inflammation, myocardial stress, and excessive sympathetic activity. AF is considered to be the most frequent arrhythmia in TTC patients and is associated with higher rates of cardiovascular and all-cause mortality. AF is also linked with a worse prognosis concerning the hemodynamic status, cardiac fibrosis, lethal arrhythmias, thromboembolic events, and adverse heart failure associated outcomes. The early diagnosis of AF in these patients plays significant role in the prevention of adverse events, the reversibility of left ventricular function, and the restoration of sinus rhythm.

Update on Management of Cardiovascular Diseases in Women

Cardiovascular diseases (CVD) have a lower prevalence in women than men; although, a higher mortality rate and a poorer prognosis are more common in women. However, there is a misperception of CVD female risk since women have commonly been considered more protected so that the real threat is vastly underestimated. Consequently, female patients are more likely to be treated less aggressively, and a lower rate of diagnostic and interventional procedures is performed in women than in men. In addition, there are substantial sex differences in CVD, so different strategies are needed. This review aims to evaluate the main gender-specific approaches in CVD.

Transfusion double whammy? Adrenaline-takotsubo-anaphylaxis-Kounis complex post transfusion?

BACKGROUND AND OBJECTIVES

The adrenaline-takotsubo-anaphylaxis-Kounis, or the ATAK complex, where there are clinical and pathophysiological overlaps between takotsubo and Kounis syndromes, in which histaminergic, adrenergic and other mediators may play roles, was recently described. The objective of this report was to describe three cases where the ATAK complex was suspected to have occurred after transfusion.

MATERIALS AND METHODS

Three cases were recently reported to the New Zealand Blood Service haemovigilance programme that appeared to have features in common suggestive of the ATAK complex.

RESULTS

All three patients had had a blood component transfused, an initial severe allergic reaction, treatment with adrenaline or a congener, subsequent acute left ventricular failure or transfusion-associated circulatory overload, and features suggestive of takotsubo cardiomyopathy.

CONCLUSIONS

Although rarely described, transfusion-associated ATAK complex may be occurring more often than believed. Circumstances during a transfusion may predispose to it. It should be suspected if the sequence of events described above occur. Its characteristics need to be better understood. Risk factors for it may be modifiable.

Takotsubo syndrome associated with cardioversion: a systematic review

Background

Direct current cardioversion is a well-established and safe procedure to restore normal sinus rhythm for atrial and ventricular arrhythmias. Takotsubo syndrome has been rarely described with cardioversion. We reviewed the literature for descriptions of Takotsubo syndrome associated with the stress of cardioversion, to better understand its risks.

Methods

We queried MEDLINE, EMBASE, Google Scholar and Cochrane for cases of Takotsubo syndrome secondary to synchronized cardioversion as defined by Mayo Clinic Diagnostic Criteria.

Results

We identified 11 cases of cardioversion-associated Takotsubo syndrome. Average age was 76 years (range: 61–87 years) and most (10 out of 11, 91%) were female. Diagnosis was made soon after cardioversion (median: 10 h, range: 0–48 h). Only 2 of 11 had ST elevations noted, while apical ballooning was noted in all cases. Pulmonary edema developed in 6 and cardiogenic shock developed in 5 patients. The median recovery time was 7 days (range: 3–11).

Conclusions

Cardioversion-associated TS has an overall favorable outcome with complete recovery in most cases. A higher risk of this complication may exist for elderly females undergoing synchronized cardioversion.

Cardiac macrophages regulate isoproterenol-induced Takotsubo-like cardiomyopathy

Takotsubo syndrome (TTS) is an acute, stress-induced cardiomyopathy that occurs predominantly in women after extreme physical and/or emotional stress. To date, our understanding of the molecular basis for TTS remains unknown and, consequently, specific therapies are lacking. Myocardial infiltration of monocytes and macrophages in TTS has been documented in clinical studies. However, the functional importance of these findings remains poorly understood. Here, we show that a single high dose of isoproterenol (ISO) in mice induced a TTS-like cardiomyopathy phenotype characterized by female predominance, severe cardiac dysfunction, and robust myocardial infiltration of macrophages. Single-cell RNA-Seq studies of myocardial immune cells revealed that TTS-like cardiomyopathy is associated with complex activation of innate and adaptive immune cells in the heart, and macrophages were identified as the dominant immune cells. Global macrophage depletion (via clodronate liposome administration) or blockade of macrophage infiltration (via a CCR2 antagonist or in CCR2-KO mice) resulted in recovery of cardiac dysfunction in ISO-challenged mice. In addition, damping myeloid cell activation by HIF1α deficiency or exposure to the immunomodulatory agent bortezomib ameliorated ISO-induced cardiac dysfunction. Collectively, our findings identify macrophages as a critical regulator of TTS pathogenesis that can be targeted for therapeutic gain.

Transient left ventricular dysfunction following chimeric antigen receptor T‐cell‐mediated encephalopathy: A form of stress cardiomyopathy

Chimeric antigen receptor (CAR) T‐cell therapy represents a new strategy in treating lymphoid malignancies, such as relapsed‐refractory diffuse large B‐cell lymphoma (DLBCL). Several toxicities including cytokine release syndrome (CRS), neurotoxicity, and cardiovascular toxicity have been linked to CAR T‐cell therapy. Transient impairment in left ventricular systolic function is described after CAR‐T, however, the mechanism remains poorly understood. This paper reports the clinical presentation and outcome of two patients with relapsed‐refractory DLBCL who experienced encephalopathy and CRS following CAR T‐cell therapy and developed transient left ventricular dysfunction consistent with stress cardiomyopathy.

Acute Left Ventricular Systolic Dysfunction Following Device Closure of Ruptured Sinus of Valsalva Aneurysm

Acute cardiorespiratory distress following device closure of ruptured sinus of Valsava (RSOV) aneurysm can have a battery of differentials. We report a case of acute left ventricular dysfunction with aspiration that caused cardiorespiratory distress immediately following RSOV device closure. Supportive medical therapy led to complete recovery. (Level of Difficulty: Intermediate.)

Diagnostic value of Cardiac Magnetic Resonance Imaging and Intracoronary Optical Coherence Tomography in patients with a working diagnosis of Myocardial Infarction with Non-obstructive Coronary Arteries - A Systematic review and Meta-analysis

BACKGROUND

We aimed to study the efficacy of cardiac magnetic resonance imaging (CMR) and intracoronary optical coherence tomography (OCT) in detecting the etiology of myocardial infarction with non-obstructive coronary arteries (MINOCA).

METHODS

A systematic search was conducted in PubMed, Medline, and Cochrane databases. Search terms used: Myocardial infarction, Coronary angiography, Normal coronary arteries, CMR, and OCT. Inclusion criteria was fulfilled by 18 studies. Meta-analysis was performed with 15 studies.

RESULTS

A total of 2697 patients were included. The mean age of all the patients was 51.5 and 56.4% were men. CMR established diagnosis in 74% of the patients; 29% had acute myocarditis, 18% had true myocardial infarction and 12% had takotsubo cardiomyopathy. Combining OCT with CMR was better at finding the etiology than either modality individually.

CONCLUSION

CMR is integral in identifying the etiology of MINOCA. Coupling OCT and CMR is better than either technique individually at finding the cause.

Cardiovascular Imaging in Stress Cardiomyopathy (Takotsubo Syndrome)

Stress cardiomyopathy (Takotsubo syndrome) is a reversible syndrome stemming from myocardial injury leading to systolic dysfunction and is usually noted in the setting of a stressful event, be it an emotional or physical trigger. While the exact pathophysiology behind stress cardiomyopathy is yet unknown, there is ample evidence suggesting that neurocardiogenic mechanisms may play an important role. Although historically stress cardiomyopathy was generally thought to be a relatively benign condition, there is growing recognition of the cardiovascular complications associated with it despite its reversibility. Our review aims to shed light onto key cardiovascular imaging modalities used to diagnose stress cardiomyopathy while highlighting the role that imaging plays in assessing disease severity, identifying complications, dictating treatment approaches, and in short-term and long-term prognosis.

Stress-Induced Cardiomyopathy—Considerations for Diagnosis and Management during the COVID-19 Pandemic

The novel coronavirus disease 2019 (COVID-19) is associated with several cardiovascular manifestations including myocardial injury, myocarditis, arrhythmia, and pulmonary embolism. Rare cases of stress-induced cardiomyopathy, or takotsubo syndrome have also been reported during the acute infection, and secondary to stress following lockdown and self-isolation. Diagnosis in the setting of the acute infection is challenging since conventional imaging modalities such as transthoracic echocardiography and coronary angiography should be restricted to minimize physician-patient contact until the patients is tested negative for COVID-19. The use of point of care hand-held ultrasound is appropriate for this purpose. The overall course of the disease seems to be similar to takotsubo in the general population. Physicians should be familiar with the clinical presentation, possible complications, and management of takotsubo during COVID-19 outbreak. Here, we review the special considerations in the diagnosis and management of takotsubo syndrome during the current pandemic.

The Role of Cardiac Magnetic Resonance in Myocardial Infarction and Non-obstructive Coronary Arteries

Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) accounts for 5–15% of all presentations of acute myocardial infarction. The absence of obstructive coronary disease may present a diagnostic dilemma and identifying the underlying etiology ensures appropriate management improving clinical outcomes. Cardiac magnetic resonance (CMR) imaging is a valuable, non-invasive diagnostic tool that can aide clinicians to build a differential diagnosis in patients with MINOCA, as well as identifying non-ischemic etiologies of myocardial injury (acute myocarditis, Takotsubo Syndrome, and other conditions). The role of CMR in suspected MINOCA is increasingly recognized as emphasized in both European and American clinical guidelines. In this paper we review the indications for CMR, the clinical value in the differential diagnosis of patients with suspected MINOCA, as well as its current limitations and future perspectives.