Takotsubo Syndrome: Uncovering Myths and Misconceptions

Temporal Trends in Takotsubo Syndrome: Results From the International Takotsubo Registry

BACKGROUND

The perception of takotsubo syndrome (TTS) has evolved significantly over the years, primarily driven by increased recognition of acute complications and mortality.

OBJECTIVES

This study aimed to explore temporal trends in demographic patterns, risk factors, clinical presentations, and outcomes in patients with TTS.

METHODS

Patients diagnosed with TTS between 2004 and 2021 were enrolled from the InterTAK (International Takotsubo) registry. To assess temporal trends, patients were divided into 6 groups, each corresponding to a 3-year interval within the study period.

RESULTS

Overall, 3,957 patients were included in the study. There was a significant demographic transition, with the proportion of male patients rising from 10% to 15% (P = 0.003). Although apical TTS remained the most common form, the diagnosis of midventricular TTS increased from 18% to 28% (P = 0.018). The prevalence of physical triggers increased from 39% to 58% over the years (P < 0.001). There was a significant increase in 60-day mortality over the years (P < 0.001). However, a landmark analysis excluding patients who died within the first 60 days showed no differences in 1-year mortality (P = 0.150).

CONCLUSIONS

This study of temporal trends in TTS highlights a transition in patients demographic with a growing prevalence among men, increasing recognition of midventricular TTS type, and increased short-term mortality and rates of cardiogenic shock in recent years. This transition aligns with the rising prevalence of physical triggers, as expression of increased recognition of TTS in association with acute comorbidities.

Stress cardiomyopathy in the paediatric population: a case series

Background

Stress cardiomyopathy (Takotsubo syndrome) defined as Takotsubo syndrome is defined as a reversible acute myocardial syndrome with myocardial injury with regional wall motion abnormality and no coronary explanations in the context of stress. The pathophysiology remains partially unknown, and these cases are probably underestimated in paediatrics. We report six cases of Takotsubo probably secondary to neurological damage.

Case summary

Six patients (10, 13, 16, 10, and 9 years and 5 months) presented with haemodynamic lability with echocardiography data leading to suspicion of Takotsubo syndrome. These cases were secondary to neurological involvement (cerebral haemorrhage, intraventricular haemorrhage, brain damage due to bifrontal oedema, posterior fossa tumour, pneumococcal meningitis, high-grade glioma). All patients were rapidly started on amine. Reversibility of the acute myocardial syndrome was complete in all but one child, who rapidly progressed to encephalic death.

Discussion

Neurological distress has been suggested as a potential cause of Takotsubo syndrome. The pathophysiology is possibly related to excessive stimulation of the sympathetic system. This syndrome should probably be considered in the setting of left heart failure with neurological distress so as not to delay the use of amines especially since in the paediatric population the probability of a coronary origin is low.

Takotsubo Syndrome and Coronary Artery Disease: Which Came First-The Chicken or the Egg?

Takotsubo syndrome (TTS) is a clinical condition characterized by temporary regional wall motion anomalies and dysfunction that extend beyond a single epicardial vascular distribution. Various pathophysiological mechanisms, including inflammation, microvascular dysfunction, direct catecholamine toxicity, metabolic changes, sympathetic overdrive-mediated multi-vessel epicardial spasms, and transitory ischemia may cause the observed reversible myocardial stunning. Despite the fact that TTS usually has an acute coronary syndrome-like pattern of presentation, the absence of culprit atherosclerotic coronary artery disease is often reported at coronary angiography. However, the idea that coronary artery disease (CAD) and TTS conditions are mutually exclusive has been cast into doubt by numerous recent studies suggesting that CAD may coexist in many TTS patients, with significant clinical and prognostic repercussions. Whether the relationship between CAD and TTS is a mere coincidence or a bidirectional cause-and-effect is still up for debate, and misdiagnosis of the two disorders could lead to improper patient treatment with unfavourable outcomes. Therefore, this review seeks to provide a profound understanding of the relationship between CAD and TTS by analyzing potential common underlying pathways, addressing challenges in differential diagnosis, and discussing medical and procedural techniques to treat these conditions appropriately.

Current Pharmacology and Modulation of the Purinergic System in Takotsubo Syndrome Triggered by Cytokine Storm

Studies show that with the COVID-19 pandemic, the world's population went through multiple stress and anxiety factors, generating serious psychological problems, in addition, the virus also caused damage and physical stress to those contaminated. In this way, the intense emotional experiences and stressful effects on the body caused by SARS-CoV-2 are capable of triggering the excessive release of catecholamines in the body. Thus, the framework of Takotsubo Syndrome is characterized by myocardial dysfunction as a response of cardiac receptors to the spillage of such hormones in an unregulated way in the human body. The purinergic system plays a central role in this process, as it actively participates in actions responsible for the syndromic cascade, such as the stress generated by the cytokine storm triggered by the virus and the stimulation of deregulated catecholamine release. Therefore, further pharmacological studies on the role of purines in this pathology should be developed in order to avoid the evolution of the syndrome and to modulate its P1 and P2 receptors aiming at developing means of reversing or treating the Takotsubo Syndrome.

Multi-Omics Analysis Reveals the Role of Sigma-1 Receptor in a Takotsubo-like Cardiomyopathy Model

Takotsubo syndrome (TTS) is a stress-induced cardiomyopathy that presents with sudden onset of chest pain and dyspneic and cardiac dysfunction as a result of extreme physical or emotional stress. The sigma-1 receptor (Sigmar1) is a ligand-dependent molecular chaperone that is postulated to be involved in various processes related to cardiovascular disease. However, the role of Sigmar1 in TTS remains unresolved. In this study, we established a mouse model of TTS using wild-type and Sigmar1 knockout mice to investigate the involvement of Sigmar1 in TTS development. Our results revealed that Sigmar1 knockout exacerbated cardiac dysfunction, with a noticeable decrease in ejection fraction (EF) and fractional shortening (FS) compared to the wild-type model. In terms of the gut microbiome, we observed regulation of Firmicutes and Bacteroidetes ratios; suppression of probiotic Lactobacillus growth; and a rise in pathogenic bacterial species, such as Colidextribacter. Metabolomic and transcriptomic analyses further suggested that Sigmar1 plays a role in regulating tryptophan metabolism and several signaling pathways, including MAPK, HIF-1, calcium signaling, and apoptosis pathways, which may be crucial in TTS pathogenesis. These findings offer valuable insight into the function of Sigmar1 in TTS, and this receptor may represent a promising therapeutic target for TTS.

Diagnosis and Management of Takotsubo Syndrome in Acute Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Review

Takotsubo syndrome (TS) is a frequent complication of subarachnoid hemorrhage (SAH), especially in massive SAH with severe neurological damage. The initial presentation of TS is similar to acute coronary syndrome, causing differential diagnostic issues. Unnecessary diagnostic steps and uncertainty in therapy may delay the definitive treatment of the aneurysm, therefore increasing the risk of rebleeding. The purpose of this review is to summarize the latest knowledge on the diagnosis and therapy of TS in SAH and to provide a diagnostic and therapeutic algorithm for the acute phase, promoting the early definitive treatment of the aneurysm. Rapid hemodynamic stabilization and early aneurysm securing are key points in reducing the risk of delayed cerebral ischemia and improving outcomes. In acute SAH noninvasive bedside diagnostic methods are preferred and securing the aneurysm is the priority. The combination of electrocardiography, cardiac biomarkers, and echocardiography is of great importance in differentiating TS from acute myocardial infarction. The risk-benefit ratio of coronary angiography should be carefully and individually considered and its use should be limited to patients with strong evidence of myocardial ischemia, after the successful endovascular treatment of the aneurysm. Invasive hemodynamic monitoring may be beneficial in cases of cardiogenic shock or pulmonary edema. In patients with hemodynamical instability secondary to TS, the use of non-catecholamine inotropes, especially levosimendan is recommended. In refractory hypotension, mechanical support should be considered. The left ventricular function improves within days to months after the acute event, low initial ejection fraction may predispose to delayed recovery.

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.

Clinical correlates and prognostic impact of neurologic disorders in Takotsubo syndrome

Cardiac alterations are frequently observed after acute neurological disorders. Takotsubo syndrome (TTS) represents an acute heart failure syndrome and is increasingly recognized as part of the spectrum of cardiac complications observed after neurological disorders. A systematic investigation of TTS patients with neurological disorders has not been conducted yet. The aim of the study was to expand insights regarding neurological disease entities triggering TTS and to investigate the clinical profile and outcomes of TTS patients after primary neurological disorders. The International Takotsubo Registry is an observational multicenter collaborative effort of 45 centers in 14 countries (ClinicalTrials.gov, identifier NCT01947621). All patients in the registry fulfilled International Takotsubo Diagnostic Criteria. For the present study, patients were included if complete information on acute neurological disorders were available. 2402 patients in whom complete information on acute neurological status were available were analyzed. In 161 patients (6.7%) an acute neurological disorder was identified as the preceding triggering factor. The most common neurological disorders were seizures, intracranial hemorrhage, and ischemic stroke. Time from neurological symptoms to TTS diagnosis was ≤ 2 days in 87.3% of cases. TTS patients with neurological disorders were younger, had a lower female predominance, fewer cardiac symptoms, lower left ventricular ejection fraction, and higher levels of cardiac biomarkers. TTS patients with neurological disorders had a 3.2-fold increased odds of in-hospital mortality compared to TTS patients without neurological disorders. In this large-scale study, 1 out of 15 TTS patients had an acute neurological condition as the underlying triggering factor. Our data emphasize that a wide spectrum of neurological diseases ranging from benign to life-threatening encompass TTS. The high rates of adverse events highlight the need for clinical awareness.