Recurrent Takotsubo Cardiomyopathy Triggered by Convulsive Status Epilepticus

Recurrent biventricular takotsubo cardiomyopathy with fatal outcome

A woman in her 60s presented initially with nausea, vomiting and abdominal pain. She rapidly progressed to respiratory failure requiring intubation. ECG demonstrated no significant ST segment changes. Troponin I and brain natriuretic peptide were elevated. Chest CT angiography demonstrated small non-occlusive segmental pulmonary emboli. Transthoracic echocardiogram findings suggested biventricular takotsubo cardiomyopathy (TCM) with left ventricular ejection fraction of less than 20%. She improved with aggressive management and was discharged on carvedilol, lisinopril, atorvastatin and apixaban. Follow-up echocardiogram revealed complete resolution of the left and right ventricular wall motion abnormalities at 9 weeks. She had symptoms recurrence after 7 months from the initial presentation. Repeated echocardiogram was consistent with biventricular TCM recurrence. Despite aggressive medical therapy, multiorgan failure developed and patient care was later transitioned to palliative care.

Stress Cardiomyopathy Triggered by Status Epilepticus Secondary to Herpes Simplex Virus Encephalitis: Case Report and Literature Review

Stress cardiomyopathy (SCM) occurs in approximately 1% of patients presenting with troponin-positive suspected acute coronary syndrome (ACS). We present here a 50-year-old female who presented to the emergency department (ED) with altered mental status. In the hospital, she was found to have status epilepticus (SE) secondary to Herpes simplex virus encephalitis. Her hospital stay was complicated by high troponins and a transthoracic echocardiogram showed reduced ejection fraction and wall motion abnormality. Repeat echo five days later showed normal ventricular systolic function with no wall motion abnormality. Extensive ischemia workup was negative. A diagnosis of stress cardiomyopathy has been made. We urge physicians to include SCM in their differential diagnosis especially in cases of status epilepticus in order to avoid invasive procedures and for better management of patients.

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

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

Epileptic heart: A clinical syndromic approach

Prevention of premature death in patients with chronic epilepsy remains a major challenge. Multiple pathophysiologic factors have been implicated, with intense investigation of cardiorespiratory mechanisms. Up to four in five patients with chronic epilepsy exhibit cardiovascular comorbidities. These findings led us to propose the concept of an "epileptic heart," defined as "a heart and coronary vasculature damaged by chronic epilepsy as a result of repeated surges in catecholamines and hypoxemia leading to electrical and mechanical dysfunction." Among the most prominent changes documented in the literature are high incidence of myocardial infarction and arrhythmia, altered autonomic tone, diastolic dysfunction, hyperlipidemia, and accelerated atherosclerosis. This suite of pathologic changes prompted us to propose for the first time in this review a syndromic approach for improved clinical detection of the epileptic heart condition. In this review, we discuss the key pathophysiologic mechanisms underlying the candidate criteria along with standard and novel techniques that permit evaluation of each of these factors. Specifically, we present evidence of the utility of standard 12-lead, ambulatory, and multiday patch-based electrocardiograms, along with measures of cardiac electrical instability, including T-wave alternans, heart rate variability to detect altered autonomic tone, echocardiography to detect diastolic dysfunction, and plasma biomarkers for assessing hyperlipidemia and accelerated atherosclerosis. Ultimately, the proposed clinical syndromic approach is intended to improve monitoring and evaluation of cardiac risk in patients with chronic epilepsy to foster improved therapeutic strategies to reduce premature cardiac death.

Recurrent Stress-Induced Cardiomyopathy With Cardiogenic Shock Requiring Impella Left Ventricular Assist Device

Stress-induced cardiomyopathy (SIC) is associated with varying etiologies. We present a case of a 65-year-old female with recurrent SIC secondary to seizures who presented in cardiogenic shock requiring mechanical circulatory support using an Impella CP via the right axillary approach.

Children with refractory epilepsy demonstrate alterations in myocardial strain

OBJECTIVE

To test whether children with epilepsy have impairments in myocardial mechanics compared to controls without epilepsy.

METHODS

Children with refractory epilepsy with epilepsy duration of at least 3 years underwent echocardiography including conventional measurements and speckle tracking to assess longitudinal and circumferential strain. Parent-completed surveys, capturing critical aspects of the children's seizure history and cardiac risk factors, complemented retrospective chart reviews, which also included antiepileptic drug history. Normal echocardiograms from controls, matched for age and gender, were obtained from our institutional database and evaluated for strain.

RESULTS

Forty-one patients (median age = 10 years, interquartile range [IQR] = 5-15; 58.5% male) were enrolled. Epilepsy etiology included genetic (n = 26), structural (n = 6), genetic and structural (n = 5), infection (n = 3), and unknown (n = 1). No cardiac structural abnormalities were identified. Both longitudinal and circumferential strain were impaired (P < .03) in patients compared to controls (median [IQR] = 22.7% [21.2-24.2] vs 23.6% [22.2-26.1] and 22.0% [20.3-25.4] vs 24.5% [22.3-27.0], respectively), indicating decreased myocardial deformation/contraction. Shortening fraction was higher in patients (37.6% [35.7-39.7] vs 34.9% [32.5-38.7], P = .009); mitral valve E wave inflow velocity (84.8 cm/s [78.4-92.8] vs 97.2 cm/s [85.9-105.8], P = .005) and tissue Doppler lateral E' wave (13.9 cm/s [12.3-16.1] vs 17.3 cm/s [15.4-18.5], P < .001) were decreased compared to controls. Findings were similar in the pairs with epilepsy patients distinguished by the ability to independently ambulate. There was no difference between patients and controls in ejection fraction. Among the epilepsy patients, there were no associations between cardiac measurements and epilepsy characteristics, including seizure type and frequency and cardiotoxic antiseizure medication exposure after correction for multiple comparisons.

SIGNIFICANCE

Children with refractory epilepsy had impaired systolic ventricular strain compared to controls, not correlated with epilepsy history. Further studies are needed to determine the significance of these changes.

Spontaneous Recurrent Seizures Mediated Cardiac Dysfunction via mTOR Pathway Upregulation: A Putative Target for SUDEP Management

Background:

Alteration in electrophysiology, leading to cardiac dysfunction and subsequently a nontraumatic death is a complication of epilepsy known as “SUDEP” (Sudden Unexpected Death in Epilepsy).

Aims:

The present study was designed to understand the molecular changes and cardiac parameters during different phases of epileptogenesis in lithium-pilocarpine (Li-pilo) rat model of epilepsy.

Methods:

The animals were exposed to Li-pilo to induce Spontaneous Recurrent Seizures (SRS). Noninvasive blood pressure and electrocardiography was recorded at 7th, 28th and 75th day following pilocarpine administration, considered as latent, initial and late SRS phases, respectively. The serum biochemistry, cardiac histopathology, protein and mRNA expressions were studied, following electrocardiography on day 75.

Results:

The mean arterial pressure decreased during the latent phase, thereafter it progressively increased during the initial and the late SRS phases, as compared to the basal and the latent phase. Histopathological analysis of the heart sections indicated hypertrophy, degenerative changes and fibrous tissue deposition in epileptic animals, along with increased levels of lactate dehydrogenase and creatine kinase-MB in the serum. The expression of HIF-1α, phospho-S6, phospho-mTOR, TGF-β, collagen I and Na+/K+-ATPase α1 proteins, and mRNA levels of HIF-1α, mTOR, Rps6, Scn1b, Scn3b, Nav1.5 and TGF-β were increased in the cardiac tissue of epileptic animals, as compared to control.

Conclusion:

Our results conclusively showed that Li-pilo-induced SRS leads to cardiac dysfunction via mTOR pathway upregulation, thus suggested the regulatory control of mTOR pathway as a potential target for SUDEP management.

Epilepsy and ultra-structural heart changes: The role of catecholaminergic toxicity and myocardial fibrosis. What can we learn from cardiology?

In this article, we explore the interaction of brain and heart in patients with epilepsy (PWE), focusing on new insights into possible pathways from epilepsy, catecholaminergic toxicity, subtle cardiac changes and sudden death. Initial evidence and biological plausibility point to an interaction between autonomic dysfunction, higher sympathetic drive, myocardial catecholaminergic toxicity and cardiac fibrosis resulting in subtle myocardial changes in structure, function, arrhythmogenesis and/or a heart failure-like phenotype in PWE. Non invasive imaging and biomarkers of cardiac injury and fibrosis are emerging as possible diagnostic tools to better stratify the risk of such individuals. Translational lessons from cardiac models of disease and ultra-structural lesions are used to support these considerations.

Takotsubo cardiomyopathy triggered by status epilepticus: case report and literature review

Takotsubo cardiomyopathy (TC) is acute stress-induced cardiomyopathy with characteristic transient wall motion abnormalities. TC has a clinical presentation similar to an acute coronary syndrome, including chest pain or dyspnoea, ECG changes and elevated cardiac enzymes. TC often occurs after emotional stress. There are approximately 50 TC cases reported related to seizure activity, and our review revealed 15 articles which were associated with status epilepticus. This condition can be a serious complication of seizures. We report a case of TC after status epilepticus in a patient who had been seizure-free for 20 years.

Immediate versus delayed detection of Takotsubo syndrome after epileptic seizures

Takotsubo syndrome(TTS) is often preceded by emotional or physical stress. Epileptic seizures are described in >100 cases. It is unknown whether patients with immediate and delayed detection of seizure-induced TTS differ. We screened the literature and compared clinical and electrocardiographic (ECG) findings. In 48 cases with seizure-associated TTS, the time between seizure and TTS-detection was reported. Troponin levels were elevated in 37/40. ECG abnormalities were negative T-waves(40%), ST-elevations(33%) and ventricular fibrillation/flutter(10%). Immediate detection was reported in 23 patients, in the remaining 25 patients, TTS was detected 5-288 h postictally. Patients did not differ in gender, age or symptoms. Negative T-waves were more frequent in patients with delayed detection(64 vs. 13%, p = .0009), whereas ECG-abnormalities suggesting acute myocardial infarction tended to be more prevalent in patients with immediate detection. Due to lack of typical symptoms, seizure-induced TTS can be overlooked. Postictally, an ECG should be recorded and troponin levels measured. New T-wave inversions might indicate seizure-induced TTS.

Echocardiographic risk markers of sudden death in patients with temporal lobe epilepsy

Patients with epilepsy (PWE) have an increased risk for sudden unexpected death compared to the general population. Echocardiography can analyze structural and functional heart changes that have impact on outcomes, including sudden cardiac and all-cause death. Our hypothesis is that subtle heart abnormalities occur in PWE. Thirty patients with temporal lobe epilepsy without any known cardiovascular disease, followed for at least 1 year, were enrolled between July 2015 and July 2016 and submitted to a 12-lead electrocardiogram, treadmill test and transthoracic echocardiogram. PWE were matched with individuals without epilepsy by sex, age and body mass index. A literature review of studies comparing echocardiographic findings in PWE and individuals without epilepsy was performed. PWE had a higher left ventricle stiffness (β= 5.97 ± 0.05 × 5.94 ± 0.03; p = 0.02), left ventricle filling pressures (9.7 ± 1.3 mmHg × 9 ± 0.8; p = 0.02) and a greater left atrial volume (44.7 ± 13.6 ml × 34.1 ± 9.6 ml; p = 0.003). Seventeen (56.6%) PWE had a total of 22 of six known echocardiographic markers related to increased risk for sudden death in the general population, versus 11 (36.7%) controls with 12 markers (p = 0.07). Stiffness is related to fibrosis through extracellular matrix deposition, which promotes systolic and diastolic dysfunction and arrhythmogenesis. Subtle echocardiographic findings in PWE could help to explain why this population has an increased risk to die suddenly.

Acute Systemic Complications of Convulsive Status Epilepticus-A Systematic Review

OBJECTIVES

Status epilepticus is a neurologic emergency with high morbidity and mortality requiring neurointensive care and treatment of systemic complications. This systematic review compiles the current literature on acute systemic complications of generalized convulsive status epilepticus in adults and their immediate clinical impact along with recommendations for optimal neurointensive care.

DATA SOURCES

We searched PubMed, Medline, Embase, and the Cochrane library for articles published between 1960 and 2016 and reporting on systemic complications of convulsive status epilepticus.

STUDY SELECTION

All identified studies were screened for eligibility by two independent reviewers.

DATA EXTRACTION

Key data were extracted using standardized data collection forms.

DATA SYNTHESIS

Thirty-two of 3,046 screened articles were included. Acute manifestations and complications reported in association with generalized convulsive status epilepticus can affect all organ systems fueling complex cascades and multiple organ interactions. Most reported complications result from generalized excessive muscle contractions that increase body temperature and serum potassium levels and may interfere with proper and coordinated function of respiratory muscles followed by hypoxia and respiratory acidosis. Increased plasma catecholamines can cause a decay of skeletal muscle cells and cardiac function, including stress cardiomyopathy. Systemic complications are often underestimated or misinterpreted as they may mimic underlying causes of generalized convulsive status epilepticus or treatment-related adverse events.

CONCLUSIONS

Management of generalized convulsive status epilepticus should center on the administration of antiseizure drugs, treatment of the underlying causes, and the attendant systemic consequences to prevent secondary seizure-related injuries. Heightened awareness, systematic clinical assessment, and diagnostic workup and management based on the proposed algorithm are advocated as they are keys to optimal outcome.

Cardiac injury after convulsive status epilepticus in children

OBJECTIVE

Convulsive status epilepticus (CSE) is a medical emergency with high mortality that usually occurs within 30 days following the seizure activity. One of the potential mechanisms contributing to mortality in this period following CSE is cardiac injury. The aim of the present study was to evaluate cardiac injury after CSE in children.

PATIENTS AND METHODS

Sixty children presented with CSE were enrolled in this study. Thirty healthy children with matched age and sex were taken as a control. Electrocardiogram (ECG), echocardiographic examinations, plasma concentration of cardiac troponin I (cTnI) and brain-type natriuretic peptide (BNP) were done 6 h after control of seizure for patients and control groups.

RESULTS

Thirty three patients were presented with CSE for the first time. ECG changes were present in 55% of patients with CSE in the form of conduction abnormalities, ischemic changes, and arrhythmias. Echocardiographic examinations revealed a significant increase in left ventricular end-diastolic dimension (LVEDD) and left ventricular end systolic dimension (LVESD) in patients with CSE than control group. Moreover, a significant decrease in LV systolic function and RV diastolic function were detected by tissue Doppler. The mean plasma concentrations of BNP and cTnI were significantly higher in patients with CSE than the control group (p value < 0.001). The overall mortality in our study was 8.3% (5/60); four of them had ECG changes. There was significant increase in duration of CSE, length of intensive care and hospital admission in CSE patients with ECG changes than those without ECG changes with p values 0.001, 0.031 and <0.001 respectively.

CONCLUSION

Cardiac injury in convulsive SE is common and may be under recognized. So, cardiac assessment should be a routine step in CSE patients' management.

Recurrence of Postoperative Stress-Induced Cardiomyopathy Resulting from Status Epilepticus

Introduction. Classically, stress-induced cardiomyopathy (SIC), also known as takotsubo cardiomyopathy, displays the pathognomonic feature of reversible left ventricular apical ballooning without coronary artery stenosis following stressful event(s). Temporary reduction in ejection fraction (EF) resolves spontaneously. Variants of SIC exhibiting mid-ventricular regional wall motion abnormalities have been identified. Recent case series present SIC as a finding in association with sudden unexplained death in epilepsy (SUDEP). This case presents a patient who develops recurrence of nonapical cardiomyopathy secondary to status epilepticus. Case Report. Involving a postoperative, postmenopausal woman having two distinct episodes of status epilepticus (SE) preceding two incidents of SIC. Preoperative transthoracic echocardiogram (TTE) confirms the patient's baseline EF of 60% prior to the second event. Postoperatively, SE occurs, and the initial electrocardiogram exhibits T-wave inversions with subsequent elevation of troponin I. Postoperative TTE shows an EF of 30% with mid-ventricular wall akinesia restoring baseline EF rapidly. Conclusion. This case identifies the need to understand SIC and its diagnostic criteria, especially when cardiac catheterization is neither indicated nor available. Sudden cardiac death should be considered as a possible complication of refractory status epilepticus. The pathophysiology in SUDEP is currently unknown; yet a correlation between SUDEP and SIC is hypothesized to exist.

Management of status epilepticus

Status epilepticus is a neurologic and medical emergency manifested by prolonged seizure activity or multiple seizures without return to baseline. It is associated with substantial medical cost, morbidity, and mortality. There is a spectrum of severity dependent on the type of seizure, underlying pathology, comorbidities, and appropriate and timely medical management. This chapter discusses the evolving definitions of status epilepticus and multiple patient and clinical factors which influence outcome. The pathophysiology of status epilepticus is reviewed to provide a better understanding of the mechanisms which contribute to status epilepticus, as well as the potential long-term effects. The clinical presentations of different types of status epilepticus in adults are discussed, with emphasis on the hospital course and management of the most dangerous type, generalized convulsive status epilepticus. Strategies for the evaluation and management of status epilepticus are provided based on available evidence from clinical trials and recommendations from the Neurocritical Care Society and the European Federation of Neurological Societies.

Regenerative Medicine: Potential Mechanisms of Cardiac Recovery in Takotsubo Cardiomyopathy

OPINION STATEMENT

Takotsubo cardiomyopathy is an increasingly reported cause of acute chest pain and acute heart failure and is often associated with significant hemodynamic compromise. The illness is remarkable for the reversibility in systolic dysfunction seen in the disease course. While the pathophysiology of takotsubo syndrome is not completely elucidated, research suggests the presence of a cytoprotective process that allows the myocardium to recover following the inciting insult. Here, we summarize molecular and histologic studies exploring the response to injury in takotsubo disease and provide some discussion on how they may contribute to further investigations in cardiac recovery and regeneration.

Prevalence and Risk Factors of Stress Cardiomyopathy After Convulsive Status Epilepticus in ICU Patients

OBJECTIVE

Although stress cardiomyopathy has been described in association with epilepsy, its frequency in patients with convulsive status epilepticus remains unknown. Accordingly, we sought to determine the prevalence and risk factors of stress cardiomyopathy in patients admitted to the ICU for convulsive status epilepticus.

DESIGN

Prospective, descriptive, single-center study.

SETTING

Medical-surgical ICU of a teaching hospital.

PATIENTS

Thirty-two consecutive ventilated patients (21 men; age, 50 ± 18 yr; Simplified Acute Physiology Score II, 53 ± 15; Sequential Organ Failure Assessment, 6 ± 2) hospitalized in the ICU for convulsive status epilepticus.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Hemodynamic parameters, transthoracic echocardiography, biological data, and electrocardiogram were obtained serially on ICU admission (H0), and after 6, 12, 24, and 48 hours of hospitalization (H6, H12, H24, and H48). Stress cardiomyopathy was defined as a 20% decrease in left ventricular ejection fraction between H0 or H6 and H48. Stress cardiomyopathy was diagnosed in 18 patients (56%; 95% CI, 38-74%). Mean left ventricular ejection fraction, left ventricular stroke index and cardiac index were initially (at H0 or H6 according to lowest individual values) significantly reduced in stress cardiomyopathy patients (45 ± 14% vs 61 ± 6%, p < 0.001; 24 ± 8 vs 28 ± 8 mL/m(2), p < 0.05; 2.3 ± 0.7 vs 3.0 ± 0.8 L/min/m(2), p < 0.05, respectively) and increased secondarily to reach similar mean values than those observed in patients without transient left ventricular dysfunction at H24. Dobutamine was more frequently used in patients with stress cardiomyopathy. Mean lactate level was increased and significantly higher in stress cardiomyopathy patients at H0 and H6, whereas mean central venous oxygen saturation was preserved but significantly lower in this group. Only three patients with stress cardiomyopathy had left ventricular regional wall motion abnormalities but normal coronary angiography. Risk factors of stress cardiomyopathy were age and Simplified Acute Physiology Score II.

CONCLUSIONS

These results suggest that stress cardiomyopathy is common in patients admitted to the ICU for convulsive status epilepticus. Accordingly, these patients should be screened for stress cardiomyopathy and monitored if they present with hemodynamic compromise.

Cardiac and autonomic mechanisms contributing to SUDEP

Sudden unexpected death in epilepsy is likely caused by a cascade of events affecting the vegetative nervous system leading to cardiorespiratory failure and death. Multiple genetic, electrophysiological, neurochemical, and pharmacological cardiac alterations have been associated with epilepsy, which can affect autonomic regulation of the heart and predispose patients to sudden unexpected death in epilepsy. These cardiac and autonomic changes are more frequently seen in patients with longstanding and medication refractory epilepsy and may be a prerequisite for sudden unexpected death in epilepsy. Cardiac changes are also observed within the immediate periictal period in patients with and without preexisting cardiac pathology and could be the tipping point in the cascade of events compromising autonomic, respiratory, and cardiac function during an epileptic convulsion. Better understanding if and how these cardiac alterations can make a particular individual with epilepsy more susceptible to sudden unexpected death in epilepsy will hopefully lead us to more effective preventative strategies.

Systemic complications of status epilepticus--An update

Systemic complications occur at every stage of status epilepticus, involve every organ system, and may worsen outcome. Initially, there is a massive catecholamine release and hyperadrenergic state that may result in neurocardiogenic, pulmonary, and, sometimes, musculoskeletal or renal injury. Further medical complications accompany the various treatments used to abort the seizures including the use of nonanesthetic antiseizure drugs and high-dose anesthetic infusions. Later, sequelae of prolonged immobility and critical illness occur and add to the cumulative morbidity of these patients. Clinicians should follow a protocol to guide screening for early markers of systemic injury, complications of specific pharmacologic and adjunctive treatments, and periodic surveillance for complications related to prolonged immobility. This article is part of a Special Issue entitled "Status Epilepticus".

CNS disease triggering Takotsubo stress cardiomyopathy

There are a number of hereditary and non-hereditary central nervous system (CNS) disorders, which directly or indirectly affect the heart (brain-heart disorders). The most well-known of these CNS disorders are epilepsy, stroke, infectious or immunological encephalitis/meningitis, migraine, and traumatic brain injury. In addition, a number of hereditary and non-hereditary neurodegenerative disorders may impair cardiac functions. Affection of the heart may manifest not only as arrhythmias, myocardial infarction, autonomic impairment, systolic dysfunction/heart failure, arterial hypertension, or pulmonary hypertension, but also as stress cardiomyopathy (Takotsubo syndrome, TTS). CNS disease triggering TTS includes subarachnoid bleeding, epilepsy, ischemic stroke, intracerebral bleeding, migraine, encephalitis, traumatic brain injury, PRES syndrome, or ALS. Usually, TTS is acutely precipitated by stress triggered by various different events. TTS is one of the cardiac abnormalities most frequently induced by CNS disorders. Appropriate management of TTS from CNS disorders is essential to improve the outcome of affected patients.

Involvement of cardiomyocyte apoptosis in myocardial injury of hereditary epileptic rats

Many clinical cases have been reported where epilepsy profoundly influenced the pathophysiological function of the heart; however, the underlying mechanisms were not elucidated. We use the tremor (TRM) rat as an animal model of epilepsy to investigate the potential mechanisms of myocardial injury. Cardiac functions were assessed by arrhythmia score, heart rate, heart:body mass ratio, and hemodynamic parameters including left ventricular systolic pressure (LVSP), left ventricular end-diastolic pressure (LVEDP), and maximum rate of left ventricular pressure rise and fall (+dp/dtmax and -dp/dtmax). Catecholamine level was detected by HPLC. Apoptotic index was estimated by TUNEL assay. The expressions of Bcl-2, Bax, caspase-3, extracellular signal-regulated protein kinase (ERK), c-Jun NH2-terminal protein kinases (JNK), and p38 were evaluated by Western blot. The results indicated that there existed cardiac dysfunction and cardiomyocyte apoptosis, accompanied by increasing catecholamine levels in TRM rats. Further investigation revealed that apoptosis was mediated by reducing Bcl-2, upregulating Bax, and activating caspase-3. Additional experiments demonstrated that P-ERK1/2 was decreased, whereas P-JNK and P-p38 were up-regulated. Our results suggest that the sympathetic nervous system activation and cardiomyocyte apoptosis are involved in the myocardial injury of TRM rats. The mechanisms of apoptosis might be associated with the activation of the mitochondria-initiated and the mitogen-activated protein kinase pathways.

β adrenergic blockade prevents cardiac dysfunction following status epilepticus in rats

Status epilepticus (SE) can result in temporary cardiac dysfunction in patients, characterized by reduced ejection fraction, decreased ventricular contractility, and alterations in electrical activity of the heart. Although reversible, the cardiac effects of seizures are acutely life threatening, and may contribute to the delayed mortality following SE. The precise mechanisms mediating acute cardiac dysfunctions are not known. These studies evaluated effects of self-sustaining limbic SE in rats on cardiac performance 24h following seizures, and determined if sympathetic nervous system activation during seizures contributed to cardiac dysfunction. Rats subjected to SE received either vehicle (saline) or the B1 adrenergic antagonist atenolol (AT) prior to and during 90 min of seizure activity. Control rats were similarly treated, except they did not undergo seizures. Twenty-four hours after SE, animals were anesthetized and catheterized for measurement of cardiac performance variables. Animals undergoing SE demonstrated significantly reduced cardiac output, decreased ventricular contractility and relaxation, increased blood pressure, and prolonged QT interval. However, heart rate was not altered. Treatment with AT prevented all changes in cardiac performance due to SE, and attenuated the increase in QT interval. These data demonstrate that SE in the rat results in cardiac dysfunction 24h following seizures, mediated by the sympathetic nervous system.

Takotsubo cardiomyopathy after electroconvulsive therapy: a case report and review

Takotsubo cardiomyopathy (TCM) is a syndrome of reversible stress-induced cardiomyopathy associated with profound emotional stress and a variety of medical illnesses and procedures, including electroconvulsive therapy (ECT). We describe 1 case of ECT-induced TCM followed by a successful retrial of ECT. We further discuss the management of ECT-induced TCM and the decision to perform a second trial of ECT in patients with this complication. Given the current understanding of the pathogenesis of TCM, it is appropriate to discontinue ECT during the acute setting of TCM. After the resolution of the acute episode of TCM, a second trial of ECT may be warranted depending on the severity of psychiatric illness (ie, suicidal ideation, catatonia, psychotic symptoms). If a retrial of ECT is performed, oral and intravenous β-blockers should be used for cardioprotection, and patients should be monitored for signs and symptoms of an evolving cardiomyopathy. It is preferable to perform retrials of ECT-at least initially-in a general hospital setting, where immediate invasive monitoring and intensive treatments are available in the event of acute cardiac failure.

Recurrent takotsubo cardiomyopathy in the setting of transient neurological symptoms: a case report

Introduction

First described in Japan, takotsubo cardiomyopathy is increasingly becoming recognized worldwide as a cause of sudden and reversible diminished left ventricular function characterized by left apical ballooning and hyperkinesis of the basal segments, often with symptoms mimicking a myocardial infarction. Associated with physical or emotional stress, its exact pathogenesis has not been established, though evidence supports a neurohumoral etiology. Additionally, recurrence of this condition is rare. In this report, we present a rare case of recurrent takotsubo cardiomyopathy in a post-menopausal woman who presented with transient neurological complaints on both occasions.

Case presentation

We present a rare case of a 76-year-old Caucasian woman with no history of congestive heart failure who presented to our emergency department twice with transient neurological complaints. On the first occasion, she was found to have transient aphasia which resolved within 24 hours, yet during that period she also developed symptoms of congestive heart failure and was noted to have a new, significantly depressed ejection fraction with apical akinesis and possible apical thrombus. One month after her presentation a repeat echocardiogram revealed complete resolution of all wall motion abnormalities and a return to baseline status. Seven months later she presented with ataxia, was diagnosed with vertebrobasilar insufficiency, and again developed symptoms and echocardiography findings similar to those of her first presentation. Once again, at her one-month follow-up examination, all wall motion abnormalities had completely resolved and her ejection fraction had returned to normal.

Conclusion

Though the exact etiology of takotsubo cardiomyopathy is unclear, a neurohumoral mechanism has been proposed. Recurrence of this disorder is rare, though it has been reported in patients with structural brain abnormalities. This report is the first to describe recurrent takotsubo cardiomyopathy in a patient with transient neurological symptoms. In our patient, as expected in patients with this condition, complete resolution of all left ventricular abnormalities occurred within a short period of time. It is important for clinicians to be aware of this increasingly recognized syndrome, including its association with recurrence, especially in the clinical setting of neurologic dysfunction.

Seizure-associated Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is characterized by chest pain, dyspnea, electrocardiographic changes resembling an acute coronary syndrome, and transient wall-motion abnormalities without identifiable coronary culprit lesion explaining the wall-motion abnormality. Takotsubo cardiomyopathy occurs frequently after emotional or physical stress. Seizures have been reported as triggers of takotsubo cardiomyopathy. It is unknown if seizure-associated takotsubo cardiomyopathy differs from takotsubo cardiomyopathy associated with other triggers. Seizure-associated takotsubo cardiomyopathy cases from the literature were compared with takotsubo cardiomyopathy series comprising 30 or more patients. Thirty-six seizure-associated takotsubo cardiomyopathy cases (6 male, mean-age 61.5 years) were found. Seizure-type were tonic-clonic (n = 13), generalized (n = 5), status epilepticus (n = 6), grand mal (n = 2), or not reported (n = 13). Twelve patients had a history of epilepsy, in 15 patients takotsubo cardiomyopathy-associated seizure was the first or the information was not given (n = 9). In 17 patients takotsubo cardiomyopathy occurred immediately after the seizure, in 9 patients 1-72 h postictally, and in 10 patients, the interval was not reported. In 20 patients neurologic disorders were reported and in 14 psychiatric disorders were reported. There were medical comorbidities in 17 patients, arterial hypertension (n = 11), hyponatremia (n = 2), and cancer (n = 2). Compared with 974 patients reported in takotsubo cardiomyopathy -series, patients with seizure-associated takotsubo cardiomyopathy were younger (61.5 vs. 68.5 years, p < 0.0001), more frequently males (17 vs. 9%, p = 0.004), had less frequent chest pain (6 vs.76%, p < 0.005), more frequent cardiogenic shock (25 vs. 8%, p = 0.003), and more frequent recurrency (14 vs. 3%, p = 0.004). Seizure-associated takotsubo cardiomyopathy manifests frequently as sudden hemodynamic deterioration, which could result in death in the absence of adequate help. Probably some cases of sudden unexpected death in epilepsy are attributable to takotsubo cardiomyopathy.

Autonomic and cellular mechanisms mediating detrimental cardiac effects of status epilepticus

Prolonged seizure activity (status epilepticus; SE) can result in increased susceptibility to lethal ventricular arrhythmias for an extended period of time following seizure termination. SE is accompanied by acute, intense activation of the sympathetic nervous system (SymNS) and results in myocyte myofilament damage, arrhythmogenic alterations in cardiac electrical activity, and increased susceptibility to ventricular arrhythmias. However, the mechanisms mediating the changes in cardiac function, and the specific arrhythmogenic substrate produced during SE are unknown. To determine if detrimental cardiac effects of SE are mediated by SymNS stimulation of the heart, we examined the effects of B-adrenergic blockade (atenolol) during seizure activity on blood pressure, heart rate, myocyte myofilament injury (cardiac troponin I, cTnI), electrocardiographic activity, and susceptibility to arrhythmias. Furthermore, we determined if SE was associated with altered expression of the Kv4.x potassium channels, which are critical for action potential repolarization and thereby contribute significantly to normal cardiac electrical activity. Lithium-pilocarpine induced SE was associated with acute tachycardia, hypertension, and cardiomyocyte damage. Arrhythmogenic alterations in cardiac electrical activity accompanied by increased susceptibility to experimentally induced arrhythmias were evident during the first 2 weeks following SE. Both were prevented by atenolol treatment during seizures. Furthermore, one and two weeks after SE, myocyte ion channel remodeling, characterized by a decreased expression of cardiac Kv4.2 potassium channels, was evident. These data suggest that the cardiac effects of prolonged and intense SymNS activation during SE induce myofilament damage and downregulation of Kv4.2 channels, which alter cardiac electrical activity and increase susceptibility to lethal arrhythmias.

Stress cardiomyopathy

Recently, an increasing number of cases of stress cardiomyopathy, mainly occurring in elderly women, have been documented in many parts of the world. In Japan, this disease is known as takotsubo cardiomyopathy (named after the fishing pot used for trapping octopus). Symptoms of this condition are akin to those of acute myocardial infarction, but no obstructive lesions are found in the coronary arteries, and left ventricular apical ballooning is present. Stress cardiomyopathy is now a well-recognized cause of acute heart failure, lethal ventricular arrhythmias, and ventricular rupture. Although the precise mechanism of onset of this condition is still controversial, two major pathogenic mechanisms have been proposed: catecholamine cardiotoxicity and neurogenic stunned myocardium. We summarize the findings of studies conducted to date on stress cardiomyopathy-from bench to bedside and bedside to bench.

Autonomic alterations and cardiac changes in epilepsy

Studies with heart rate variability have revealed interictal autonomic alterations in patients with epilepsy. In addition, epilepsy is frequently associated with ictal tachycardia or bradycardia, which sometimes precedes the onset of seizures. Ictal tachycardia is sometimes associated with electrocardiography (ECG) morphologic changes and ictal bradycardia often progresses to asystole. Such cardiac manifestations of seizures have been hypothesized as possible causes for sudden unexplained death in epilepsy (SUPEP). The present review relates to interictal and ictal cardiac manifestations of epilepsy with focus on heart rate, heart rate variability, and ECG changes. Aspects of the supporting mechanisms are discussed and attention is drawn to the interaction between central and peripheral effects, interictal autonomic conditions, ictal autonomic discharges, and administration of antiepileptic drugs in shaping the ictal cardiac changes. Because these interactions are complex and not totally understood, closer surveillance of patients and more experimental work is necessary to elucidate the mechanistic support of autonomic and cardiac changes in epilepsy, and to design better strategies to avoid their undesirable effects. It is also suggested that some of these changes could be used as predictors or markers for the onset of seizures.

Status epilepticus induces cardiac myofilament damage and increased susceptibility to arrhythmias in rats

Status epilepticus (SE) is a seizure or series of seizures that persist for >30 min and often results in mortality. Death rarely occurs during or immediately following seizure activity, but usually within 30 days. Although ventricular arrhythmias have been implicated in SE-related mortality, the effects of this prolonged seizure activity on the cardiac function and susceptibility to arrhythmias have not been directly investigated. We evaluated myocardial damage, alterations in cardiac electrical activity, and susceptibility to experimentally induced arrhythmias produced by SE in rats. SE resulted in seizure-related increases in blood pressure, heart rate, and the first derivative of pressure, as well as modest, diffuse myocyte damage assessed by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling staining. Ten to twelve days following seizures, electrocardiographic recordings showed arrhythmogenic alterations in cardiac electrical activity, denoted by prolonged QT interval corrected for heart rate and QT dispersion. Finally, SE increased susceptibility to experimentally induced (intravenous aconitine) cardiac arrhythmias. These data suggest that SE produces tachycardic ischemia following the activation of the sympathetic nervous system, resulting in cardiac myofilament damage, arrhythmogenic alterations in cardiac electrical activity, and increased susceptibility to ventricular arrhythmias.