Pathophysiology of takotsubo syndrome: Acute cardiac sympathetic disruption (ACSD) syndrome

Cardiovascular Manifestations and Complications of Pheochromocytomas and Paragangliomas

Pheochromocytomas and paragangliomas (PPGLs) are rare neuro-endocrine tumors. The catecholamine surge causes paroxysmal or chronic secondary hypertension. PPGLs may present as hypertensive- or PPGL-crisis with severe life-threatening cardiac and cerebrovascular complications. PPGLs-induced cardiac manifestations have been reported with diagnoses as PPGLs-induced electrocardiogram (ECG) changes “mimicking acute myocardial infarction”, arrhythmias, myocarditis, acute coronary syndrome, dilated cardiomyopathy, and lately as takotsubo syndrome. Critical analysis of these reports reveals that most of these cardiac manifestations have certain features in common. They have a dramatic clinical presentation and are reversible if the disease is treated with appropriate medical therapy and surgical resection of the PPGL tumor. They may have the same repolarization ECG changes irrespective of the clinical cardiac diagnosis, usually associated with mild to moderate elevations of myocardial biomarkers as troponins and normal coronary arteries. The histopathological findings are usually focal or multifocal in the form hypercontracted sarcomeres and contraction band necrosis (myofibrillar degeneration) with subsequent secondary mononuclear cell infiltration. Evidences argue the PPGL caused surge of catecholamines triggers hyperactivation of the sympathetic nervous system with cardiac sympathetic nerve terminal disruption with norepinephrine spillover causing the cardiac complications. A comprehensive review of various reported cardiovascular manifestations and complications of PPGLs are presented.

The ECG in the differential diagnosis between takotsubo cardiomyopathy and acute coronary syndrome

INTRODUCTION

Takotsubo cardiomyopathy (TC) is an acquired cardiomyopathy affecting mostly postmenopausal women mimicking an acute coronary syndrome (ACS). TC clinical presentation involves chest pain, elevated cardiac enzymes, wall motion abnormalities and electrocardiographic changes, all of which share striking similarities to ACS. Areas covered: Differential diagnosis between TC and ACS can be complex since there are no reliable and widely-accepted electrocardiographic criteria and, at the moment, only coronary angiography can rule out one of the two diagnoses with good certainty. The present review will discuss the pros and cons of the ECG in TC, focusing on how the signal changes through the acute phase, the hospitalization, and after discharge. Specific information will be provided for each component of the ECG trace, and potential pitfalls will be highlighted, in order get to the core of this important unmet clinical issue. Expert commentary: There are at least several reasons why the ECG is still not considered a useful tool in differential diagnosis between TC and ACS. These include recent awareness of the syndrome, lack of evidence-based therapy, and, more importantly, a wide range of ECG features according to race, patient characteristics, wall motion abnormalities, triggers, and time from symptoms onset.

Takotsubo cardiomyopathy in the setting of acute hydrocephalus secondary to neurocysticercosis

We report the case of a 45-year-old male who presented with transient neurogenic stunned myocardium, or takotsubo cardiomyopathy, secondary to acute hydrocephalus caused by obstruction of the third ventricle by neurocysticercosis.

The pathogenesis of reversible T-wave inversions or large upright peaked T-waves: Sympathetic T-waves

Reversible electrocardiographic (ECG) repolarization changes including T-wave inversions (TWI), large upright peaked T-waves (LUPTW) and prolongation of the corrected QT interval (P-QTc) have been reported in association with myriads of acute cardiac and non-cardiac diseases. Through the last 70 years, the TWIs have been described under different terms as; cerebral, giant, global, canyon, Wellens or coronary and cardiac memory T waves. During the last 15 years, the reversible TWI and LUPTW in association with P-QTc have been described as characteristic ECG features in takotsubo syndrome (TS), which also may be triggered by the same aforementioned acute cardiac and non-cardiac disease entities. The pathogenesis of these reversible T-wave changes is not clear-cut. In this manuscript, substantial evidences for a causal link between the local cardiac sympathetic disruption and the development of the reversible TWI and LUPTW are presented. As a result, a pathogenetic term for the reversible TWI or LUPTW, which is sympathetic T waves (sympathetic TWI or sympathetic LUPTW), would be the most appropriate term.