The coronary flow reserve is transiently impaired in tako-tsubo cardiomyopathy: a prospective study using serial Doppler transthoracic echocardiography

Myocardial microvascular function assessed by cardiovascular magnetic resonance first-pass perfusion in patients with Takotsubo syndrome

OBJECTIVE

The purpose of this study was to explore microvascular function impairment using first-pass cardiovascular magnetic resonance (CMR) in patients with Takotsubo syndrome (TS). Moreover, we explored myocardial microcirculation in patients with TS and related this to demographic data, cardiovascular risk factors, clinical parameters, cardiac biomarkers, and cardiac function.

METHODS

This retrospective study performed CMR first-pass perfusion scans in 42 consecutive patients with TS (37 females, 70.6 ± 9.4 years). Moreover, we included 44 sex- and age-matched healthy controls (33 females, 66.4 ± 10.5 years). CMR-derived myocardial microcirculation function was analyzed and compared between TS patients and controls.

RESULTS

Compared to age-, sex-, and cardiovascular risk factors-matched control group, TS patients demonstrated a lower perfusion index (PI) (0.140 ± 0.060 vs. 0.182 ± 0.056, p = 0.001). In multivariable analysis with adjustment for demographic data and cardiovascular risk factors, an impairment in PI was independently associated with left ventricle ejection fraction (β coefficient = 3.793, p = 0.001) and T2 mapping (β coefficient = -4.316, p = 0.001).

CONCLUSION

TS patients exhibited myocardial microvascular dysfunction, which was non-invasively assessed using first-pass CMR. This impaired myocardial microvascular function was found to be independently associated with left ventricular ejection fraction and myocardial edema.

KEY POINTS

Question Can cardiovascular magnetic resonance (CMR) cardiac MR first-pass perfusion help to better understand Takotsubo pathophysiology by exploring microvascular impairment? Findings CMR first-pass perfusion revealed significant microvascular dysfunction during the acute phase of Takotsubo syndrome, independently associated with left ventricular ejection fraction and myocardial edema. Clinical relevance Identifying an abnormal microvascular network using non-invasive biomarkers could enhance risk stratification and guide tailored management during the acute phase of Takotsubo syndrome.

Emotions & Heart:Exploring the Impact of Negative Emotions on Cardiovascular Health

Negative emotions can have a significant impact on individuals, which then influences their cardiovascular system. However, the underlying pathophysiological mechanisms and clinical implications of this association remain inadequately defined. A narrative review of pertinent literature was conducted to examine the pathophysiology, clinical manifestations, and treatment related to the interplay between emotions and conditions such as takotsubo cardiomyopathy, atherosclerosis, acute plaque rupture, and cardiac arrhythmias. Negative emotions can instigate a chronic stress response, which in turn heightens sympathetic nervous system activity and increases vulnerability to cardiovascular diseases. This intricate relationship between emotional states and cardiovascular health underscores the necessity for targeted lifestyle interventions and clinical strategies aimed at mitigating the adverse effects of negative emotions.

Psychosocial and psychopathological dimensions of patients with Takotsubo Syndrome

BACKGROUND

Takotsubo syndrome (TTS) is an acute reversible heart dysfunction affecting mostly post-menopausal women, frequently precipitated by a significant stressful event, presenting as an acute coronary syndrome (ACS) in the absence of obstructive coronary artery disease. The pathogenesis is not fully understood, but a close relationship between individual's mind, brain, neuroendocrine system and the heart may be involved in a mind-heart axis. The purpose of this study was to compare the prevalence of psychopathological findings in TTS patients as compared to healthy subjects, patients affected by psychiatric diseases and patients affected by ACS.

METHODS

This observational study enrolled 40 female subjects divided into 4 subgroups: TTS patients, healthy subjects, psychiatric patients and ACS patients, matched for age. Psychosocial factors and psychopathological dimensions have been evaluated. Patients who signed informed consent were interviewed by the administration of a complex psychometric battery, including Mini International Neuropsychiatric Interview, Hamilton Rating Scale for Depression, State Trait Anxiety Inventory, Form Y.

RESULTS

Comparing the groups, the TTS group showed a statistically significant difference vs. ACS group concerning psychological violence subscale (P=0.049) of the Childhood Trauma Questionnaire, while significant statistical difference emerged in TTS group vs. healthy subjects control group, regarding cyclothymia subscale (P=0.008). Statistically significant differences were documented in TTS group vs. psychiatric cohort in cyclothymia subscale (P=0.012). Moreover, comparison between TTS and ACS group, revealed a statistically significant difference in the sub-scale of self-confidence and management of negative emotions (P=0.0028). One of the most significant features was the evidence of statistically significant differences in TTS vs. ACS group, concerning total and average value of anxiety (P=0.014 and P=0.031 respectively) and in the comparison of TTS group vs. healthy subjects (P=0.005 for the total anxiety value and P=0.021 for the average value). Finally, both depression and mania were statistically significant raised in the TTS group compared to the healthy subjects' group (P=0.00 and P=0.013, respectively).

CONCLUSIONS

Psychosocial and psychopathological dimensions of TTS patients have been explored and analyzed in a cohort of TTS patients vs. ACS, healthy subjects and psychiatric patients, showing statistically significant differences among the various groups. Psychopathological symptoms were more frequent in TTS patients, suggesting an evident involvement of mind-heart axis in this disease. Future studies are needed to investigate the cause-effect relationship between psychopathological features and the occurrence of TTS.

Coronary microvascular dysfunction in patients with Takotsubo syndrome

BACKGROUND

The pathophysiology of Takotsubo syndrome (TTS) remains incompletely understood. While coronary microvascular dysfunction (CMD) is a potential pathophysiologic mechanism, evidence is limited.

OBJECTIVES

We sought to evaluate CMD in patients with TTS.

METHODS

Consecutive patients diagnosed with TTS were included and underwent coronary angiography with invasive microvascular function evaluation, including fractional flow reserve, Coronary Flow Reserve (CFR), Index of Microcirculatory Resistance (IMR), and Resistive Reserve Ratio (RRR). Patients had an echocardiography evaluation during their index admission and at approximately 6 weeks.

RESULTS

Thirty patients were included (mean age 74 ±9, 90 % female). Twenty-five patients (83 %) had at least one abnormal coronary microvascular function parameter. Abnormal parameters included CFR<2.5 in 20 patients (67 %), IMR>25 in 18 patients (60 %), and RRR<3.5 in 25 (83 %). Longer time from symptoms to angiography correlated with a higher CFR (r = 0.51, P<0.01), and had an area under the receiver operating characteristic curve of 0.793 (95 % CI 0.60-0.98) for pathologic CFR. Patients with emotional trigger had a lower rate of pathologic IMR compared with non-emotional trigger (36 % vs 81 %, p = 0.01). Follow up echocardiography performed at a median of 1.5 months (IQR 1.15-6) showed an improvement in left ventricular ejection fraction for all patients (from mean of 40 % to 57 %).

CONCLUSION

CMD was present in most patients with TTS. The role of microvascular function in TTS may vary according to the clinical presentation and RRR may be more sensitive for the diagnosis of CMD in TTS.

Coronary microvascular dysfunction beyond the spectrum of chronic coronary syndromes

The prevalence of coronary microvascular dysfunction (CMD) beyond the spectrum of chronic coronary syndromes (CCS) is non-negligible, pertaining to pathophysiological and therapeutical implications. Thanks to the availability of accurate and safe non-invasive technique, CMD can be identified as a key player in heart failure, cardiomyopathies, Takotsubo syndrome, aortic stenosis. While CMD is widely recognized as a cause of myocardial ischemia leading to a worse prognosis even in the absence of obstructive coronary artery disease, the characterization of CMD patterns beyond CCS might provide valuable insights on the underlying disease progression, being potentially a "red flag" of adverse cardiac remodeling and a major determinant of response to therapy and outcomes. In this review, we aimed to provide an overview of the latest evidence on the prevalence, mechanistic and prognostic implications of CMD beyond the spectrum of CCS (i.e. heart failure, cardiomyopathies, Takotsubo syndrome, aortic stenosis).

Contemporary characteristics, outcomes and novel risk score for Takotsubo cardiomyopathy: a national inpatient sample analysis

BACKGROUND

Takotsubo cardiomyopathy (TC) is an established differential diagnosis of myocardial infarction with non-obstructive coronaries with significant interest but limited data on prognostication. We reviewed the characteristics and in-hospital outcomes and developed a novel risk score for TC.

METHODS

Using the National Inpatient Sample data from 2016 to 2020, we identified adult patients (≥18 years) with acute coronary syndrome (ACS) and TC. We divided the cohort into ACS with and without TC and retrieved baseline data. Multivariable regression analysis was conducted to identify factors associated with TC diagnosis and adverse outcomes, leading to the development of a risk-scoring system.

RESULTS

Among 7 219 004 adult ACS admissions, 78 214 (1.0%) were diagnosed with TC, with a mean age of 68.2 years, 64 526 (82.5%) being female and 5475 (7.0%, compared with 8.4% for other ACS) in-hospital mortality events. Factors significantly associated with TC were female sex (OR 6.78 (95% CI 6.47 to 7.09), p<0.001) and chronic heart failure (OR 1.60 (95% CI 1.54 to 1.66), p<0.001). A novel risk score was developed, including the following parameters: male sex, age >70 years, non-white race, hypertension, hyperlipidemia, history of coronary artery bypass grafting, history of percutaneous coronary intervention, cardiac arrhythmias, renal failure, cardiogenic shock and vasopressor use. The area under curves for in-hospital mortality was 0.716 in the derivation and 0.725 in the validation cohorts.

CONCLUSIONS

TC remains a high-risk diagnosis in a minority of ACS cases, with mortality rates similar to other ACS causes. Our novel risk score offers a valuable tool for risk stratification in patients with TC, but external validation is needed to confirm its utility.

Noninvasive Assessment in Takotsubo Syndrome: A Diagnostic Challenge

Takotsubo syndrome (TTS) is a clinical syndrome characterized by a transient left ventricular dysfunction whose diagnosis can be challenging due to its resemblance to acute myocardial infarction (AMI). Despite the growing recognition of TTS, acute complications and long-term mortality rates are comparable to those observed in AMI patients. In this context, a systematic diagnostic approach is imperative for an accurate patient assessment, with due consideration of the distinctive characteristics and optimal timing of each imaging modality. Coronary angiography with ventriculography may be reserved for cases presenting with ST-segment elevation, whereas in all other cases, the use of multimodality noninvasive imaging allows for a comprehensive evaluation of typical diagnostic features and detection of acute complications while also providing prognostic insights. The aim of this review is to evaluate the current research on non-invasive modalities and to propose a diagnostic algorithm that will facilitate the identification and management of TTS.

Myocardial flow reserve recovery in patients with Takotsubo syndrome: Insights from positron emission tomography

BACKGROUND

Coronary microvascular dysfunction (CMD) has been implicated in the pathogenesis of Takotsubo syndrome (TTS). Positron emission tomography (PET) plays a key role in the assessment of CMD through myocardial flow reserve (MFR). However, there is limited information on the temporal progression of MFR and its relationship to coronary artery disease (CAD) in TTS patients.

METHODS

This study evaluated patients with TTS who underwent cardiac catheterization and PET within one year of hospitalization. Patients were categorized into acute (≤10 days), subacute (11-30 days), and chronic (≥31 days) stages based on post-onset time of PET assessment. MFR values and prevalence of abnormal MFR (<2.0) were compared between stages. Temporal MFR changes in patients with obstructive CAD (≥70% stenosis by coronary angiography), non-obstructive CAD, and normal coronaries were compared.

RESULTS

Of the 88 patients studied (mean age 70; 96% female), 52 (59%) were in the acute, 17 (19%) in the subacute, and 19 (22%) in the chronic stage. Median MFR in the acute stage was 2.0 (1.5-2.3), with 58% of patients showing abnormal MFR. A significant time-dependent improvement in MFR was observed (P = 0.002), accompanied by a decreased prevalence of abnormal MFR (P = 0.016). While patients with normal coronaries showed significant MFR improvement over time (P = 0.045), patients with obstructive or non-obstructive CAD demonstrated no improvement across three stages (P = 0.346 and 0.174, respectively).

CONCLUSION

PET-derived MFR was impaired in TTS patients during the acute phase, with improvement suggesting potential recovery from CMD over time. The concurrent presence of obstructive CAD might impede this recovery process.

Takotsubo syndrome : A cause of reversible microvascular coronary dysfunction

Since the first description of takotsubo syndrome 30 years ago, only a little is known on the underlying physiopathology leading to peculiar left ventricular function alteration and myocardial damage related to acute emotional or physical stress. In the present case, we used continuous invasive thermodilution to evaluate coronary microvascular function at the acute phase of takotsubo and after recovery. The acute phase of takotsubo was characterized by a reduced coronary output and altered reserved flow with persistently high resistance during hyperaemia. At 6 weeks, we described a complete recovery of microvascular function, concomitant to LVEF recovery.

Takotsubo syndrome is a coronary microvascular disease: experimental evidence

BACKGROUND AND AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

Evolution of non-invasive myocardial work in tako-tsubo cardiomyopathy

Tako-tsubo cardiomyopathy (TTC) is characterized by left ventricular (LV) systolic dysfunction with transient wall motion abnormalities (WMA). However, whether systolic performance fully recovers is unclear. Non-invasive myocardial work (MW) is a new tool to assess the LV performance, never described in this setting. To assess MW in apical TTC. Fifty patients with the apical variant TTC (77 ± 10 years, 47 women) were enrolled and underwent a transthoracic echocardiography within 24 h of admission and a median of 36 days at follow-up (FU). Constructive work (CW), wasted work (WW), MW index (MWI) and efficiency (MWE) were derived from a strain- pressure loop obtained from non-invasive brachial blood pressure and 2D strain. Hospital complications (HC) were defined as heart failure, LV apical thrombus, and ventricular arrhythmia. A control group of 24 matched-subjects was used. Myocardial work improved significantly between the acute phase and follow-up (global, and all apical and middle segments for all indices, all, p < 0.01; and some basal segments for MWI and CW, all p < 0.05). The degree of impairment of MW followed an apical-basal gradient (worse in apical segments), which inverted at follow-up. Furthermore, in TTC, global CW and MWI were significantly impaired in patients with HC (n = 10, all p < 0.05). At follow-up, global and regional MW remained significantly reduced by comparison to the control group (CW, MWI, MWE, WW, all p < 0.01), despite similar hemodynamics, LVEF and 2D-strain (all, p = NS). Myocardial work is transiently altered in apical TTC and significantly associated to HC. Despite total recovery of WMA, subtle dysfunction of myocardial performance persists at FU.

Assessment and Treatment for Coronary Microvascular Dysfunction by Contrast Enhanced Ultrasound

With growing evidence in clinical practice, the understanding of coronary syndromes has gradually evolved out of focusing on the well-established link between stenosis of epicardial coronary artery and myocardial ischemia to the structural and functional abnormalities at the level of coronary microcirculation, known as coronary microvascular dysfunction (CMD). CMD encompasses several pathophysiological mechanisms of coronary microcirculation and is considered as an important cause of myocardial ischemia in patients with angina symptoms without obstructive coronary artery disease (CAD). As a result of growing knowledge of the understanding of CMD assessed by multiple non-invasive modalities, CMD has also been found to be involved in other cardiovascular diseases, including primary cardiomyopathies as well as heart failure with preserved ejection fraction (HFpEF). In the past 2 decades, almost all the imaging modalities have been used to non-invasively quantify myocardial blood flow (MBF) and promote a better understanding of CMD. Myocardial contrast echocardiography (MCE) is a breakthrough as a non-invasive technique, which enables assessment of myocardial perfusion and quantification of MBF, exhibiting promising diagnostic performances that were comparable to other non-invasive techniques. With unique advantages over other non-invasive techniques, MCE has gradually developed into a novel modality for assessment of the coronary microvasculature, which may provide novel insights into the pathophysiological role of CMD in different clinical conditions. Moreover, the sonothrombolysis and the application of artificial intelligence (AI) will offer the opportunity to extend the use of contrast ultrasound theragnostics.

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.

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.

An Unfortunate Case of Takotsubo Cardiomyopathy During Plasmapheresis for Myasthenia Crisis

A literature review shows scarce reports of myasthenic crises (MC) complicated by Takotsubo cardiomyopathy (TC). This patient cohort (0.11%) has higher all-cause mortality and prolonged in-hospital course. We present a rare case of a 72-year-old man who developed cardiogenic shock post-plasmapheresis for myasthenia crisis. He became hemodynamically unstable and developed acute respiratory failure requiring intubation 30 minutes after completion of plasma exchange. Serum troponin peaked at 3.19 ng/mL while an emergent 12-lead electrocardiogram (EKG) showed new-onset diffuse ST-segment elevation. Hypokinesis of the entire apex, anterior septum, mid-and apical inferior septum, and mid-and apical inferior wall consistent with Takotsubo cardiomyopathy was seen on bedside echocardiogram. The patient received a continuous infusion of norepinephrine and vasopressin. The hospital course was complicated by multiorgan failure and eventual demise. This case highlights MC and the potential of plasma exchange therapy to induce TC.

Coronary Microvascular Dysfunction Across the Spectrum of Cardiovascular Diseases: JACC State-of-the-Art Review

Coronary microvascular dysfunction (CMD) encompasses several pathogenetic mechanisms involving coronary microcirculation and plays a major role in determining myocardial ischemia in patients with angina without obstructive coronary artery disease, as well as in several other conditions, including obstructive coronary artery disease, nonischemic cardiomyopathies, takotsubo syndrome, and heart failure, especially the phenotype associated with preserved ejection fraction. Unfortunately, despite the identified pathophysiological and prognostic role of CMD in several conditions, to date, there is no specific treatment for CMD. Due to the emerging role of CMD as common denominator in different clinical phenotypes, additional research in this area is warranted to provide personalized treatments in this "garden variety" of patients. The purpose of this review is to describe the pathophysiological mechanisms of CMD and its mechanistic and prognostic role across different cardiovascular diseases. We will also discuss diagnostic modalities and the potential therapeutic strategies resulting from recent clinical studies.

Microcirculation in Patients with Takotsubo Syndrome-The Prospective CIRCUS-TTS Study

The pathophysiology of Takotsubo syndrome (TTS) is incompletely understood. A sympathetic overdrive with coronary microvascular dysfunction might play a central role. The aim of our study was to assess the status of the systemic microcirculation (MC) of patients with TTS, compared to patients with myocardial infarction (MI) and healthy subjects. The systemic microvascular function of 22 TTS patients, 20 patients with MI and 20 healthy subjects was assessed via sublingual sidestream dark-field imaging. In TTS and MI patients, measurements were performed during the acute phase (day 1, 3 and 5) and after 3 months. The measurement in healthy subjects was performed once. The assessed parameters were number of vessel crossings, number of perfused vessel crossings, proportion of perfused vessels, total vessel density and perfused vessel density. The results did not show relevant differences between the investigated groups. Some minor, albeit statistically significant, differences occurred rather randomly. The MC parameters of the TTS group did not show any relevant changes in the temporal course. A systemic microvascular dysfunction could not be identified as a contributing factor in the pathogenesis of TTS. A possible microvascular dysfunction might instead be caused by a local effect restricted to the coronary microvascular bed.

Current Knowledge and Future Challenges in Takotsubo Syndrome: Part 1-Pathophysiology and Diagnosis

First recognized in 1990, takotsubo syndrome (TTS) constitutes an acute cardiac condition that mimics acute myocardial infarction commonly in the absence of obstructive coronary artery disease; it is characterized by temporary left ventricular dysfunction, regularly in a circumferential apical, midventricular, or basal distribution. Considering its acute clinical presentation, coronary angiography with left ventriculography constitutes the gold standard diagnostic tool to exclude or confirm TTS. Frequently, TTS is related to severe emotional or physical stress and a subsequent increased adrenergic stimulation affecting cardiac function. Beyond clinical presentation, epidemiology, and novel diagnostic biomarkers, this review draws attention to potential pathophysiological mechanisms for the observed reversible myocardial dysfunction such as sympathetic overdrive-mediated multi-vessel epicardial spasms, microvascular dysfunction, the direct toxicity of catecholamines, lipotoxicity, and inflammation. Considering the long-term prognosis, further experimental and clinical research is indispensable to elucidate further pathophysiological mechanisms underlying TTS before randomized control trials with evidence-based therapeutic management can be performed.

Takotsubo syndrome and rheumatic diseases-a critical systematic review

Since its description in 1990, Takotsubo syndrome (TTS), an acute cardiac condition triggered by physical or emotional stress, has been believed to be related to catecholamine surge from overwhelming sympathetic activity. While symptomatology, biochemical features, ECG and echocardiogram alterations are largely indistinguishable from acute coronary syndrome, the absence of culprit coronary lesions often necessitates further investigations, uncovering underlying inflammatory processes. Mechanistically, animal models of TTS reveal early neutrophil infiltration followed by staged ingression of two subtypes of macrophages (M1, M2) mediating initial acute inflammatory changes (M1), followed by switching to anti-inflammatory signals (M2) that enhance myocardial tissue recovery. Here, we begin with a description of two TTS patients with primary Sjögren's syndrome and Takayasu's arteritis, followed by a systematic literature review that summarizes the demographic and clinical features of TTS patients with rheumatological conditions. Potential impact of disease manifestations and treatment of rheumatological conditions on TTS are critically discussed.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase.

Takotsubo cardiomyopathy in the setting of a myasthenic crisis

BACKGROUND

Myasthenic crisis is characterized by severe weakness in bulbar and respiratory muscles leading to respiratory failure and can be a natural result of myasthenia gravis or precipitate due to infections, surgeries, and pregnancy. It has been shown that stressful emotional events can lead to stress, or takotsubo cardiomyopathy. Takotsubo cardiomyopathy is characterized by transient reversible left ventricular dysfunction in the absence of obstructive artery disease with hypo- or akinesis of the apex with hypercontractility of the base.

METHODS

Case report and review of literature.

RESULTS

We report a 77-year old man with myasthenia gravis that was admitted to the neurological intensive care unit due to a myasthenic crisis. During the course of his treatment with plasma exchange, he developed hypotension with a reduced cardiac ejection fraction found on transthoracic electrocardiography. Repeat echocardiography 2 and 8 days later showed a normal ejection fraction and resolved cardiac function.

CONCLUSION

While takotsubo cardiomyopathy rarely presents concurrently with a myasthenic crisis, its consideration is warranted in the face of cardiovascular decompensation. Given that several cardiac complications are known to be associated with myasthenic crisis, cardiac monitoring is advised. Nine reports describe takotsubo cardiomyopathy occurring concurrently with a myasthenic crisis; however, only one report demonstrates this association in the absence of concomitant comorbidities or significant emotional distress.

Racial differences in takotsubo cardiomyopathy outcomes in a large nationwide sample

Aims

Takotsubo cardiomyopathy (TC) is characterized by transient ventricular impairment, often preceded by emotional or physical stress. Racial differences affect the outcomes of several cardiovascular conditions; however, the effect of race on TC remains unknown. This investigation aims to assess the effect of race on in‐hospital outcomes of TC in a large national sample.

Methods and results

We conducted a US‐wide analysis of TC hospitalizations from 2006 to 2014 by querying the National Inpatient Sample database for the International Classification of Diseases‐ninth Revision TC code, characteristics, and inpatient outcomes. Patients with a primary diagnosis of acute coronary syndrome were excluded to reduce selection bias. Caucasians were compared with African Americans (AA) for differences in baseline characteristics and in‐hospital outcomes. Multivariate regression models were created to adjust for potential confounders. Of 97 650 TC patients, 83 807 (86.9%) were women, 89 624 (91.8%) identified as Caucasians, and 8026 (8.2%) as AA. The annual number of TC hospitalizations increased significantly from 2006 to 2014 in both races (from 335 to 21 265 annual cases, P < 0.001). In‐hospital mortality initially increased (1–2% in 2006 to 5–6% in 2009, P < 0.001) and subsequently remained relatively stable around 5–7% with no significant difference between races. In unadjusted analysis, AA had more cardiac arrests [304 (3.8%) vs. 2569 (2.9%), P = 0.04], invasive mechanical ventilation [1671 (20.8%) vs. 15 897 (17.7%), P = 0.002], tracheostomies [242 (3%) vs. 1600 (1.8%), P = 0.001], acute kidney injuries [1765 (22%) vs. 14 608 (16.3%), P < 0.0001], and longer hospital stays [4.5 (3.2–4.8) vs. 3.8 (3.7–3.9) days, P < 0.0001] compared with Caucasians. After the adjustment for differences in age, gender, comorbidities (using the enhanced Charlson comorbidity index), hospital location/teaching status, and socio‐economic factors, all differences were significantly attenuated or eliminated. Additionally, the adjusted risk was lower in AA compared with Caucasians, for cardiogenic shock [odds ratio (OR) 0.61 (0.47–0.78), P < 0.0001], mechanical ventilation [OR 0.8 (0.70–0.92), P = 0.002] and intraaortic balloon pump insertion [OR 0.63 (0.41–0.99), P = 0.04].

Conclusions

Our investigation is the first large US‐wide analysis studying racial variations in TC outcomes. AA overall have more in‐hospital complications; however, the differences are driven by racial disparities in demographics, comorbidities, and socio‐economic factors.

International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology

Takotsubo syndrome (TTS) is a poorly recognized heart disease that was initially regarded as a benign condition. Recently, it has been shown that TTS may be associated with severe clinical complications including death and that its prevalence is probably underestimated. Since current guidelines on TTS are lacking, it appears timely and important to provide an expert consensus statement on TTS. The clinical expert consensus document part I summarizes the current state of knowledge on clinical presentation and characteristics of TTS and agrees on controversies surrounding TTS such as nomenclature, different TTS types, role of coronary artery disease, and etiology. This consensus also proposes new diagnostic criteria based on current knowledge to improve diagnostic accuracy.

An Emerging Cardiovascular Disease: Takotsubo Syndrome

Takotsubo syndrome (TTS) is a recently identified cardiac disease, which is far from being completely known. The aims of this narrative review are to provide a better understanding of the pathophysiological features of TTS and to update clinical findings in order to improve the management of subjects affected by this syndrome (according to the most recent consensus papers issued by the international scientific societies). We based our search on the material obtained via PubMed up to April 2019. The terms used were "Takotsubo Syndrome and Takotsubo cardiomyopathy" in combination with "heart failure, pathophysiology, complications, diagnosis, and treatment." TTS is a reversible form of ventricular dysfunction usually characterized by akinesia of the apex in the absence of obstructive coronary artery disease. In its initial phase, TTS may be indistinguishable from AMI and is usually triggered by a sudden emotional/physical stressor which abruptly increases catecholamine levels. However, the mechanisms by which catecholamines or other unidentified molecules can cause myocardial dysfunction is unknown. In-hospital stay may be hampered by various life-threatening complications, while data on long-term survival remain scarce and unclear. Furthermore, TTS may sometimes recur. We believe that TTS is clearly a much more complex condition than previously thought. Much remains to be discovered about its pathophysiologic mechanisms, the role of the link between the heart and brain and that of triggering factors and gender, and the reasons why this syndrome displays different phenotypes and sometimes recurs. Undoubtedly, preliminary evidence from pathophysiological studies (mainly genetic studies) has shown promising advances. However, prospective randomized clinical trials are still needed in order to identify and to tailor the best medical treatments for TTS patients.

Comparison of quantitative flow ratio value of left anterior descending and circumflex coronary artery in patients with Takotsubo syndrome

Takotsubo syndrome (TTS) is an acute cardiac event without epicardial coronary obstruction but often with reversible ventricular motion abnormalities. Quantitative flow ratio (QFR) is a novel approach to evaluate the coronary stenosis significance on the basis of 3-dimensional quantitative coronary angiography (3D-QCA) and contrast flow by Thrombolysis in Myocardial Infarction frame count. This study aimed to evaluate and compare the QFR value in the left anterior descending artery (LAD) and the left circumflex artery (LCx) in patients with TTS. This retrospective and observational study enrolled 30 patients with TTS who underwent coronary angiography. We evaluated the QFR data using the 3D-QCA analysis and compared the QFR data in the LAD and the LCx. No significant differences were observed in terms of flow velocity, percent diameter stenosis, minimum lumen diameter, and reference diameter between LAD and LCx. However, vessel QFR in the LAD was significantly reduced compared with that in the LCx (0.98 [0.94 to 0.99] vs. 1.00 [0.99 to 1.00], P < 0.001). Ejection fraction at baseline and initial troponin-I levels were not correlated with the vessel QFR both in the LAD and the LCx. The QFR value in the LAD was significantly reduced compared to that in the LCx in patients with TTS.

Advancements in the diagnostic workup, prognostic evaluation, and treatment of takotsubo syndrome

Takotsubo syndrome (TTS) is an acute and mostly reversible cardiomyopathy that mimics an acute coronary syndrome with left ventricular (LV) systolic dysfunction without relevant obstructive coronary artery disease. Its prevalence is probably underestimated and reaches 1.2-2% in patients with acute coronary syndrome undergoing coronary catheterization. Although supraphysiological epinephrine levels have been associated with TTS, the detailed pathophysiology is incompletely understood. Chest pain is the most common clinical presentation; however, cardiac decompensation, cardiogenic shock, and sudden cardiac death due to ventricular fibrillation may also be the first clinical manifestations. Patients are mostly postmenopausal women, in whom the condition is commonly associated with emotional triggers; however, men have a higher prevalence of TTS being associated with physical triggers, which has a worse prognosis compared with TTS associated with emotional triggers. As a diagnosis of exclusion, TTS has no single definitive diagnostic test. According to the distribution of LV wall motion abnormalities, various morphological subtypes have been identified. The final diagnosis depends on cardiac imaging with left ventricular angiography during acute heart catheterization, as well as on echocardiography and cardiac magnetic resonance. Most patients recover completely, albeit several factors have been associated with worse prognosis. Management is based on observational data, while randomized multicenter studies are still lacking. This review provides a general overview of TTS and focuses on the hypothesized pathophysiology, and especially on current practices in diagnosis, prognosis, and treatment.

Usefulness of Malignancy as a Predictor of WorseIn-Hospital Outcomes in Patients With Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TC) is a form of dilated cardiomyopathy often associated with physical or emotional stress. Association with cancer has been reported, however, in-hospital outcomes in TC patients with history of malignancy have not been fully characterized. We conducted a retrospective chart review of hospitalized patients with diagnosis of TC between January 2006 and January 2017. Patients were divided into 2 groups based on the previous history of malignancy. Presenting symptoms, cardiac imaging and short-term events including in-hospital complications and mortality, were compared. Of 318 patients with TC, 81 (25.4%) had a previous diagnosis of cancer. Mean age was 67.5 (SD 12.6), 151 (47.5%) were African American, 122 (38.4%) Caucasian, and 10 (3.1%) of other ethnicities. Patients with history of malignancy were older (70.0 [SD 10.6] vs 66.6 [SD 13.1] years, p = 0.03), had higher heart rate on presentation (93 [SD 19] vs 87 [SD 25] beats/minute, p = 0.03), higher prevalence of severely decreased cardiac function (left ventricular ejection fraction <25%) (29.6% vs 16%, p = 0.01), longer hospitalization (7 (4-13) vs 4 (3-8) days, p = 0.001) and experienced more in-hospital cardiac arrests (6 [7.4%] vs 5 [2.1%], p = 0.035) compared with patients without malignancy history. Higher percentage of longer hospitalization and left ventricular ejection fraction <25% in the cancer group persisted after controlling for sepsis, chemotherapy exposure, and metastatic disease. In conclusion, in a racially diverse hospitalized population of TC, prevalence of cancer history is high, and diagnosis of previous malignancy is associated with adverse in-hospital outcomes.

International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management

The clinical expert consensus statement on takotsubo syndrome (TTS) part II focuses on the diagnostic workup, outcome, and management. The recommendations are based on interpretation of the limited clinical trial data currently available and experience of international TTS experts. It summarizes the diagnostic approach, which may facilitate correct and timely diagnosis. Furthermore, the document covers areas where controversies still exist in risk stratification and management of TTS. Based on available data the document provides recommendations on optimal care of such patients for practising physicians.

International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology

Takotsubo syndrome (TTS) is a poorly recognized heart disease that was initially regarded as a benign condition. Recently, it has been shown that TTS may be associated with severe clinical complications including death and that its prevalence is probably underestimated. Since current guidelines on TTS are lacking, it appears timely and important to provide an expert consensus statement on TTS. The clinical expert consensus document part I summarizes the current state of knowledge on clinical presentation and characteristics of TTS and agrees on controversies surrounding TTS such as nomenclature, different TTS types, role of coronary artery disease, and etiology. This consensus also proposes new diagnostic criteria based on current knowledge to improve diagnostic accuracy.

The Sympathetic Nervous System in the Pathogenesis of Takotsubo Syndrome

Takotsubo syndrome is a unique clinical condition of acute heart failure and reversible left ventricular dysfunction frequently precipitated by sudden emotional or physical stress. There is growing evidence that exaggerated sympathetic stimulation is central to the pathogenesis of this syndrome. Precisely how catecholamines mediate myocardial stunning in takotsubo syndrome remains incompletely understood; but possible mechanisms include epicardial spasm, microvascular dysfunction, direct adrenergic-receptor-mediated myocyte injury, and systemic vascular effects that alter ventricular-arterial coupling. Risk factors that increase sympathetic tone and/or catecholamine sensitivity may render individuals particularly susceptible to takotsubo syndrome during episodes of acute stress.

Contemporary Imaging in Takotsubo Syndrome

Transthoracic echocardiography is the first-line imaging modality for evaluating patients with Takotsubo syndrome (TTS). Beyond diagnosis, TTE enables detection of peculiar complications and is useful for risk stratification and management of patients with cardiogenic shock. Cardiac magnetic resonance can be used to detect myocardial edema typically associated with TTS and is helpful in the differential diagnosis with other disease states. Coronary computed tomography angiography can be performed as an alternative to coronary angiography to confirm coronary artery patency. Molecular imaging is a promising approach for identifying patients at increased risk of recurrence.

Recurrent takotsubo with prolonged QT and torsade de pointes and left ventricular thrombus

Takotsubo cardiomyopathy, also known as “takotsubo syndrome,” refers to transient apical ballooning syndrome, stress cardiomyopathy, or broken heart syndrome and is a recently recognized syndrome typically characterized by transient and reversible left ventricular dysfunction that develops in the setting of acute severe emotional or physical stress. Increased catecholamine levels have been proposed to play a central role in the pathogenesis of the disease, although the specific pathophysiology of this condition remains to be fully determined. At present, there have been very few reports of recurrent takotsubo cardiomyopathy. In this case report, we present a patient with multiple recurrences of takotsubo syndrome triggered by severe emotional stress that presented with recurrent loss of consciousness, QT prolongation, and polymorphic ventricular tachycardia (torsade de pointes) and left ventricular apical thrombus.

Myocardial perfusion echocardiography and coronary microvascular dysfunction

Our understanding of coronary syndromes has evolved in the last two decades out of the obstructive atherosclerosis of epicardial coronary arteries paradigm to include anatomo-functional abnormalities of coronary microcirculation. No current diagnostic technique allows direct visualization of coronary microcirculation, but functional assessments of this circulation are possible. This represents a challenge in cardiology. Myocardial contrast echocardiography (MCE) was a breakthrough in echocardiography several years ago that claimed the capability to detect myocardial perfusion abnormalities and quantify coronary blood flow. Research demonstrated that the integration of quantitative MCE and fractional flow reserve improved the definition of ischemic burden and the relative contribution of collaterals in non-critical coronary stenosis. MCE identified no-reflow and low-flow within and around myocardial infarction, respectively, and predicted the potential functional recovery of stunned myocardium using appropriate interventions. MCE exhibited diagnostic performances that were comparable to positron emission tomography in microvascular reserve and microvascular dysfunction in angina patients. Overall, MCE improved echocardiographic evaluations of ischemic heart disease in daily clinical practice, but the approval of regulatory authorities is lacking.

Takotsubo

Takotsubo cardiomyopathy (often referred to as broken heart syndrome) typically presents as apical ballooning, chest pain, shortness of breath, abnormal cardiac enzymes, and electrocardiogram changes. Although takotsubo cardiomyopathy mimics symptoms of an acute coronary event, in most cases it is a reversible cardiomyopathy with no long-term effects. Echocardiography is the noninvasive test of choice for initial presentation and follow-up of this syndrome. A case of takotsubo cardiomyopathy is presented and its clinical signs, echocardiographic features, and management discussed.

Systolic anterior motion of the mitral valve in tako-tsubo cardiomyopathy: Still a matter of debate?

We present a case which developed a typical tako-tsubo-like cardiomyopathy (TTC) during dobutamine stress echocardiography (DSE). Its originality is related to several findings, which have never been described simultaneously in the same patient. This 63-year-old woman with normal coronary angiography and no evidence of coronary vasospasm had a biphasic response to DSE, a finding which usually occurs in coronary artery disease. Moreover, the symmetric extensive wall motion abnormalities (WMA) occurred simultaneously with the development of a systolic anterior motion of the mitral valve (SAM) and left ventricular obstruction, and was clinically asymptomatic. Although in TTC the stunning usually occurs for several days, WMA and SAM resolved within few minutes after cessation of dobutamine and administration of a beta-blocker. And finally, exercise echo performed at the same target heart rate few days later did not induce neither a SAM nor WMA, which suggests that left ventricular obstruction could have played a role in the pathogenesis of this case by supply-demand mismatch. Concomitant coronary microvascular dysfunction was also demonstrated by a reduction of the non-invasive coronary flow reserve in the distal part of the left anterior descending artery.

Coronary flow reserve during dobutamine stress in Takotsubo stress cardiomyopathy

OBJECTIVES

Takotsubo stress cardiomyopathy (TSC) is an increasingly recognised and diagnosed disease, although the underlying pathophysiology is still unknown. Our aim was to investigate the effect of the catecholamine dobutamine on coronary flow reserve (CFR) measured non-invasively in patients with TSC and controls. Our hypothesis was that dobutamine stress can induce microvascular dysfunction in patients with a previous episode of TSC.

SETTING

This is a case-control study and a substudy of the Stockholm Myocardial Infarction with Normal Coronaries (SMINC) study. Elective dobutamine investigations were performed focusing on non-invasive measurements of CFR. The investigations were performed more than 6 months after the acute event.

PARTICIPANTS

22 patients with a previous episode of TSC and 22 sex-matched and age-matched controls were recruited from the SMINC study. All patients with TSC had a previous normal cardiovascular MR investigation.

RESULTS

CFR at low-dose dobutamine was significantly lower in the TSC group compared with controls, 1.51 and 1.72, respectively (p=0.017). At high-dose dobutamine, CFR was 1.95 and 2.21 in the TSC group and controls, respectively (p=0.098).

CONCLUSIONS

We could not confirm that the catecholamine dobutamine induced microvascular dysfunction in patients with TSC. However, we found a small but significant difference in CFR at low-dose dobutamine, which implies that the role of microvascular function in TSC needs to be further explored.

Coronary Flow Velocity Reserve Assessment with Transthoracic Doppler Echocardiography

Coronary flow velocity reserve (CFVR) reflects global coronary atherosclerotic burden, endothelial function and state of the microvasculature. It could be measured using transthoracic Doppler echocardiography in a non-invasive, feasible, reliable and reproducible fashion, following a standardised protocol with different vasodilatory stimuli. CFVR measurement is a recommended complement to vasodilator stress echocardiography. It could serve as a diagnostic tool for coronary microvascular dysfunction and in the setting of epicardial coronary artery stenoses could help in identification and assessment of functional significance of coronary lesions and follow-up of patients after coronary interventions. CFVR has also a prognostic significance in different clinical situations.

Single-wire pressure and flow velocity measurement for quantifying microvascular dysfunction in patients with coronary vasospastic angina

Endothelial and vascular smooth muscle dysfunction of epicardial coronary arteries play a pivotal role in the pathogenesis of vasospastic angina (VSA). However, coronary microvascular (MV) function in patients with VSA is not fully understood. In the present study, subjects without coronary obstruction were divided into two groups according to the acetylcholine provocation test: VSA group ( n = 29) and non-VSA group ( n = 21). Hyperemic MV resistance (hMR) was measured using a dual-sensor (Doppler velocity and pressure)-equipped guidewire, and guidewire-derived hemodynamic parameters were compared. There were no between-group differences in clinical demographics, including potential factors affecting MV function (e.g., diabetes). Although coronary flow velocity reserve was similar between the two groups [2.4 ± 1.0 (VSA group) vs. 2.4 ± 0.9 (non-VSA group); P = 0.8], coronary vessel resistance and hMR were significantly elevated in the VSA group compared with the non-VSA group (2.6 ± 3.1 vs. 1.2 ± 0.8, P = 0.04; 1.9 ± 0.6 vs. 1.6 ± 0.5, P = 0.03, respectively). Coronary vasospasm, older age, E/e', and estimated glomerular filtration rate were significantly associated with MV dysfunction [defined as ≥ median value of hMR (1.6)] in univariate analysis. Coronary vasospasm most strongly predicted higher hMR in multivariate logistic regression analysis (odds ratio, 4.61; 95% confidence interval, 0.98–21.60; P = 0.053). In conclusion, coronary MV resistance is impaired in patients with VSA compared with non-VSA patients, whereas coronary flow velocity reserve is maintained at normal levels in both groups. In vivo assessment of hMR might be a promising index of coronary MV dysfunction in patients with VSA.

Apical myocardial infarction with bizarre coronary images mimicking left ventricular apical ballooning syndrome: a case report

Introduction

Although several etiopathogenetic mechanisms have been proposed, the causes of left ventricular apical ballooning syndrome are still controversial.

Case presentation

A 51-year-old Japanese woman consulted the emergency room complaining of the sudden onset of anterior chest pain while shopping. We initially suspected her disease as left ventricular apical ballooning syndrome based on her clinical background and laboratory examinations. However, the initial coronary angiogram demonstrated diffuse lesions in her distal left anterior descending coronary artery, and she was finally diagnosed with apical myocardial infarction. The blood flow in her distal left anterior descending coronary artery had markedly improved in the chronic phase. If the reduced blood flow in her distal left anterior descending coronary artery was induced by coronary vasospasm and the vasospasm was relieved before the coronary angiogram was performed, this case must be diagnosed as left ventricular apical ballooning syndrome.

Conclusion

We think this case may promote discussion regarding the pathophysiology of left ventricular apical ballooning syndrome.

Standard and advanced echocardiography in takotsubo (stress) cardiomyopathy: clinical and prognostic implications

Echocardiography is frequently the initial noninvasive imaging modality used to assess patients with takotsubo cardiomyopathy (TTC). Standard transthoracic echocardiography can provide, even in the acute care setting, useful information about left ventricular (LV) morphology as well as regional and global systolic or diastolic function. It allows the differentiation of different LV morphologic patterns according to the localization of wall motion abnormalities. A "circumferential pattern" of LV myocardial dysfunction characterized by symmetric wall motion abnormalities involving the midventricular segments of the anterior, inferior, and lateral walls should be considered suggestive of TTC and included in the differential diagnosis of acute coronary syndromes. Moreover, advanced echocardiographic techniques, including speckle-tracking, myocardial contrast, and coronary flow studies, are providing mechanistic and pathophysiologic insights into this unique syndrome. Early identification of any potential complications (i.e., LV outflow tract obstruction, reversible moderate to severe mitral regurgitation, right ventricular involvement, thrombus formation, and cardiac rupture) are crucial for the management, risk stratification, and follow-up of patients with TTC. Because of the dynamic evolution of the syndrome, comprehensive serial echocardiographic examinations should be systematically performed. This review focuses on these aspects of imaging and the increasing understanding of the clinical and prognostic utility of echocardiography in TTC.

Coronary vasospasm is an unlikely cause of Takotsubo syndrome, although we should keep an open mind

This viewpoint pertains to the still elusive pathophysiology of the Takotsubo syndrome (TTS), maintaining the position that this affliction is not the result of coronary vasospasm (CV) involving one or more coronary arteries. Although CV has been rarely encountered in the acute stage of TTS, or elicited via provocative testing in the subacute stage of the disease, it does not appear to be the cause of TTS as shown by the bulk of the published relevant literature. The author provides some speculations to explain the spontaneous appearance of CV, or its artificial elicitation, in some patients with TTS. However while we are striving to unravel the pathophysiology of TTS, we should keep an open mind about a possible role for CV in the causation of TTS.

Role of echocardiography in takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC) is characterized by transient and reversible left ventricular (LV) systolic dysfunction due to extended myocardial stunning. Despite a good long term prognosis, approximately one-third of patients with TTC experience life-threatening complications during the acute phase. Echocardiography is the first imaging modality for an early evaluation of LV systolic and diastolic function in patients with TTC. Moreover, echocardiography allows the detection of specific findings associated with TTC, such as LV outflow tract obstruction, mitral regurgitation, and right ventricular involvement, providing crucial information for clinical management and therapy and for monitoring myocardial function recovery during the follow-up.