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Balta A, Ceasovschih A, Șorodoc V, Dimitriadis K, Güzel S, Lionte C, Stătescu C, Sascău RA, Mantzouranis E, Sakalidis A, Vlachakis PK, Tsioufis P, Kordalis A, Tsiamis E, Tsioufis K, Șorodoc L. Broad Electrocardiogram Syndromes Spectrum: From Common Emergencies to Particular Electrical Heart Disorders. J Pers Med 2022; 12:jpm12111754. [PMID: 36573711 PMCID: PMC9697753 DOI: 10.3390/jpm12111754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/13/2022] [Accepted: 10/19/2022] [Indexed: 12/30/2022] Open
Abstract
Electrocardiogram (ECG) still remains a very useful diagnostic method in modern cardiology. Its broad availability, noninvasiveness and good sensitivity explain why it plays a capital role in the very beginning of the process of diagnosis for every patient, with or without cardiac-related complaints. For the practitioner, good training in ECG interpretation is mandatory. Sometimes, the ECG trace reveals particular aspects that may cause confusion and complicate decision-making. In this article, we present several less common situations underlying the general context and ECG features. The syndromes studied have a high pathological significance and may range from acute emergencies that call for a rapid therapeutical response to chronic syndromes that require prolonged observation, monitoring and risk stratification.
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Affiliation(s)
- Anastasia Balta
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, 700115 Iasi, Romania
| | - Alexandr Ceasovschih
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, 700115 Iasi, Romania
- Correspondence: (A.C.); (V.Ș.); (K.D.)
| | - Victorița Șorodoc
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
- Correspondence: (A.C.); (V.Ș.); (K.D.)
| | - Kyriakos Dimitriadis
- 1st Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527 Athens, Greece
- Correspondence: (A.C.); (V.Ș.); (K.D.)
| | - Sara Güzel
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, 700115 Iasi, Romania
| | - Cătălina Lionte
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, 700115 Iasi, Romania
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Cristian Stătescu
- Cardiology Department, Cardiovascular Diseases Institute, 700503 Iasi, Romania
| | - Radu Andy Sascău
- Cardiology Department, Cardiovascular Diseases Institute, 700503 Iasi, Romania
| | - Emmanouil Mantzouranis
- 1st Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527 Athens, Greece
| | - Athanasios Sakalidis
- 1st Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527 Athens, Greece
| | - Panayotis K. Vlachakis
- 1st Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527 Athens, Greece
| | - Panagiotis Tsioufis
- 1st Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527 Athens, Greece
| | - Athanasios Kordalis
- 1st Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527 Athens, Greece
| | - Eleftherios Tsiamis
- 1st Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527 Athens, Greece
| | - Konstantinos Tsioufis
- 1st Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527 Athens, Greece
| | - Laurențiu Șorodoc
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, 700115 Iasi, Romania
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
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Topf A, Mirna M, Paar V, Motloch LJ, Bacher N, Franz M, Hoppe UC, Kretzschmar D, Lichtenauer M. Differential Diagnosis between Takotsubo Syndrome and Acute Coronary Syndrome—A Prospective Analysis of Novel Cardiovascular Biomarkers for a More Selective Triage. J Clin Med 2022; 11:jcm11112974. [PMID: 35683362 PMCID: PMC9180967 DOI: 10.3390/jcm11112974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 05/22/2022] [Accepted: 05/23/2022] [Indexed: 12/11/2022] Open
Abstract
Introduction: Takotsubo syndrome (TTS) is clinically indistinguishable from an ACS. Despite the implementation of clinical scoring systems and novel biomarkers, coronary angiography currently remains necessary for differential diagnosis. Methods: 93 patients with chest pain and the suspicion of TTS were enrolled in two study centers. Fetuin-A, IGFBP-2, Galectin-3, and TNF α were determined in serum samples, collected within 24 h after the onset of symptoms. Serum levels of biomarkers were analyzed for the differential diagnostic value between TTS and ACS. Results: Compared to TTS, patients with ACS had significantly lower serum levels of Fetuin-A and IGFBP-2. The cut-off value of Fetuin-A for the identification of TTS compared to ACS was 55.74 μg/mL (sensitivity: 100.0%, specificity: 82.6%, PPV: 63.2%, NPV: 100.0%). An optimal cut-off value for IGFBP-2 for the differential diagnosis between TTS and ACS was determined as 171.77 ng/mL (sensitivity: 76.0%, specificity: 82.6%, PPV: 76.4%, NPV 72.7%). Conclusion: Fetuin-A and IGFBP-2 might facilitate the triage between TTS and ACS and could be therefore of great benefit for the guidance of treatment.
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Affiliation(s)
- Albert Topf
- Clinic for Internal Medicine II, University Hospital Salzburg, Paracelsus University Salzburg, Müllner Hauptstraße 48, A-5020 Salzburg, Austria; (M.M.); (V.P.); (L.J.M.); (N.B.); (U.C.H.); (M.L.)
- Correspondence: ; Tel.: +43-(0)-57-57418; Fax: +43-(0)-57255-4111
| | - Moritz Mirna
- Clinic for Internal Medicine II, University Hospital Salzburg, Paracelsus University Salzburg, Müllner Hauptstraße 48, A-5020 Salzburg, Austria; (M.M.); (V.P.); (L.J.M.); (N.B.); (U.C.H.); (M.L.)
| | - Vera Paar
- Clinic for Internal Medicine II, University Hospital Salzburg, Paracelsus University Salzburg, Müllner Hauptstraße 48, A-5020 Salzburg, Austria; (M.M.); (V.P.); (L.J.M.); (N.B.); (U.C.H.); (M.L.)
| | - Lukas J. Motloch
- Clinic for Internal Medicine II, University Hospital Salzburg, Paracelsus University Salzburg, Müllner Hauptstraße 48, A-5020 Salzburg, Austria; (M.M.); (V.P.); (L.J.M.); (N.B.); (U.C.H.); (M.L.)
| | - Nina Bacher
- Clinic for Internal Medicine II, University Hospital Salzburg, Paracelsus University Salzburg, Müllner Hauptstraße 48, A-5020 Salzburg, Austria; (M.M.); (V.P.); (L.J.M.); (N.B.); (U.C.H.); (M.L.)
| | - Marcus Franz
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, 07743 Jena, Germany; (M.F.); (D.K.)
| | - Uta C. Hoppe
- Clinic for Internal Medicine II, University Hospital Salzburg, Paracelsus University Salzburg, Müllner Hauptstraße 48, A-5020 Salzburg, Austria; (M.M.); (V.P.); (L.J.M.); (N.B.); (U.C.H.); (M.L.)
| | - Daniel Kretzschmar
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, 07743 Jena, Germany; (M.F.); (D.K.)
| | - Michael Lichtenauer
- Clinic for Internal Medicine II, University Hospital Salzburg, Paracelsus University Salzburg, Müllner Hauptstraße 48, A-5020 Salzburg, Austria; (M.M.); (V.P.); (L.J.M.); (N.B.); (U.C.H.); (M.L.)
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Tako-tsubo syndrome and atrial fibrillation. New trigger for cardiomyopathy. A clinical case. COR ET VASA 2022. [DOI: 10.33678/cor.2021.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Topf A, Mirna M, Paar V, Motloch LJ, Grueninger J, Dienhart C, Schulze PC, Brandt MC, Larbig R, Hoppe UC, Kretzschmar D, Lichtenauer M. The differential diagnostic value of selected cardiovascular biomarkers in Takotsubo syndrome. Clin Res Cardiol 2022; 111:197-206. [PMID: 34727211 PMCID: PMC8816755 DOI: 10.1007/s00392-021-01956-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 10/18/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Takotsubo syndrome (TTS) is clinically indistinguishable from an acute coronary syndrome (ACS). In the absence of valid markers for differential diagnosis, coronary angiography has been indispensable. METHODS In our study, we evaluated the serum levels of sST-2, GDF-15, suPAR and H-FABP in 92 patients with the suspicion of TTS (51 TTS and 41 ACS patients) and 40 gender matched controls (no coronary artery disease or signs of heart failure) at baseline. RESULTS H-FABP was significantly higher in ACS patients compared to TTS patients. Even in in propensity score matching for left ventricular ejection fraction, sex and cardiovascular risk factors, differences in the plasma levels of H-FABP in the matched cohort of TTS vs ACS remained statistically significant. Whereas, sST-2 was significantly elevated in TTS patients. H-FABP was superior for prediction of an ACS with even higher accuracy than hs troponin in differential diagnosis (AUC 0.797, p ≤ 0.0001); the optimal cut off for discrimination towards a TTS was calculated as 2.93 ng/ml (sensitivity 70.0%, specificity 82.4%, PPV 75.7%, NPV 77.4%). sST-2 seemed most appropriate for identification of a TTS (AUC 0.653, p = 0.012). The optimal cut off for differential diagnosis was 11018.06 pg/ml (sensitivity 82.0%, specificity 51.2%, PPV 69.4%, NPV 71.9 %). CONCLUSION H-FABP and sST-2 are the most promising markers with better accuracy than preexisting biomarkers in differential diagnosis in our study and therefore, could be crucial for the guidance of treatment in patients with high bleeding risk, advanced renal failure or multimorbidity.
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Affiliation(s)
- Albert Topf
- Clinic for Internal Medicine II, Department of Internal Medicine II, Paracelsus Medical University, University Hospital Salzburg, Paracelsus University Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria.
| | - Moritz Mirna
- Clinic for Internal Medicine II, Department of Internal Medicine II, Paracelsus Medical University, University Hospital Salzburg, Paracelsus University Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Vera Paar
- Clinic for Internal Medicine II, Department of Internal Medicine II, Paracelsus Medical University, University Hospital Salzburg, Paracelsus University Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Lukas J Motloch
- Clinic for Internal Medicine II, Department of Internal Medicine II, Paracelsus Medical University, University Hospital Salzburg, Paracelsus University Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Janine Grueninger
- Clinic for Internal Medicine II, Department of Internal Medicine II, Paracelsus Medical University, University Hospital Salzburg, Paracelsus University Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Christiane Dienhart
- Department of Internal Medicine I, Paracelsus Medical University, 5020, Salzburg, Austria
| | - Paul C Schulze
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, 07743, Jena, Germany
| | - Mathias C Brandt
- Clinic for Internal Medicine II, Department of Internal Medicine II, Paracelsus Medical University, University Hospital Salzburg, Paracelsus University Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Robert Larbig
- Devision of Cardiology, Hospital Maria Hilf Moenchengladbach, 41063, Möenchengladbach, Germany
| | - Uta C Hoppe
- Clinic for Internal Medicine II, Department of Internal Medicine II, Paracelsus Medical University, University Hospital Salzburg, Paracelsus University Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Daniel Kretzschmar
- Division of Cardiology, Department of Internal Medicine I, University Hospital Jena, 07743, Jena, Germany
| | - Michael Lichtenauer
- Clinic for Internal Medicine II, Department of Internal Medicine II, Paracelsus Medical University, University Hospital Salzburg, Paracelsus University Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
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Anesthetic implications of perioperative Takotsubo syndrome: a retrospective cohort study. Can J Anaesth 2021; 68:1747-1755. [PMID: 34570351 DOI: 10.1007/s12630-021-02109-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/05/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Takotsubo syndrome is a reversible cardiomyopathy triggered by emotional or physical stressors. Although surgeries could be physical triggers, this has been scantily investigated. We aimed to describe the baseline characteristics, surgical/anesthesia-related triggering events, clinical presentation, and in-hospital outcomes of a cohort of patients diagnosed with perioperative Takotsubo syndrome. METHODS In this retrospective study, we included all consecutive adult patients who were admitted to Hospital Italiano de Buenos Aires between 1 June 2008 and 30 November 2017 and diagnosed with Takotsubo syndrome according to the revised criteria of the European Society of Cardiology during hospitalization. RESULTS We diagnosed 21 patients with perioperative Takotsubo syndrome out of 305,906 patients undergoing procedures with anesthesia care. The median (interquartile range [IQR]) patient age was 75 (55-82) yr, and 16 (76%) were women. The median (IQR) left ventricular ejection fraction was 35 (35-42)% at diagnosis and 55 (46-55)% at discharge. Fifteen patients (71%) required inotropic/vasopressor support; however, this is a controversial treatment considering the physiopathology of the syndrome. Severe complications such as unexplained syncope/cardiac arrest, cardiogenic shock, and ventricular thrombus formation occurred in seven (33%) patients, and two (10%) patients died. These results were compared with 31 patients who experienced non-perioperative Takotsubo syndrome during the same period of time. CONCLUSION Perioperative Takotsubo syndrome is a reversible cardiomyopathy. Nevertheless, it seems to be associated with severe complications, the need for aggressive treatment, and non-negligible mortality.
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Gimelli A, Liga R, Agostini D, Bengel FM, Ernst S, Hyafil F, Saraste A, Scholte AJHA, Verberne HJ, Verschure DO, Slart RHJA. The role of myocardial innervation imaging in different clinical scenarios: an expert document of the European Association of Cardiovascular Imaging and Cardiovascular Committee of the European Association of Nuclear Medicine. Eur Heart J Cardiovasc Imaging 2021; 22:480-490. [PMID: 33523108 DOI: 10.1093/ehjci/jeab007] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/08/2021] [Indexed: 02/06/2023] Open
Abstract
Cardiac sympathetic activity plays a key role in supporting cardiac function in both health and disease conditions, and nuclear cardiac imaging has always represented the only way for the non-invasive evaluation of the functional integrity of cardiac sympathetic terminals, mainly through the use of radiopharmaceuticals that are analogues of norepinephrine and, in particular, with the use of 123I-mIBG imaging. This technique demonstrates the presence of cardiac sympathetic dysfunction in different cardiac pathologies, linking the severity of sympathetic nervous system impairment to adverse patient's prognosis. This article will outline the state-of-the-art of cardiac 123I-mIBG imaging and define the value and clinical applications in the different fields of cardiovascular diseases.
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Affiliation(s)
- Alessia Gimelli
- Department of Imaging, Fondazione Toscana/CNR Gabriele Monasterio1, via Moruzzi n.1, Pisa 56124, Italy
| | - Riccardo Liga
- Cardiac-Thoracic-Vascular Department, Università di Pisa, Pisa, Italy
| | - Denis Agostini
- Department of Nuclear Medicine, University Hospital of Normandy, CHU Cote de Nacre, Caen, France
| | - Frank M Bengel
- Department of Nuclear Medicine, Hannover Medical School (MHH), Hannover, Germany
| | - Sabine Ernst
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College, London, UK
| | - Fabien Hyafil
- Department of Nuclear Medicine, European Hospital Georges-Pompidou, DMU IMAGINA, Assistance Publique-Hôpitaux de Paris, University of Paris, Paris, France
| | - Antti Saraste
- Turku PET Centre, University of Turku, Turku, Finland.,Heart Center, Turku University Hospital, Turku, Finland
| | - Arthur J H A Scholte
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Derk O Verschure
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Cardiology, Zaans Medical Center, Zaandam, the Netherlands
| | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Centre, University Medical Center Groningen, Groningen, The Netherlands.,Faculty of Science and Technology, Biomedical Photonic Imaging, University of Twente, Enschede, The Netherlands
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Manfredini R, De Giorgi A, Fabbian F. Anemia: Another Stone in the Wall of Takotsubo Outcomes? Angiology 2021; 72:803-804. [PMID: 33769077 DOI: 10.1177/00033197211005608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Roberto Manfredini
- Clinica Medica Unit, Department of Medical Sciences, University of Ferrara, Italy
| | - Alfredo De Giorgi
- Clinica Medica Unit, Department of Medical Sciences, University of Ferrara, Italy
| | - Fabio Fabbian
- Clinica Medica Unit, Department of Medical Sciences, University of Ferrara, Italy
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Looi JL, Poppe K, Lee M, Gilmore J, Webster M, To A, Kerr AJ. A Score to differentiate Takotsubo syndrome from non-ST-elevation myocardial nfarction in women at the bedside. Open Heart 2020; 7:e001197. [PMID: 32201588 PMCID: PMC7066633 DOI: 10.1136/openhrt-2019-001197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/02/2020] [Accepted: 02/03/2020] [Indexed: 12/22/2022] Open
Abstract
Objective A score to distinguish Takotsubo syndrome (TS) from acute coronary syndrome would be useful to facilitate appropriate patient investigation and management. This study sought to derive and validate a simple score using demographic, clinical and ECG data to distinguish women with non-ST elevation myocardial infarction (NSTEMI) from NSTE-TS. Methods The derivation cohort consisted of women with NSTE-TS (n=100) and NSTEMI (n=100). Logistic regression was used to derive the score using ECG values available on the postacute ward round on day 1 post-hospital admission. The score was then temporally validated in subsequent consecutive patients with NSTE-TS (n=40) and NSTEMI (n=70). Results The five variables in the score and their relative weights were: T-wave inversion in ≥6 leads (+3), recent stress (+2), diabetes (−1), prior cardiovascular disease (−2) and ST-depression in any lead (−3). When calculated using ECG values obtained at admission, discrimination between conditions was very good (area under the curve (AUC) 0.87 95% CI 0.83 to 0.92). The optimal score cut-point of ≥1 to predict NSTE-TS had 73% sensitivity and 90% specificity. When applied to the validation cohort at admission, AUC was 0.82 (95% CI 0.75 to 0.90) and positive and negative predictive values were 78% and 81%, respectively. On day 1 post-admission, AUC was 0.92 (95% CI 0.87 to 0.97), with positive and negative predictive values of 77% and 91%, respectively. Conclusion This NSTE-TS score is easy to use and may prove useful in clinical practice to distinguish women with NSTE-TS from NSTEMI. Further validation in external cohorts is needed.
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Affiliation(s)
- Jen-Li Looi
- Cardiology, Middlemore Hospital, Auckland, New Zealand
| | - Katrina Poppe
- Epidemiology & Biostatistics, University of Auckland, Auckland, New Zealand
| | - Mildred Lee
- Cardiology, Middlemore Hospital, Auckland, New Zealand
| | - Jill Gilmore
- Cardiology, Middlemore Hospital, Auckland, New Zealand
| | - Mark Webster
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Andrew To
- Lakeview Cardiology Centre, North Shore Hospital, Auckland, New Zealand
| | - Andrew J Kerr
- Cardiology, Middlemore Hospital, Auckland, New Zealand
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Takotsubo Syndrome Associated with ST Elevation Myocardial Infarction. Case Rep Cardiol 2019; 2019:1010243. [PMID: 31223504 PMCID: PMC6541970 DOI: 10.1155/2019/1010243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/03/2019] [Accepted: 02/26/2019] [Indexed: 12/31/2022] Open
Abstract
Background Takotsubo syndrome is a reversible heart failure syndrome which often presents with symptoms and ECG changes that mimic an acute myocardial infarction. Obstructive coronary artery disease has traditionally been seen as exclusion criteria for the diagnosis of takotsubo; however, recent reports have called this into question and suggest that the two conditions may coexist. Case Summary We describe a case of an 83-year-old male presenting with chest pain consistent with acute myocardial infarction. The ECG demonstrated anterior ST elevation with bedside echocardiography showing apical wall motion abnormalities. Cardiac catheterisation found an occluded OM2 branch of the left circumflex artery with ventriculography confirming apical ballooning consistent with takotsubo and not in the vascular territory supplied by the occluded epicardial vessel. Repeat echocardiogram 6 weeks later confirmed resolution of the apical wall motion abnormalities consistent with a diagnosis of takotsubo. Discussion This case demonstrates the finding of takotsubo syndrome in a male patient with acute myocardial infarction. Traditionally, this would preclude a diagnosis of takotsubo; however, following previous reports of takotsubo in association with coronary artery dissection and acute myocardial infarction in female patients, new diagnostic criteria have been proposed which allow the diagnosis of takotsubo in the presence of obstructive coronary artery disease. This case adds to the growing body of literature that suggests takotsubo can coexist with acute myocardial infarction; however, it remains to be elucidated if it is a consequence or cause of myocardial infarction.
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Short- and medium-term prognosis of Takotsubo syndrome in a Portuguese population. Rev Port Cardiol 2019; 38:349-357. [DOI: 10.1016/j.repc.2018.07.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 06/24/2018] [Accepted: 07/18/2018] [Indexed: 01/26/2023] Open
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Short- and medium-term prognosis of Takotsubo syndrome in a Portuguese population. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.repce.2019.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Manfredini R, Cappadona R, Fabbian F. Is Takotsubo Syndrome Still a Benign Disease? Complications (and Gender) Make the Difference. Angiology 2019; 70:795-796. [DOI: 10.1177/0003319719830011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Roberto Manfredini
- Faculty of Medicine, Pharmacy and Prevention, University of Ferrara, Ferrara, Italy
| | - Rosaria Cappadona
- Faculty of Medicine, Pharmacy and Prevention, University of Ferrara, Ferrara, Italy
| | - Fabio Fabbian
- Faculty of Medicine, Pharmacy and Prevention, University of Ferrara, Ferrara, Italy
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Manfredini R, Fabbian F, De Giorgi A, Cappadona R, Zucchi B, Storari A, Rodriguez Borrego MA, Carmona Torres JM, Lopez Soto PJ. Takotsubo syndrome and dialysis: an uncommon association? J Int Med Res 2018; 46:4399-4406. [PMID: 30178683 PMCID: PMC6259368 DOI: 10.1177/0300060518794249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
This review was performed to investigate the association between treatment with dialysis and Takotsubo syndrome in patients with end-stage renal disease. We systematically explored the PubMed database using the search terms "Takotsubo cardiomyopathy" and/or "stress-induced cardiomyopathy" and/or "Takotsubo syndrome" in combination with "dialysis" and "uremia." Of 3630 articles found, 8 articles reporting 10 cases were selected for analysis. Most patients were women, and their age ranged from 51 to 84 years. Diabetes mellitus and hypertension were diagnosed in 40% of patients, and glomerular disease was diagnosed in 30%. One only patient was treated with peritoneal dialysis; all others were treated with hemodialysis. The outcome was unfavorable in only one patient. An association between Takotsubo syndrome and dialysis is uncommon, but not negligible, and comorbidities play a major role in determining the clinical outcome.
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Affiliation(s)
- Roberto Manfredini
- 1 Faculty of Medicine, Pharmacy and Prevention, University of Ferrara, Italy.,2 Azienda Ospedaliera-Universitaria, Ferrara, Italy.,3 Instituto Maimonides de Investigacion Biomedica de Cordoba (IMIBIC), University of Cordoba, Spain
| | - Fabio Fabbian
- 1 Faculty of Medicine, Pharmacy and Prevention, University of Ferrara, Italy.,2 Azienda Ospedaliera-Universitaria, Ferrara, Italy.,3 Instituto Maimonides de Investigacion Biomedica de Cordoba (IMIBIC), University of Cordoba, Spain
| | | | - Rosaria Cappadona
- 1 Faculty of Medicine, Pharmacy and Prevention, University of Ferrara, Italy
| | - Beatrice Zucchi
- 1 Faculty of Medicine, Pharmacy and Prevention, University of Ferrara, Italy
| | - Alda Storari
- 2 Azienda Ospedaliera-Universitaria, Ferrara, Italy
| | | | | | - Pablo Jesus Lopez Soto
- 3 Instituto Maimonides de Investigacion Biomedica de Cordoba (IMIBIC), University of Cordoba, Spain
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Manfredini R, Fabbian F, Cappadona R, Zucchi B, Lopez-Soto PJ, Rodriguez-Borrego MA. Attempted suicide as a trigger of Takotsubo syndrome: a minireview of available case reports. Intern Emerg Med 2018; 13:629-631. [PMID: 29498012 DOI: 10.1007/s11739-018-1812-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 02/25/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Roberto Manfredini
- Center for Studies on Gender Medicine, Faculty of Medicine, Pharmacy and Prevention, University of Ferrara, Ferrara, Italy.
- Instituto Maimonides de Investigacion Biomedica de Cordoba (IMIBIC), University of Cordoba, Córdoba, Spain.
- Clinica Medica Unit, Department of Medical Sciences, University of Ferrara, via L. Ariosto 35, 44121, Ferrara, Italy.
| | - Fabio Fabbian
- Center for Studies on Gender Medicine, Faculty of Medicine, Pharmacy and Prevention, University of Ferrara, Ferrara, Italy
- Instituto Maimonides de Investigacion Biomedica de Cordoba (IMIBIC), University of Cordoba, Córdoba, Spain
- Clinica Medica Unit, Department of Medical Sciences, University of Ferrara, via L. Ariosto 35, 44121, Ferrara, Italy
| | - Rosaria Cappadona
- Center for Studies on Gender Medicine, Faculty of Medicine, Pharmacy and Prevention, University of Ferrara, Ferrara, Italy
| | - Beatrice Zucchi
- Center for Studies on Gender Medicine, Faculty of Medicine, Pharmacy and Prevention, University of Ferrara, Ferrara, Italy
| | - Pablo Jesus Lopez-Soto
- Instituto Maimonides de Investigacion Biomedica de Cordoba (IMIBIC), University of Cordoba, Córdoba, Spain
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Vergel J, Tamayo-Orozco S, Vallejo-Gómez AF, Posada MT, Restrepo D. [Acute Stress and Broken Heart Syndrome. A Case Report]. REVISTA COLOMBIANA DE PSIQUIATRIA 2017; 46:257-262. [PMID: 29122235 DOI: 10.1016/j.rcp.2016.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 09/05/2016] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Stress has been associated with an acute heart failure syndrome of important morbidity and mortality. METHODS Case report and non-systematic review of the relevant literature. CASE PRESENTATION A 65-year-old woman with a history of an untreated generalized anxiety disorder, whom after the violent death of her son presented with oppressive chest pain irradiated to neck and left superior extremity, lasting for more than 30minutes, initial clinical suspect suggests acute coronary syndrome. LITERATURE REVIEW Tako-tsubo cardiomyopathy is characterized by a reversible left ventricular dysfunction and wall movement abnormalities, without any compromise of the coronary arteries, associated to high plasma levels of catecholamines which in most cases correlates with an acute stress of emotional or physical type. CONCLUSIONS Tako-tsubo cardiomyopathy has to be considered by physicians among the differential diagnosis when facing a patient with suspected acute coronary syndrome, especially in post-menopausal women with a history of psychiatric comorbidities such as a generalized anxiety disorder.
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Manfredini R, Manfredini F, Fabbian F, Salmi R, Gallerani M, Bossone E, Deshmukh AJ. Chronobiology of Takotsubo Syndrome and Myocardial Infarction: Analogies and Differences. Heart Fail Clin 2017; 12:531-42. [PMID: 27638023 DOI: 10.1016/j.hfc.2016.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Several pathophysiologic factors, not harmful if taken alone, are capable of triggering unfavorable events when presenting together within the same temporal window (chronorisk), and the occurrence of many cardiovascular events is not evenly distributed in time. Both acute myocardial infarction and takotsubo syndrome seem to exhibit a temporal preference in their onset, characterized by variations according to time of day, day of the week, and month of the year, although with both analogies and differences.
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Affiliation(s)
- Roberto Manfredini
- Clinica Medica Unit, School of Medicine, University of Ferrara, Via Lodovico Ariosto, 35, Ferrara 44121, Italy.
| | - Fabio Manfredini
- Department of Biomedical Sciences and Surgical Specialties, Vascular Diseases Center, School of Medicine, University of Ferrara, Via Lodovico Ariosto, 35, Ferrara 44121, Italy
| | - Fabio Fabbian
- Clinica Medica Unit, School of Medicine, University of Ferrara, Via Lodovico Ariosto, 35, Ferrara 44121, Italy
| | - Raffaella Salmi
- 2nd Internal Unit of Internal Medicine, General Hospital of Ferrara, Via Aldo Moro 8, Ferrara 44020, Italy
| | - Massimo Gallerani
- 1st Internal Unit of Internal Medicine, General Hospital of Ferrara, Via Aldo Moro 8, Ferrara 44020, Italy
| | - Eduardo Bossone
- 'Cava de' Tirreni and Amalfi Coast' Division of Cardiology, Heart Department, University Hospital of Salerno, Via San Leonardo 1, Salerno 84013, Italy
| | - Abhishek J Deshmukh
- Mayo Clinic Heart Rhythm Section, Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55902, USA
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A novel clinical score (InterTAK Diagnostic Score) to differentiate takotsubo syndrome from acute coronary syndrome: results from the International Takotsubo Registry. Eur J Heart Fail 2016; 19:1036-1042. [DOI: 10.1002/ejhf.683] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 08/23/2016] [Accepted: 08/26/2016] [Indexed: 12/25/2022] Open
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Bossone E, Erbel R. Takotsubo: From Cardiomyopathy to Acute Reversible Heart Failure Syndrome. Heart Fail Clin 2016; 12:xiii-xiv. [PMID: 27638030 DOI: 10.1016/j.hfc.2016.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eduardo Bossone
- Cardiology Division, "Cava de' Tirreni and Amalfi Coast", Heart Department, University Hospital, Via De Marinis, 4, 84013 Cava de' Tirreni (SA), Italy.
| | - Raimund Erbel
- Institute of Medical Informatics Biometry and Epidemiology, University Clinic Essen, Hufelandstrasse 55, D-45147 Essen, Germany.
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19
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Takotsubo cardiomyopathy and its relevance to anesthesiology: a narrative review. Can J Anaesth 2016; 63:1059-74. [DOI: 10.1007/s12630-016-0680-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 04/21/2016] [Accepted: 06/02/2016] [Indexed: 12/14/2022] Open
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20
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Duchesne J, Hoffman I. Is LAD encasement a common substrate component in Takotsubo cardiomyopathy? J Electrocardiol 2016; 49:629-31. [PMID: 27113845 DOI: 10.1016/j.jelectrocard.2016.03.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Indexed: 02/08/2023]
Abstract
Evidence from computerized tomographic angiography (CTA) has demonstrated LAD encasement with compromised antegrade systolic flow In Takotsubo cardiomyopathy patients. This mechanism may explain both the contractile and ECG abnormalities observed in this disorder.
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Affiliation(s)
- Joshua Duchesne
- University of New Mexico School of Medicine, Department of Internal Medicine, Albuquerque, NM
| | - Irwin Hoffman
- CHRISTUS St Vincent Hospital, 455 St Michaels Drive, Santa Fe, NM.
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21
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Madias JE. Index of microvascular resistance: a potential enhancement to coronary arteriography for patients with Takotsubo syndrome. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2015; 4:565-567. [PMID: 26598761 DOI: 10.1177/2048872613519746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- John E Madias
- Icahn School of Medicine at Mount Sinai/Cardiology Division, Elmhurst Hospital Center, New York, USA
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Landefeld K, Saleh Q, Sander GE. Stress Cardiomyopathy in the Setting of COPD Exacerbation. J Investig Med High Impact Case Rep 2015; 3:2324709615612847. [PMID: 26904708 PMCID: PMC4748508 DOI: 10.1177/2324709615612847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 09/28/2015] [Accepted: 09/29/2015] [Indexed: 11/16/2022] Open
Abstract
Introduction. Stress cardiomyopathy, or takotsubo cardiomyopathy, is an acute, reversible left ventricular dysfunction usually initiated by a psychological or physical stress. We report this case of stress cardiomyopathy following a chronic obstructive pulmonary disease exacerbation and the subsequent treatment. Case Description. A 49-year-old white female with a history of chronic obstructive pulmonary disease presented to the emergency room via emergency medical services with worsening severe shortness of breath and productive cough for 2 weeks but denied any chest pain on arrival. On presentation, she was noted to be tachypneic, using her accessory muscles and with bilateral coarse expiratory wheezing on lung auscultation. Initial electrocardiogram demonstrated sinus tachycardia. She was treated with multiple albuterol treatments. Soon afterwards, the course was complicated by hypoxic respiratory failure eventually requiring intubation. Her repeat electrocardiogram showed acute changes consistent with myocardial infarction, and an echocardiograph demonstrated apical akinesia with an ejection fraction of 25% to 30%. The patient was urgently taken for cardiac catheterization, which showed no angiographic evidence of coronary artery disease. Three days after initial presentation, a repeat transthoracic echocardiogram showed overall left ventricular systolic function improvement. Discussion. This case provided a unique look at the difficulty of balancing catecholamines in a patient with bronchospasm and stress cardiomyopathy.
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Affiliation(s)
| | - Qusai Saleh
- Tulane University School of Medicine, New Orleans, LA, USA
| | - Gary E Sander
- Tulane University School of Medicine, New Orleans, LA, USA
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Takotsubo cardiomyopathy, sepsis and clinical outcome: does gender matter? Am J Emerg Med 2015; 33:1525-7. [DOI: 10.1016/j.ajem.2015.06.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 06/11/2015] [Indexed: 01/15/2023] Open
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Abstract
Heart rate variability (HRV), a noninvasive technique used to quantify fluctuations in the interval between normal heart beats (NN), is a predictor of mortality in some patient groups. The aim of this study was to assess HRV in burn trauma patients as a predictor of mortality. The authors prospectively performed 24-hour Holter monitoring on burn patients and collected demographic information, burn injury details, and in-hospital clinical events. Analysis of HRV in the time and frequency domains was performed. A total of 40 burn patients with a mean age of 44 ± 15 years were enrolled. Mean %TBSA burn was 27 ± 22% for the overall population and was significantly higher in those who died compared with those who survived (55 ± 23% vs 19 ± 13%; P < .0001). There was a statistically significant inverse linear correlation between SD of NN intervals and %TBSA (r = -.337, R = 0.113, 95% CI = -0.587 to -0.028, two-tailed P = .034), as well as with ultra low frequency power and %TBSA burn (r = -0.351, R = 0.123, 95% CI = -0.152 to -0.009; P = .027). The receiver-operator characteristic showed the area under the curve for %TBSA as a predictor of death was 0.82 (P < .001), for SDANN was 0.94 (P < .0001), and for ultra low frequency power was 0.96 (P < .0001). Deranged HRV in the early postburn period is a strong predictor of death.
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Lisung FG, Shah AB, Levitt HL, Coplan NB. Stress-induced cardiomyopathy. CASE REPORTS 2015; 2015:bcr-2014-208690. [DOI: 10.1136/bcr-2014-208690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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26
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Hefner J, Csef H, Frantz S, Glatter N, Warrings B. Recurrent Tako-Tsubo cardiomyopathy (TTC) in a pre-menopausal woman: late sequelae of a traumatic event? BMC Cardiovasc Disord 2015; 15:3. [PMID: 25601763 PMCID: PMC4361199 DOI: 10.1186/1471-2261-15-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 01/08/2015] [Indexed: 02/07/2023] Open
Abstract
Background “Tako-Tsubo cardiomyopathy” (TTC) is a syndrome characterized by left ventricular (LV) wall motion abnormalities, usually without coronary artery disease, mimicking the diagnosis of acute coronary syndrome. It most often affects post-menopausal women and TTC tends to run a benign course with very low rates of recurrence, complications or mortality. The condition is also called “stress-induced cardiomyopathy” because acute physical or emotional stress appears to be frequently related to its onset. The pathogenic role of premorbid or comorbid psychiatric illnesses has been discussed controversially. For the first time, we present a case of fourfold recurrent TTC with severe complications in a pre-menopausal woman. Furthermore, a long history of flaring posttraumatic stress symptoms anteceded the first event. Case presentation A 43-year old, pre-menopausal Caucasian woman was hospitalized with symptoms of acute coronary syndrome. Clinical examination revealed hypokinetic wall motion in the apical ventricular region with no signs of coronary artery disease and diagnosis of TTC was established. She experienced recurrence three times within the following ten months, which led to thrombembolism and myocardial scarring among others. The circumstances of chronic distress were striking. 16 years ago she miscarried after having removed a myoma according to her doctor’s suggestion. Since then, she has suffered from symptoms of posttraumatic distress which peaked annually at the day of abortion. Chronic distress became even more pronounced after the premature birth of a daughter some years later. The first event of TTC occurred after a family dispute about parenting. Conclusion This is the first case report of fourfold TTC in a pre-menopausal woman. From somatic perspectives, the course of the disease with recurrences and complications underlines the fact that TTC is not entirely benign. Furthermore, it is the first case report of long lasting symptoms of traumatic stress anteceding TTC. Close connections between adrenergic signaling and late onset of clinical stress symptoms are well known in the psychopathology of traumatization. Although larger clinical trials are needed to elucidate possible interactions of premorbid psychiatric illnesses and TTC, cardiologists should be vigilant especially in cases of recurrent TTC.
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Affiliation(s)
- Jochen Hefner
- Section of Psychosomatic Medicine and Psychotherapy, Department of Internal Medicine II, Julius-Maximilian-University of Wuerzburg, Oberduerrbacher Str, 6, D- 97080 Wuerzburg, Germany.
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Murthy A, Arora J, Singh A, Gedela M, Karnati P, Nappi A. Takotsubo Cardiomyopathy: Typical and Atypical Variants, A Two-Year Retrospective Cohort Study. Cardiol Res 2014; 5:139-144. [PMID: 28348711 PMCID: PMC5358118 DOI: 10.14740/cr349w] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2014] [Indexed: 02/06/2023] Open
Abstract
Background Typical or classical takotsubo cardiomyopathy (TCM) is associated with the characteristic abnormality of a ballooned left ventricular apex with basal segmental hyperkinesis. TCM may not present with the “classical” wall motion abnormalities but can have a variety of segmental wall motion abnormalities. The aim of our work was to assess for any unique identifying factors that can help distinguish typical and atypical variants of TCM. Methods We studied 11 consecutive patients between 2010 and 2012 admitted with chest pain, electrocardiographic and cardiac biomarker changes consistent with acute coronary syndrome (ACS) who underwent left heart angiography and were clinically diagnosed to have TCM. Results Our study found no specific features distinguishing typical and atypical variants of TCM. In our study, all patients were female and all had excellent outcome. One patient was in fourth decade of life, three patients in fifth and sixth decade of life, while remaining were older. One patient had diabetes mellitus, five had hypertension, four had concurrent coronary artery disease, but no patient had any family history of TCM. Nine of 11 patients had immediate clear-cut stressors. Three patients had normal ECG, two with ST segment elevation, with nine patients having only modest troponin elevations. One patient had an anomalous RCA take-off from the right coronary cusp, otherwise remaining patients had normal anatomy. One patient had only apical involvement, remaining had multiple wall motion abnormalities, and all patients had involvement of the anterior wall. Four patients had apical sparing. No inverted TCM pattern with basal akinesis with normal wall motion in the midventricular and apical regions was found among our patients. Conclusions We report that the classification of TCM as typical versus atypical is probably not clinically meaningful. The regional wall motion abnormalities are related to catecholamine excess and to the susceptibility of that particular region to excess catecholamine. We do not know why such differences in regional susceptibility exist, and agree with the other authors that sub-classification would only add to confusion, and a delay in understanding of the disease process.
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Affiliation(s)
- Avinash Murthy
- Division of Cardiology, Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06484, USA
| | - Jaspreet Arora
- Department of Internal Medicine, Albany Medical Center, 47 New Scotland Avenue, Albany, NY 12208, USA
| | - Arti Singh
- Division of Cardiology, Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06484, USA
| | - Maheedhar Gedela
- Division of Cardiology, Department of Internal Medicine, Albany Medical Center, 47 New Scotland Avenue, Albany, NY 12208, USA
| | - Pavan Karnati
- Department of Medicine, Clinch Valley Medical Center, 6801 Gov. G. C. Peery Highway, Richlands, VA 24641, USA
| | - Anthony Nappi
- Division of Cardiology, Department of Internal Medicine, Albany Medical Center, 47 New Scotland Avenue, Albany, NY 12208, USA
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Hefner J, Michalke F, Csef H. Stress management in females with Tako-Tsubo cardiomyopathy compared to females with acute coronary syndrome. Int J Cardiol 2014; 170:e1-2. [PMID: 24383066 DOI: 10.1016/j.ijcard.2013.10.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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De Giorgi A, Fabbian F, Tiseo R, Parisi C, Misurati E, Molino C, Pala M, Salmi R, Volpi R, Manfredini R. Takotsubo cardiomyopathy and endocrine disorders: a mini-review of case reports. Am J Emerg Med 2014; 32:1413-7. [PMID: 25261397 DOI: 10.1016/j.ajem.2014.07.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 07/17/2014] [Accepted: 07/26/2014] [Indexed: 01/20/2023] Open
Affiliation(s)
- Alfredo De Giorgi
- Clinica Medica, Department of Medicine, Azienda Ospedaliera-Universitaria (AOU), Ferrara, Italy.
| | - Fabio Fabbian
- Clinica Medica, Department of Medicine, AOU, Ferrara, Italy.
| | - Ruana Tiseo
- Clinica Medica, Department of Medicine, AOU, Ferrara, Italy.
| | - Claudia Parisi
- Clinica Medica, Department of Medicine, AOU, Ferrara, Italy.
| | - Elisa Misurati
- Clinica Medica, Department of Medicine, AOU, Ferrara, Italy.
| | | | - Marco Pala
- Clinica Medica, Department of Medicine, AOU, Ferrara, Italy.
| | - Raffaella Salmi
- Second Internal Medicine, Department of Medicine, AOU, Ferrara, Italy.
| | - Riccardo Volpi
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy.
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Ha JH, Lee H, Park YJ, Kang HH, Lee SH, Moon HS. Takotsubo cardiomyopathy caused by pulmonary tuberculosis: a case report. Tuberc Respir Dis (Seoul) 2014; 77:24-7. [PMID: 25114700 PMCID: PMC4127409 DOI: 10.4046/trd.2014.77.1.24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 03/11/2014] [Accepted: 03/14/2014] [Indexed: 11/24/2022] Open
Abstract
Takotsubo cardiomyopathy (TTC) is defined as a reversible, acute ventricular dysfunction without any evidence of coronary artery obstruction. There have been reports of TTC caused by emotional or physical stress, drug use, hormone imbalance, or medical conditions such as pulmonary disease, sepsis, and trauma, but a relationship between TTC and pulmonary tuberculosis has not previously been reported. From our knowledge, this is the first report of TTC caused by pulmonary tuberculosis.
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Affiliation(s)
- Jick Hwan Ha
- Division of Pulmonology, Critical Care and Sleep Medicine, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hyewon Lee
- Division of Pulmonology, Critical Care and Sleep Medicine, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Young Jae Park
- Division of Pulmonology, Critical Care and Sleep Medicine, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hyeon Hui Kang
- Division of Pulmonology, Critical Care and Sleep Medicine, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sang Haak Lee
- Division of Pulmonology, Critical Care and Sleep Medicine, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hwa Sik Moon
- Division of Pulmonology, Critical Care and Sleep Medicine, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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Soukoulis V, Boden WE, Smith SC, O'Gara PT. Nonantithrombotic medical options in acute coronary syndromes: old agents and new lines on the horizon. Circ Res 2014; 114:1944-58. [PMID: 24902977 PMCID: PMC4083844 DOI: 10.1161/circresaha.114.302804] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acute coronary syndromes (ACS) constitute a spectrum of clinical presentations ranging from unstable angina and non-ST-segment elevation myocardial infarction to ST-segment myocardial infarction. Myocardial ischemia in this context occurs as a result of an abrupt decrease in coronary blood flow and resultant imbalance in the myocardial oxygen supply-demand relationship. Coronary blood flow is further compromised by other mechanisms that increase coronary vascular resistance or reduce coronary driving pressure. The goals of treatment are to decrease myocardial oxygen demand, increase coronary blood flow and oxygen supply, and limit myocardial injury. Treatments are generally divided into disease-modifying agents or interventions that improve hard clinical outcomes and other strategies that can reduce ischemia. In addition to traditional drugs such as β-blockers and inhibitors of the renin-angiotensin-aldosterone system, newer agents have expanded the number of molecular pathways targeted for treatment of ACS. Ranolazine, trimetazidine, nicorandil, and ivabradine are medications that have been shown to reduce myocardial ischemia through diverse mechanisms and have been tested in limited fashion in patients with ACS. Attenuating the no-reflow phenomenon and reducing the injury compounded by acute reperfusion after a period of coronary occlusion are active areas of research. Additionally, interventions aimed at ischemic pre- and postconditioning may be useful means by which to limit myocardial infarct size. Trials are also underway to examine altered metabolic and oxygen-related pathways in ACS. This review will discuss traditional and newer anti-ischemic therapies for patients with ACS, exclusive of revascularization, antithrombotic agents, and the use of high-intensity statins.
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Affiliation(s)
- Victor Soukoulis
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.S., P.T.O.); Division of Cardiology, Department of Medicine, Albany Stratton Veteran's Affairs Medical Centre and Albany Medical College, NY (W.E.B.); and Division of Cardiology, University of North Carolina, Chapel Hill (S.C.S.)
| | - William E Boden
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.S., P.T.O.); Division of Cardiology, Department of Medicine, Albany Stratton Veteran's Affairs Medical Centre and Albany Medical College, NY (W.E.B.); and Division of Cardiology, University of North Carolina, Chapel Hill (S.C.S.)
| | - Sidney C Smith
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.S., P.T.O.); Division of Cardiology, Department of Medicine, Albany Stratton Veteran's Affairs Medical Centre and Albany Medical College, NY (W.E.B.); and Division of Cardiology, University of North Carolina, Chapel Hill (S.C.S.)
| | - Patrick T O'Gara
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.S., P.T.O.); Division of Cardiology, Department of Medicine, Albany Stratton Veteran's Affairs Medical Centre and Albany Medical College, NY (W.E.B.); and Division of Cardiology, University of North Carolina, Chapel Hill (S.C.S.).
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32
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Affiliation(s)
- Ambar A Andrade
- Department of Cardiology, Texas Heart Institute, Houston, Texas 77030
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33
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Ferrara F, Baldi C, Malinconico M, Acri E, Cirillo A, Citro R, Bossone E. Takotsubo cardiomyopathy after acute myocardial infarction: An unusual case of possible association. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 5:171-6. [DOI: 10.1177/2048872614534390] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 04/15/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Francesco Ferrara
- Heart Department, University Hospital ‘Scuola Medica Salernitana’, Salerno, Italy
- Department of Translational Medical Sciences, ‘Federico II’ University, Naples, Italy
| | - Cesare Baldi
- Heart Department, University Hospital ‘Scuola Medica Salernitana’, Salerno, Italy
| | - Marisa Malinconico
- Heart Department, University Hospital ‘Scuola Medica Salernitana’, Salerno, Italy
| | - Edvige Acri
- Clinical-Experimental Department of Medicine and Pharmacology, University of Messina, Italy
| | - Annapaola Cirillo
- Department of Advanced Biomedical Sciences, ‘Federico II’ University, Naples, Italy
| | - Rodolfo Citro
- Heart Department, University Hospital ‘Scuola Medica Salernitana’, Salerno, Italy
| | - Eduardo Bossone
- Heart Department, University Hospital ‘Scuola Medica Salernitana’, Salerno, Italy
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
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Singh K, Carson K, Shah R, Sawhney G, Singh B, Parsaik A, Gilutz H, Usmani Z, Horowitz J. Meta-analysis of clinical correlates of acute mortality in takotsubo cardiomyopathy. Am J Cardiol 2014; 113:1420-8. [PMID: 24685327 DOI: 10.1016/j.amjcard.2014.01.419] [Citation(s) in RCA: 142] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 01/03/2014] [Accepted: 01/03/2014] [Indexed: 12/27/2022]
Abstract
The incidence and clinical correlates of acute in-hospital mortality of takotsubo cardiomyopathy (TTC) are not clear. We performed a systematic review and meta-analysis to consolidate the current evidence on acute mortality in TTC. We then assessed the impact of "secondary" TTC, male gender, advancing age, and catecholamine use on mortality. A comprehensive search of 4 major databases (EMBASE, Ovid MEDLINE, PubMed, and Google Scholar) was performed from their inception to the first week of July 2013. We included original research studies, recruiting ≥10 participants, published in English language, and those that reported data on mortality and cause of death in patients with TTC. Of 382 citations, 37 studies (2,120 patients with TTC) from 11 different countries were included in the analyses. The mean age of the cohort was 68 years (95% confidence interval [CI] 67 to 69) with female predominance (87%). The in-hospital mortality rate among patients with TTC was 4.5% (95% CI 3.1 to 6.2, I2=60.8%). Among all deaths, 38% were directly related to TTC complications and rest to underlying noncardiac conditions. Male gender was associated with higher TTC mortality rate (odds ratio 2.6, 95% CI 1.5 to 4.6, p=0.0008, I2=0%) so was "secondary" TTC (risk difference -0.11, 95% CI -0.18 to -0.04, p=0.003, I2=84%). The mean age of patients dying tended to be greater than that in the whole cohort (72±7 vs 65±7 years). In conclusion, TTC is not as benign as once thought. To reduce the mortality rate, greater efforts need to be directed to the diagnosis, treatment, and ultimately prevention of "secondary" TTC.
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Affiliation(s)
- Kuljit Singh
- Department of Cardiology, University of Adelaide, Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
| | - Kristin Carson
- Department of Respiratory Medicine, University of Adelaide, Queen Elizabeth Hospital, Basil Hetzel Institute, Woodville, South Australia, Australia
| | - Ranjit Shah
- Department of Cardiology, University of Adelaide, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | | | - Balwinder Singh
- Department of Clinical Neurosciences, University of North Dakota School of Medicine & Health Sciences, Fargo, North Dakota
| | - Ajay Parsaik
- Department of Cardiology, Soroka Medical Centre, Ben Gurion University of the Negev, Beersheba, Israel
| | - Harel Gilutz
- Department of Psychiatry and Behavioral Sciences, University of Texas, Houston, Texas
| | - Zafar Usmani
- Department of Respiratory Medicine, University of Adelaide, Queen Elizabeth Hospital, Basil Hetzel Institute, Woodville, South Australia, Australia
| | - John Horowitz
- Department of Cardiology, University of Adelaide, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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35
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[Transient apical ballooning syndrome during dobutamine stress echocardiography]. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2014; 26:200-3. [PMID: 24725681 DOI: 10.1016/j.arteri.2014.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 02/10/2014] [Accepted: 02/14/2014] [Indexed: 11/22/2022]
Abstract
The transient left ventricular apical ballooning syndrome, also known as Tako-Tusbo syndrome, has an acute onset, is more common in postmenopausal women, and is characterized by transient left ventricular apical ballooning, chest pain, electrocardiographic abnormalities, and slight elevation of markers for myocardial injury, mimicking a myocardial infarction in patients with no significant coronary lesions. However, before making the diagnosis, other causes of reversible left ventricular dysfunction must be ruled out, such as subarachnoid hemorrhage, pheochromocytoma crisis, acute myocarditis, or the presence of tachycardiomyopathy. The case is presented of a patient who developed ST elevation electrocardiographic changes with apical transient dyskinesia during dobutamine stress echocardiography.
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Madias JE. Remote ischemic postconditioning for patients with Takotsubo syndrome. Int J Cardiol 2014; 172:e489-90. [PMID: 24485629 DOI: 10.1016/j.ijcard.2014.01.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 01/07/2014] [Indexed: 02/08/2023]
Affiliation(s)
- John E Madias
- Icahn School of Medicine at Mount Sinai, New York, NY, United States; Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, United States.
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37
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Ghadri JR, Bataisou RD, Diekmann J, Lüscher TF, Templin C. First case of atypical takotsubo cardiomyopathy in a bilateral lung-transplanted patient due to acute respiratory failure. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:482-5. [PMID: 24627332 DOI: 10.1177/2048872614527836] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 02/22/2014] [Indexed: 11/15/2022]
Abstract
Takotsubo cardiomyopathy which is characterised by a transient left ventricular wall motion abnormality was first described in 1990. The disease is still not well known, and as such it is suggested that an emotional trigger is mandatory in this disease. We present the case of a 51-year old female patient seven years after bilateral lung transplantation, who developed acute respiratory distress syndrome and subsequently suffered from atypical takotsubo cardiomyopathy with transient severe reduction of ejection fraction and haemodynamic instability needing acute intensive care treatment. Acute respiratory failure has emerged as an important physical trigger factor in takotsubo cardiomyopathy. Little is known about the association of hypoxia and takotsubo cardiomyopathy which can elicit a life-threatening condition requiring acute intensive care. Therefore, experimental studies are needed to investigate the role of hypoxia in takotsubo cardiomyopathy.
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Affiliation(s)
- Jelena R Ghadri
- Department of Cardiology, University Hospital Zurich, Switzerland
| | | | - Johanna Diekmann
- Department of Cardiology, University Hospital Zurich, Switzerland
| | - Thomas F Lüscher
- Department of Cardiology, University Hospital Zurich, Switzerland Center for Integrative Human Physiology (ZIHP), University of Zurich, Switzerland
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38
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Madias JE. Is there a link between Takotsubo syndrome and some cases of nonischemic cardiomyopathy? A proposal of an animal model. Int J Cardiol 2014; 172:e212-3. [DOI: 10.1016/j.ijcard.2013.12.080] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 12/26/2013] [Indexed: 10/25/2022]
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39
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Transient right ventricular dysfunction consequent to acute pulmonary embolism as a pathophysiological model of Takotsubo syndrome. Int J Cardiol 2014; 172:e366-7. [DOI: 10.1016/j.ijcard.2013.12.297] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 12/30/2013] [Indexed: 11/17/2022]
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40
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De Giorgi A, Fabbian F, Pala M, Parisi C, Misurati E, Molino C, Boccafogli A, Tiseo R, Gamberini S, Salmi R, Portaluppi F, Manfredini R. Takotsubo Cardiomyopathy and Acute Infectious Diseases. Angiology 2014; 66:257-61. [DOI: 10.1177/0003319714523673] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Takotsubo cardiomyopathy (TTC), also defined as “stress cardiomyopathy,” is characterized by a systolic dysfunction localized in the apical and medial left ventricles. Takotsubo cardiomyopathy is more prevalent in females and it is usually related to an event triggered by physical or emotional stress. We systematically explored PubMed and Embase medical information source to identify case reports showing association between infection and TTC. For each kind of infection, we collected a set of data, including pathogen, site of infection, clinical outcome, patient age and sex, and author and year of publication. We found 26 articles dealing with 27 case reports (74% women). The mean age was 61.4 ± 13.7 years and bacterial infections were more frequent (n = 23, 85.2%). In 14 cases, there was a culture-based definition of the bacterial strain: gram+ in 8 cases (57.1%) and gram− in 6 cases (42.9%). Clinical outcome was always favorable.
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Affiliation(s)
- Alfredo De Giorgi
- Clinica Medica, Azienda Ospedaliera-Universitaria of Ferrara, Ferrara, Italy
| | - Fabio Fabbian
- Clinica Medica, Azienda Ospedaliera-Universitaria of Ferrara, Ferrara, Italy
| | - Marco Pala
- Clinica Medica, Azienda Ospedaliera-Universitaria of Ferrara, Ferrara, Italy
| | - Claudia Parisi
- Clinica Medica, Azienda Ospedaliera-Universitaria of Ferrara, Ferrara, Italy
| | - Elisa Misurati
- Clinica Medica, Azienda Ospedaliera-Universitaria of Ferrara, Ferrara, Italy
| | - Christian Molino
- Clinica Medica, Azienda Ospedaliera-Universitaria of Ferrara, Ferrara, Italy
| | - Arrigo Boccafogli
- Clinica Medica, Azienda Ospedaliera-Universitaria of Ferrara, Ferrara, Italy
| | - Ruana Tiseo
- Clinica Medica, Azienda Ospedaliera-Universitaria of Ferrara, Ferrara, Italy
| | - Susanna Gamberini
- Second Internal Medicine, Azienda Ospedaliera-Universitaria of Ferrara, Ferrara, Italy
| | - Raffaella Salmi
- Second Internal Medicine, Azienda Ospedaliera-Universitaria of Ferrara, Ferrara, Italy
| | | | - Roberto Manfredini
- Clinica Medica, Azienda Ospedaliera-Universitaria of Ferrara, Ferrara, Italy
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41
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Bouabdallaoui N, Wang Z, Lecomte M, Ennezat PV, Blanchard D. Acute mitral regurgitation in Takotsubo cardiomyopathy. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:197-9. [DOI: 10.1177/2048872614521764] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Zhen Wang
- Department of Cardiology, Georges Pompidou European Hospital, France
| | - Milena Lecomte
- Department of Cardiology, Georges Pompidou European Hospital, France
| | - Pierre V Ennezat
- Department of Cardiology, Groupe Hospitalier Mutualiste de Grenoble, France
| | - Didier Blanchard
- Department of Cardiology, Georges Pompidou European Hospital, France
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42
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Bossone E, Lyon A, Citro R, Athanasiadis A, Meimoun P, Parodi G, Cimarelli S, Omerovic E, Ferrara F, Limongelli G, Cittadini A, Salerno-Uriarte JA, Perrone Filardi P, Schneider B, Sechtem U, Erbel R. Takotsubo cardiomyopathy: an integrated multi-imaging approach. Eur Heart J Cardiovasc Imaging 2013; 15:366-77. [PMID: 24128655 DOI: 10.1093/ehjci/jet167] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Takotsubo cardiomyopathy (TTC) is a distinct clinical entity characterized by the presence of transient left ventricular wall dysfunction without significant culprit obstructive coronary artery disease. Invasive coronary angiography and ventriculography are the 'gold standard' for definitive diagnosis, with an integrated multi-modality imaging approach offering advantages in various clinical scenarios. Echocardiography is a widely available, first-line, non-invasive imaging technique appropriate both in emergency setting to confirm diagnosis, assess for various potential acute complications, and in serial follow-up to track myocardial recovery. Cardiac magnetic resonance (CMR) may be helpful to discriminate TTC from other acute cardiac syndromes with troponin elevation and ventricular dysfunction. Echocardiography, CMR, and nuclear imaging may also provide new insights into possible underlying pathophysiological mechanisms, and myocardial (123)I-metaiodobenzyl-guanidine imaging may have a role for retrospective diagnosis in the subacute phase of late-presenting cases. The potential diagnostic role of coronary computed tomography angiography in the emergency room requires a further study.
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Affiliation(s)
- Eduardo Bossone
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
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Unfavorable stress management strategies in patients with Tako-Tsubo cardiomyopathy (TTC). Int J Cardiol 2013; 168:4582-3. [DOI: 10.1016/j.ijcard.2013.06.065] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 06/30/2013] [Indexed: 01/28/2023]
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44
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Madias JE. Nitric oxide and Takotsubo syndrome: an “angle” in need of exploration and exploitation. Cardiovasc Drugs Ther 2013; 28:197-8. [PMID: 24077797 DOI: 10.1007/s10557-013-6492-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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45
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Takotsubo syndrome and chest pain units. Am J Emerg Med 2013; 31:1415-6. [DOI: 10.1016/j.ajem.2013.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 06/07/2013] [Indexed: 11/23/2022] Open
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