Current Concepts in the Pathogenesis of Takotsubo Syndrome

A Case of Posterior Reversible Encephalopathy Due to Takotsubo Cardiomyopathy Triggered by Aerophobia

A 37-year-old woman, previously known to have severe airplane phobia, develops panic disorder-like symptoms in the second hour of the flight. After a while, panic disorder was accompanied by chest pain and syncope. An ECG showed no abnormalities. Transthoracic echocardiogram demonstrated decreased left ventricular ejection fraction (EF: 30), large apical akinesis, and characteristic regional wall motion abnormalities involving the middle and apical segments of the left ventricle. Findings were consistent with Takotsubo cardiomyopathy. But in the emergency department, Brain Diffusion MRI showed cortical and subcortical vasogenic edema in the posterior regions, predominantly on the left, bilaterally, compatible with posterior reversible encephalopathy. This case highlights the Takotsubo cardiomyopathy-related posterior reversible encephalopathy syndrome (PRES) syndrome and managing the disease.

Reverse Takotsubo Cardiomyopathy in a Critically Ill Patient in the ICU: A Case Report With Literature Review

Takotsubo, or stress cardiomyopathy (SC), is described as a transient systolic dysfunction of the apical segments of the left ventricle mainly triggered by emotional or physical stress resembling the presentation of an acute coronary syndrome in the absence of obstructive coronary artery disease. Reverse Takotsubo SC is a rare variant of SC that presents with basal ballooning instead of apical ballooning seen in classic SC. We present a case of a 74-year-old male who was admitted to the ICU with septic shock. Laboratory test results showed elevated troponin. An echocardiogram showed reduced cardiac contractility and relative hypokinesis of the basal and mid segments compared to the apical segments, consistent with reverse Takotsubo SC, which recovered after 10 days. It can happen in critically ill patients in the ICU secondary to severe sepsis and could contribute to hemodynamic worsening, affecting the final clinical outcomes.

Drugs as Possible Triggers of Takotsubo Cardiomyopathy- Update 2022: Systematic Review

BACKGROUND

A list of drugs that can induce takotsubo cardiomyopathy (TCM) was published in 2011 and 2016. The aim of the present review was to update this list.

METHODS

Similar to the 2011 and 2016 reviews, from April 2015 to May 2022 case reports of druginduced TCM were identified by a comprehensive search in Medline/PubMed database. The search terms were: takotsubo cardiomyopathy, tako-tsubo cardiomyopathy, stress cardiomyopathy, transientleft- ventricular ballooning syndrome, apical ballooning syndrome, ampulla cardiomyopathy OR broken heart syndrome; together with "iatrogenic", "induced by" OR "drug-induced". Registers published in English or Spanish, in humans, and with full texts were retrieved. Articles that recognized any drug associated with the development of TCM were selected.

RESULTS

Overall, 184 manuscripts were identified by the search. A total of 39 articles were included after an exhaustive revision. Eighteen drugs as possible triggers of TCM were identified in the current update. Of them, 3 (16.7%) have been previously identified, and 15 (83.3%) are different from the previous reports. Thus, the list of drugs as possible triggers of TCM updated in 2022 includes 72 drugs.

CONCLUSION

There are new case reports that link drugs with the development of TCM. The current list is principally made up of drugs that generate sympathetic overstimulation. However, some of the listed drugs do not have a clear link with sympathetic activation.

Stress Cardiomyopathy: The Midventricular Variant

• Midventricular TTC is a rare variant comprising 14.6% of stress cardiomyopathies. • TTC includes midventricular dyskinesis with normal basal and apical contractility. • Etiologies for all Takotsubo variants include physical/emotion stressors. • Pathophysiology remains unknown, although some theories exist.

The Incidence of Takotsubo Cardiomyopathy in Patients with Intracerebral Hemorrhage: A US Nationwide Study

BACKGROUND

Takotsubo cardiomyopathy (TC) is a commonly observed complication among patients with intracerebral hemorrhage (ICH); however, the incidence of TC in patients with ICH have not been investigated yet. The goal of this study was to examine the incidence of TC in ICH and identify its risk factors, incidence rate, and outcomes of TC in patients with ICH in a US nationwide scale.

METHODS

Data for patients with ICH between the years of 2015 and 2018 were extracted from the Nationwide Inpatient Sample and stratified based on the diagnosis of TC.

RESULTS

Our results showed that the incidence rate of TC in ICH discharges was 0.27% (95% confidence interval [CI] 0.24-0.31). The mean age of patients with ICH developing TC was 66.28 years ± 17.11. There were significantly more women in the TC group, with an odds ratio (OR) of 3.65 (95% CI 2.63-5.05). Acute myocardial infarction (OR 7.91, 95% CI 5.80-10.80) was significantly higher in the TC group. The mortality rate of patients with ICH who had TC was significantly higher (33.48%, p < 0.0001). Length of stay (mean days; 15.72 ± 13.56 vs. 9.56 ± 14.10, p < 0.0001) significantly increased in patients with ICH who had TC. Patients with intraventricular ICH (OR 2.46, 95% CI 1.88-3.22) had the highest odds of TC.

CONCLUSIONS

Takotsubo cardiomyopathy is associated with a higher mortality, longer hospitalization period, and more acute myocardial infarctions in patients with ICH. It is illustrated that intraventricular ICH is associated with higher odds of TC.

Conventional cardiovascular risk factors associated with Takotsubo cardiomyopathy: A comprehensive review

Takotsubo cardiomyopathy (TCM), characterized by transient left ventricular dysfunction, was first reported in Japan in 1990. Current research suggests that TCM can be affected by conventional cardiovascular factors such as hypertension (HTN), diabetes, hyperlipidemia (HLD), and obesity. Despite the increasing interest in this disease, research on TCM remains limited. Conventional cardiovascular factors are clinically related to the outcome of TCM. We reviewed the publications published in PubMed database between January 01 2010 and January 15 2021, and summarized the most current available evidence on the correlation between TCM and the conventional cardiovascular factors. TCM patients are predominantly postmenopausal women. Men and young patients are less commonly seen, but are prone to acute adverse complications and poor prognosis. HTN is common in patients with recurrent TCM. Existing evidence suggests that obesity and chronic kidney disease are related to poor prognosis in TCM. HLD is reported to be associated with fewer complications, though current evidence is limited. Finally, the relationship between diabetes and TCM prognosis is ambivalent. Current evidence suggests conventional cardiovascular risk factors are associated with the outcome of TCM, especially with mortality and complications. More prospective studies are needed to clarify the relationship between each risk factor and the prognosis of TCM.

Stress cardiomyopathy: Medical studies and extensive review

Stress cardiomyopathy (SC) was first reported in the year 1983. It is narrated as critical but quite commutative left ventricular (LV) malfunction mostly caused by poignant or psychological disorder. Numerous variations of SC have been described as well as reverse stress cardiomyopathy (rSC) which is an adaptation identified by the decreased muscle movement related with hyperkinesis that reconciles impetuously. The signature of rSC is a medical demonstration alike to syndrome by an acute coronary, with no obvious difficult coronary artery disease. The occurrence of SC is approximated to be 4% of all victims conferring with gleaned syndrome by acute coronary. The portion of victims conferring with the rSC transfiguration out of all SC patients has been inconstant, varying from 1 to 24%. Reverse stress cardiomyopathy cases are found to be common with young people, less decrease in left ventricular ejection fraction (LVEF) and more neurological disease compared to the SC. While the correct phenomenon of rSC is undetermined, postulated methods comprises of coronary microvasculature impairment, coronary artery spasm, and estrogen deficiency. Patients with rSC typically suffer with chest pain after an emotional or Psychological stressful event. The rSC can also be happened by general anesthesia, or neurological conditions. The diagnosis of rSC demands the presence of new electrocardiogram (EKG) abnormalities or elevated cardiac troponin, and absence of obstructive coronary disease, pheochromocytoma, or myocarditis. The consideration of rSC is quite analogous to that of SC, which is predominantly supportive with the treatment of complications. The recrudescence rate of rSC is around 12%. The most frequent complications of rSC include pericardial effusions, and development of LV thrombi.

Takotsubo cardiomyopathy: Review of broken heart syndrome

Takotsubo cardiomyopathy, also known as broken heart syndrome, apical ballooning syndrome, or stress cardiomyopathy, occurs when a stressful emotional or physical event causes the left ventricle of the heart to dilate, leading to acute heart failure. The syndrome was first described in Japan in 1990. Signs and symptoms of Takotsubo cardiomyopathy are similar to acute myocardial infarction. The syndrome presents with similar ECG and biomarker indications, so it often goes undiagnosed until coronary angiography is performed and reveals no blockage. Treatment is largely supportive. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) may reduce the likelihood of recurrent episodes. Overall, the prognosis is very good, with about 95% of patients making a full recovery.

Takotsubo syndrome triggered by change in position in a patient with thoracic vertebral fracture: A case report

RATIONALE

Takotsubo syndrome (TTS) is characterized by recovery of wall motion abnormalities and acute left ventricular dysfunction, which are often caused by acute physical or emotional stressors. It is rarely reported that TTS can be precipitated by change in position in the patient in the operating room. We report a case of a patient with a thoracic vertebral fracture who presented with TTS precipitated by changing from a supine to a prone position before percutaneous kyphoplasty (PKP) under local anesthesia.

PATIENT CONCERNS

A 76-year-old man who was diagnosed with a fracture in a thoracic vertebra was sent to the operating room to undergo PKP under local anesthesia. Approximately 5 minutes after changing from a supine to a prone position, which is necessary for PKP, the patient experienced chest pain, headache, and sweating.

DIAGNOSIS

A fracture in a thoracic vertebra; TTS.

INTERVENTIONS

As a result of 12-lead electrocardiography, echocardiography, left ventriculogram, and cardiac catheterization, the diagnosis of TTS was retained, and supportive therapy was initiated.

OUTCOMES

Two hours later, the patient's symptoms mitigated significantly and the ST segment returned to baseline. Four days later, echocardiography showed normal systolic function without wall motion abnormalities and the patient returned to the orthopedics ward for further treatment.

LESSONS

It is necessary for anesthetists to recognize TTS which is life-threatening during monitored anesthetic care (MAC). We highlight the importance of being alerted to the possibility of TTS when managing patients with thoracic vertebral fractures undergoing surgery under local anesthesia.

Iatrogenic Takotsubo Cardiomyopathy Following Overdose Norepinephrine Administration During Percutaneous Coronary Intervention

Takotsubo cardiomyopathy (TTC) is characterized by reversible ventricular dysfunction induced by endogenous and, occasionally, exogenous catecholamine. We present a report on a patient who developed TTC and cardiogenic shock during percutaneous coronary intervention (PCI) secondary to inadvertent norepinephrine administration. His hemodynamic status and cardiac function were totally restored within 1 week after hemodynamic support using intra-aortic balloon pump without sequela. Thus, TTC should be considered once a patient presents with symptoms mimicking acute coronary syndrome (ACS) after catecholamine administration.

Catecholamine-induced reverse takotsubo cardiomyopathy

Takotsubo cardiomyopathy is a syndrome characterized by transient left ventricular systolic and diastolic dysfunction, similar to an acute myocardial infarction but in the absence of significant obstructive epicardial coronary artery disease. This disease manifests predominantly in postmenopausal women in the presence of stressful triggers. We present a case of reverse takotsubo cardiomyopathy involving apical sparing, resulting from an iatrogenic overdose of epinephrine in a young man who was treated for anaphylaxis and angioedema.

Takotsubo cardiomyopathy: queries of the current era

: Takotsubo cardiomyopathy (TTS), also known as left ventricular apical ballooning syndrome, is an acute, usually reversible heart failure syndrome that most often affects postmenopausal women experiencing an emotionally stressful event. It is characterized by sudden left ventricular dysfunction and wall motion abnormalities involving the apical and mid segments. TTS has been increasingly recognized in recent years, and more and more information about the pathophysiology, diagnosis, and treatment of these patients has been reported. However, much is still unknown. TTS has a wide variety of clinical subtypes and has been described in several clinical contexts. Moreover, TTS simulates ST-segment elevation myocardial infarction and acute myocarditis, and it can be difficult to obtain a certain diagnosis. As a result, clinical decisions are challenging, and many patients currently receive an inappropriate management strategy. The aim of this review is to critically analyze the evidence about this disease reported in the literature, with particular focus on the pathophysiological processes, the diagnostic elements that can help the clinician differentiate it from other diseases, and the best management of these patients.

Reverse Takotsubo cardiomyopathy: a comprehensive review

Takotsubo cardiomyopathy (TTC) was first described in Japan in the 1980s. It is described as an acute but often reversible left ventricular (LV) dysfunction mainly triggered by emotional or physical stress. Multiple variants of TTC have been reported including reverse Takotsubo cardiomyopathy (rTTC) which is a variant characterized by the basal akinesis/hypokinesis associated with apical hyperkinesis that resolves spontaneously. The hallmark of rTTC is a clinical presentation similar to an acute coronary syndrome (ACS), with no evident obstructive coronary artery disease. The incidence of TTC is estimated to be 2% of all troponin-positive patients presenting with suspected ACS. The proportion of patients presenting with the rTTC variant out of all TTC patients in published literature has been variable, ranging from 1-23%. Reverse Takotsubo has been associated with younger age, less decrease in left ventricular ejection fraction (LVEF), and more neurological disease compared to the TTC. While the exact mechanism of rTTC is unknown, hypothesized mechanisms include catecholamine cardiotoxicity, coronary artery spasm, coronary microvasculature impairment, and estrogen deficiency. Patients with rTTC typically present with chest pain and/or dyspnea after an emotional or physically stressful event. rTTC can also be triggered by intracranial hemorrhage, general anesthesia, or neurological conditions. Diagnosis of rTTC requires the presence of LV basal hypokinesis/akinesis, new electrocardiogram (EKG) abnormalities or elevated cardiac troponin, and absence of obstructive coronary disease, pheochromocytoma, or myocarditis. Management of rTTC is similar to that of TTC, which is predominantly supportive with the treatment of complications. The recurrence rate of rTTC is around 10%. The most common complications of rTTC include myocarditis, pleural and pericardial effusions, and development of LV thrombi. The best predictors of mortality include decreased LVEF, development of atrial fibrillation, and neurologic disease.

Takotsubo syndrome and dialysis: an uncommon association?

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.

Takotsubo Syndrome is Associated with Mood Disorders and Antidepressants Use, not with Anxiety and Impairment of Quality of Life Due to the Psychiatric Disorder

BACKGROUND

The aim was to study the association between mood and anxiety disorders and the Tako-Tsubo Syndrome (TTS) and to determine the role of antidepressants and the impairment of quality of life due the comorbid psychiatric disorder.

METHODS

Case-control study: 19 consecutive patients (17 female) with TTS compared to 76 controls without TTS, were randomly selected from the database of a nationwide epidemiological study after matching (gender, age and residence) by controls. Psychiatric diagnoses were carried out according to the ICD-10 using semi-structured interview tools (ANTAS-SCID) administered by clinical staff. Quality of Life (Qol) was assessed by means of SF-12.

RESULTS

Only Major Depressive Disorders (MDD) showed higher frequencies in cases with statistical significance difference (p=0.014) as well as at least one Mood Disorder Diagnosis [MDD or BD] (p=0.002). The lifetime prevalence of at least one anxiety disorder with no comorbid mood disorder did not show a higher frequency in cases (p=0.57).The score at SF-12 in the TTS group was similar to those of controls (p=0.71)In the TTS group, the score at SF-12 in people with one mood or anxiety diagnosis (N=7) was similar to those without mood or anxiety diagnosis (p=0.75). The use of antidepressants was higher in TTS group (15.79% vs 1.31%; p=0.030).

CONCLUSION

The study shows an association between TTS with depressive disorders and antidepressants use and does not confirm the association with anxiety syndromes. The study suggests the need to investigate the possible interactions between antidepressants use and mood disorders in studies with appropriate design and sample size.

Current interpretation of myocardial stunning

Myocardial stunning is a temporary post-ischemic cardiac mechanical dysfunction. As such, it is a heterogeneous entity and different conditions can promote its occurrence. Transient coronary occlusion, increased production of catecholamines and endothelin, and myocardial inflammation are all possible causes of myocardial stunning. Possible underlying mechanisms include an oxyradical hypothesis, calcium overload, decreased responsiveness of myofilaments to calcium, and excitation-contraction uncoupling due to sarcoplasmic reticulum dysfunction. The aim of this review is to summarize the clinical conditions that may be responsible for stunned myocardium.

Influence of Genetics and Gender in Takotsubo Syndrome: Unexplored Areas of an Incompletely Understood Disease

Stress cardiomyopathy, also known as “Takotsubo syndrome” (TS), is a complex disease that typically affects postmenopausal women. The pathophysiology is still largely unknown, but evidence of a frequent association between TS and stressful events has evoked the hypothesis of a pathophysiologic role of sympathetic overdrive in the myocardial dysfunction. However, despite several studies, the role gender plays in TS onset remains unclear because stress cardiomyopathy also has been described in young women and in men. Moreover, although several cases of a familial cluster of TS have been reported, no responsible gene mutations or polymorphisms have been clearly identified so far, and neither the modality of transmission or the true impact of genetic background. In this review, we discuss the role of gender in the onset, course, and outcomes of TS and we report the available data about polymorphisms and gene mutations so far investigated, trying to critically analyze the evidence reported in the literature.

Takotsubo cardiomyopathy with use of salbutamol nebulisation and aminophylline infusion in a patient with acute asthma exacerbation

Takotsubo cardiomyopathy, apical ballooning syndrome or stress-induced cardiomyopathy is characterised by transient left ventricular dysfunction, mimicking myocardial infarction in the absence of obstructive coronary artery disease or acute plaque rupture on coronary angiography. The exact mechanism of myocardial dysfunction in Takotsubo cardiomyopathy is unknown; however, due to its association with physical and emotional stress, it is postulated that catecholamines play a central role in its pathogenesis. We present a case of a patient who was admitted with acute asthma exacerbation and was treated with β-2 agonist nebulisation and intravenous aminophylline. During her hospital stay she developed Takotsubo cardiomyopathy.