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Madias JE. Electrocardiogram repolarization markers and ventricular arrhythmias in patients with takotsubo syndrome. Curr Probl Cardiol 2024; 49:102757. [PMID: 39059781 DOI: 10.1016/j.cpcardiol.2024.102757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 07/23/2024] [Indexed: 07/28/2024]
Abstract
The predictive value of various ECG repolarization markers for the emergence of VA in patients with TTS was reviewed. The literature reports on QT, more recently on Tpe, and rarely on some more QT-derived metrics, revealing a contribution of these variables for the prediction of VA, complicating the acute, subacute, and follow-up clinical trajectory of patients with TTS. More recent literature reveals that Tpe and some other QT-based metrics, have outperformed the traditionally employed QT marker, although certainty about this awaits confirmation by future carefully designed and implemented studies.
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Affiliation(s)
- John E Madias
- Icahn School of Medicine at Mount Sinai, New York, NY, United States; Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY 11373, United States.
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Shadmand M, Lautze J, Md AM. Takotsubo pathophysiology and complications: what we know and what we do not know. Heart Fail Rev 2024; 29:497-510. [PMID: 38150119 DOI: 10.1007/s10741-023-10381-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 12/28/2023]
Abstract
Takotsubo cardiomyopathy or stress cardiomyopathy (SCM), was first described in 1990 and initially, it was thought to be only associated with short-term complications and mortality with a benign long-term prognosis comparable to a healthy population. However recent investigations have proven otherwise and have shown SCM patients might have comparable long-term morbidity and mortality to ST-elevation myocardial infarction (STEMI) patients. Many emotional, or physical stressors can trigger SCM, and have been able to describe an interplay of neurohormonal and inflammatory mechanisms as the pathophysiology of this disease. Additionally, given the significantly higher prevalence of SCM in post-menopausal women, estrogen levels have been thought to play a role in the pathogenesis of this disease. Furthermore, there is an elusive disparity in prognosis depending upon different triggers. Currently, many questions remain unanswered regarding the long-term management of these patients to reduce morbidity, mortality, and improve quality of life, such as the need for long-term anticoagulation. In this paper, we review the findings of most recent published investigations regarding etiologies, pathophysiology, diagnostic criteria, prognosis, short-term and in more detail, long-term complications of SCM. Finally, we will discuss what future research is needed to learn more about this disease to improve the long-term prognosis, even though as of now, data for long-term management is still lacking.
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Affiliation(s)
- Mehdi Shadmand
- Internal Medicine, Wright State University, 128 E. Apple St., 2Nd Floor, Dayton, OH, 45409, USA.
| | - Jacob Lautze
- Internal Medicine, Wright State University, 128 E. Apple St., 2Nd Floor, Dayton, OH, 45409, USA
| | - Ali Mehdirad Md
- Internal Medicine, Wright State University, 128 E. Apple St., 2Nd Floor, Dayton, OH, 45409, USA
- Medical Center, Internal Medicine, Veteran Affairs (VA), 4100 W Third St., Dayton, OH, 45428, USA
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Ahmed T, Lodhi SH, Haigh PJ, Sorrell VL. The many faces of takotsubo syndrome: A review. Curr Probl Cardiol 2024; 49:102421. [PMID: 38253114 DOI: 10.1016/j.cpcardiol.2024.102421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 01/24/2024]
Abstract
Takotsubo syndrome is a state of an acute heart failure featuring reversible left ventricular dysfunction. In recent years, the incidence of Takotsubo syndrome has risen 8-fold. In this case series and literature review, we present the rare presentations or complications of Takotsubo syndrome and highlight diagnostic or management strategies. We aim to raise the awareness on the pathologic spectrum of takotsubo syndrome for the clinicians encountering this challenging diagnosis.
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Affiliation(s)
- Taha Ahmed
- Department of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, Lexington, KY, USA.
| | - Samra Haroon Lodhi
- Department of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, Lexington, KY, USA
| | - Peter J Haigh
- Department of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, Lexington, KY, USA
| | - Vincent L Sorrell
- Department of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, Lexington, KY, USA
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Isogai T, Matsui H, Tanaka H, Makito K, Fushimi K, Yasunaga H. Incidence, management, and prognostic impact of arrhythmias in patients with Takotsubo syndrome: a nationwide retrospective cohort study. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:834-846. [PMID: 37708494 PMCID: PMC10734680 DOI: 10.1093/ehjacc/zuad110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/08/2023] [Accepted: 09/11/2023] [Indexed: 09/16/2023]
Abstract
AIMS Arrhythmia is a major complication of Takotsubo syndrome (TTS). However, its incidence, management, and prognostic impact remain to be elucidated in a large cohort. METHODS AND RESULTS We retrospectively identified 16 713 patients hospitalized for TTS between July 2010 and March 2021 from the Japanese Diagnosis Procedure Combination database. Serious arrhythmias were defined as ventricular tachycardia/fibrillation (VT/VF), 2nd-/3rd-degree atrioventricular block (AVB), sick sinus syndrome (SSS), or unspecified arrhythmias requiring device treatment. Patient characteristics and outcomes were compared based on the occurrence of serious arrhythmias. The overall incidence proportion of serious arrhythmias was 6.2% (n = 1036; 449 VT/VF, 283 2nd-/3rd-degree AVB, 133 SSS, 55 multiple arrhythmias, 116 others), which remained stable over 11 years. The arrhythmia group was younger, more often male, and exhibited greater impairment in activities of daily living (ADLs) and consciousness than the non-arrhythmia group. Although crude in-hospital mortality was higher in the arrhythmia group (9.6% vs. 5.0%, P < 0.001), the significant association between arrhythmias and mortality disappeared after adjustment for confounders (odds ratio = 1.15, 95% confidence interval = 0.90-1.49). Meanwhile, age, sex, ADLs, consciousness level, and Charlson comorbidity index were significantly associated with mortality. In the arrhythmia group, 254 (24.5%) patients received pacemakers (18.4%) or defibrillators (6.1%), which were implanted at a median of 8 and 19 days after admission, respectively. CONCLUSION Arrhythmias are not uncommon in TTS. Patients' background characteristics, rather than arrhythmia itself, may be associated with in-hospital mortality. Given the reversibility of cardiac dysfunction in TTS, there may be unnecessary device implantations for arrhythmias occurring as sequelae to TTS, warranting further investigations.
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Affiliation(s)
- Toshiaki Isogai
- Department of Cardiology, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu, 183-8524 Tokyo, Japan
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, 113-0033 Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, 113-0033 Tokyo, Japan
| | - Hiroyuki Tanaka
- Department of Cardiology, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu, 183-8524 Tokyo, Japan
| | - Kanako Makito
- Department of Biostatistics and Bioinformatics, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, 113-0033 Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, 113-8510 Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, 113-0033 Tokyo, Japan
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Pinho AI, Oliveira C, Santos LD, Marques C, Cabrita A, Dias P, Pestana G, Sousa C, Rodrigues RA. QT interval prolongation in Takotsubo syndrome: a frightening feature with no major prognostic impact. Monaldi Arch Chest Dis 2023. [PMID: 38058291 DOI: 10.4081/monaldi.2023.2834] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/04/2023] [Indexed: 12/08/2023] Open
Abstract
Despite the frequent and often severe repolarization abnormalities seen in Takotsubo syndrome (TTS), the underlying mechanism of life-threatening arrhythmias is incompletely understood, and the risk remains uncertain. TTS is considered a potential cause of acquired long QT syndrome; however, there is no robust evidence that QT prolongation has a major prognostic impact on these patients' outcomes. Our aim was to assess the prevalence and clinical implications of acquired long QT during TTS events and compare in-hospital and long-term outcomes between patients with and without corrected QT interval (QTc) prolongation. This is a retrospective cohort study that included 113 patients admitted to our tertiary care hospital with a diagnosis of TTS. The cohort was divided into two groups: a long QTc group (QTc≥460 milliseconds in any electrocardiogram at admission or during hospitalization) and a normal QTc group. Baseline characteristics, occurrences during hospitalization, and outcome data were obtained from the revision of medical registries and hospital visits. Of the 113 patients, 107 (94.7%) were female. The mean age was 67.6±11.7 years. QTc prolongation was found in 38%. Demographic characteristics, relevant chronic medication, prevalence of cardiovascular risk factors, and other comorbidities were similar between the groups, except for history of atrial fibrillation, which was more common in the long QTc group. Syncope was more prevalent in the long QTc group. In-hospital complications were not statistically different between patients with long and normal QTc (48.8% versus 44.2%, p=0.637), including ventricular arrhythmias and complete atrioventricular block (both 4.7% versus 1.4%, p=0.556). In-hospital mortality was 0.9%, corresponding to one patient in the long QTc group. The mean follow-up time was 4.8±3.8 years. 5-year all-cause mortality and the occurrence of the composite endpoint of major adverse cardiac and cerebrovascular events did not differ between the groups (p=0.511 and p=0.538, respectively). Our study found no association between prolonged QTc interval during TTS events and adverse prognosis, since in-hospital and long-term outcomes were similar between the groups. Our findings suggest that, although QT prolongation is usually a frightening feature on ECG, this repolarization abnormality during the acute phase has no major prognostic implications in the TTS population.
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Affiliation(s)
- Ana Isabel Pinho
- Department of Cardiology, University Hospital Center of São João, Porto.
| | - Cátia Oliveira
- Department of Cardiology, University Hospital Center of São João, Porto.
| | - Luís Daniel Santos
- Department of Cardiology, University Hospital Center of São João, Porto.
| | - Catarina Marques
- Department of Cardiology, University Hospital Center of São João, Porto.
| | - André Cabrita
- Department of Cardiology, University Hospital Center of São João, Porto.
| | - Paula Dias
- Department of Cardiology, University Hospital Center of São João, Porto.
| | - Gonçalo Pestana
- Department of Cardiology, University Hospital Center of São João, Porto.
| | - Carla Sousa
- Department of Cardiology, University Hospital Center of São João, Porto; Cardiovascular Research and Development Center, Faculty of Medicine, University of Porto.
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Khaloo P, Ledesma PA, Nahlawi A, Galvin J, Ptaszek LM, Ruskin JN. Outcomes of Patients With Takotsubo Syndrome Compared With Type 1 and Type 2 Myocardial Infarction. J Am Heart Assoc 2023; 12:e030114. [PMID: 37681546 PMCID: PMC10547303 DOI: 10.1161/jaha.123.030114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 08/11/2023] [Indexed: 09/09/2023]
Abstract
Background Takotsubo syndrome (TS) and myocardial infarction (MI) share similar clinical and laboratory characteristics but have important differences in causes, demographics, management, and outcomes. Methods and Results In this observational study, the National Inpatient Sample and National Readmission Database were used to identify patients admitted with TS, type 1 MI, or type 2 MI in the United States between October 1, 2017, and December 31, 2019. We compared patients hospitalized with TS, type 1 MI, and type 2 MI with respect to key features and outcomes. Over the 27-month study period, 2 035 055 patients with type 1 MI, 639 075 patients with type 2 MI, and 43 335 patients with TS were identified. Cardiac arrest, ventricular fibrillation, and ventricular tachycardia were more prevalent in type 1 MI (4.02%, 3.2%, and 7.2%, respectively) compared with both type 2 MI (2.8%, 0.8%, and 5.4% respectively) and TS (2.7%, 1.8%, and 5.3%, respectively). Risk of mortality was lower in TS compared with both type 1 MI (3.3% versus 7.9%; adjusted odds ratio [OR], 0.3; P<0.001) and type 2 MI (3.3% versus 8.2%; adjusted OR, 0.3; P<0.001). Mortality rate (OR, 1.2; P<0.001) and cardiac-cause 30-day readmission rate (adjusted OR, 1.7; P<0.001) were higher in type 1 MI than in type 2 MI. Conclusions Patients with type 1 MI had the highest rates of in-hospital mortality and cardiac-cause 30-day readmission. Risk of all-cause 30-day readmission was highest in patients with type 2 MI. The risk of ventricular arrhythmias in patients with TS is lower than in patients with type 1 MI but higher than in patients with type 2 MI.
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Affiliation(s)
- Pegah Khaloo
- Cardiac Arrhythmia Service, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Pablo A. Ledesma
- Cardiac Arrhythmia Service, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Acile Nahlawi
- Cardiac Arrhythmia Service, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Jennifer Galvin
- Cardiac Arrhythmia Service, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Leon M. Ptaszek
- Cardiac Arrhythmia Service, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Jeremy N. Ruskin
- Cardiac Arrhythmia Service, Massachusetts General HospitalHarvard Medical SchoolBostonMA
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Krishna MM, Krishna MM, Joseph M. Takotsubo Cardiomyopathy in a Polytrauma Patient With Subarachnoid Hemorrhage. Cureus 2023; 15:e38954. [PMID: 37313080 PMCID: PMC10258542 DOI: 10.7759/cureus.38954] [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] [Accepted: 05/12/2023] [Indexed: 06/15/2023] Open
Abstract
Takotsubo cardiomyopathy (TCM) is a sudden, transient myocardial stunning precipitated by severe emotional or physical stress. It is characterized by left ventricular apical ballooning and elevated cardiac enzymes without significant coronary artery stenosis. Stress-induced catecholamine surge has been proposed to be the likely mechanism of TCM. We report the case of a 23-year-old female who presented to the emergency department unconscious and in respiratory distress following a motor vehicle accident. The point-of-care ultrasonography showed prominent B lines in bilateral lung fields and a dilated inferior vena cava (IVC). An x-ray and computed tomography (CT) scan of the chest revealed bilateral diffuse ground glass opacities. A CT scan of the brain showed a subarachnoid hemorrhage (SAH). Electrocardiography (ECG) showed normal sinus rhythm, but troponin I was elevated. Echocardiography revealed left ventricular apical hypokinesia. The coronary angiogram was normal. A diagnosis of TCM with SAH was made. Appropriate emergent care was provided, and at follow-up, she made a complete cardiologic recovery. TCM is a puzzling condition in an emergency setting and accurate and timely diagnosis is imperative in the management. Early prevention of hypoxemia and maintenance of mean arterial pressure and cerebral perfusion pressure is critical in determining the long-term outcome of the patient in the setting of co-existing CNS pathologies.
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Affiliation(s)
- Mithun Murali Krishna
- Emergency Medicine, Pushpagiri Institute of Medical Sciences & Research Centre, Thiruvalla, IND
| | - Mrinal Murali Krishna
- Internal Medicine, Government Medical College, Thiruvananthapuram, Thiruvananthapuram, IND
| | - Meghna Joseph
- Pediatrics, Government Medical College, Thiruvananthapuram, Thiruvananthapuram, IND
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Abstract
Takotsubo syndrome (TTS), triggered by intense emotional or physical stress, occurring most commonly in post-menopausal women, presents as an ST-elevation myocardial infarction (MI). Cardiovascular complications occur in almost half the patients with TTS, and the inpatient mortality is comparable to MI (4-5%) owing to cardiogenic shock, myocardial rupture, or life-threatening arrhythmias. Thus, its prognosis is not as benign as previously thought, as it may cause mechanical complications (cardiac rupture) and potentially lethal arrhythmias and sudden cardiac death (SCD). Similar to MI, some patients may perish before reaching the hospital due to out-of-hospital cardiac arrest; this may lead to underestimation of the actual SCD risk. Furthermore, after discharge, some patients may develop late SCD and/or TTS recurrence that may result in SCD. There are risk factors for SCD in TTS patients, such as severe/persistent QT-interval prolongation inciting torsade-de-pointes, other ECG abnormalities (diffuse giant negative T-waves, widened QRS-complex), bradyarrhythmias, comorbidities, concurrent obstructive coronary artery disease or vasospasm, male gender, older age, severe left ventricular dysfunction, and use of sympathomimetic drugs. All these issues are herein reviewed, case reports/series and data from large cohort studies and meta-analyses are analyzed, risk factors are tabulated, and proarrhythmic effects and management strategies are discussed and pictorially illustrated.
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Affiliation(s)
| | | | - Helen Melita
- 69106Central Laboratories, Onassis Cardiac Surgery Center, Athens, Greece
| | - Antonis S Manolis
- First Department of Cardiology, Athens University School of Medicine, Athens, Greece
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Olson E, Manna Z, Tavokolian K, Desai D, Kapoor M. Takotsubo Syndrome and Complete Heart Block: A Diagnostic and Management Conundrum. J Investig Med High Impact Case Rep 2023; 11:23247096231176213. [PMID: 37209038 DOI: 10.1177/23247096231176213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023] Open
Abstract
There is increasing evidence that Takotsubo cardiomyopathy behaves more like a highly variable and dangerous syndrome than an isolated cardiomyopathy. In this case report, we describe a case of Takotsubo cardiomyopathy complicated by complete heart block. We discuss the potential mechanisms for its etiology and examine the need for pacemaker placement.
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Affiliation(s)
- Erik Olson
- Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Zachary Manna
- Jersey Shore University Medical Center, Neptune, NJ, USA
| | | | - Dhaval Desai
- Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Mahim Kapoor
- Jersey Shore University Medical Center, Neptune, NJ, USA
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Menchaca K, Ostos Perez CA, Draguljevic N, Isaac S. Management Challenge: An Atypical Variant of Takotsubo Presenting With Multiple Complications. Cureus 2022; 14:e26836. [PMID: 35854952 PMCID: PMC9286025 DOI: 10.7759/cureus.26836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 11/05/2022] Open
Abstract
An 84-year-old woman with depression, who witnessed the suicide of a close friend, presented with symptoms of chest pain, palpitations, and cold and clammy extremities. An electrocardiogram showed alternating tachycardia and bradycardia. Urgent transthoracic echocardiogram demonstrated left greater than right ventricular dysfunction, moderate mitral regurgitation, global hypokinesis, and an estimated ejection fraction of 20%. Cardiac catheterization demonstrated non-obstructive coronary artery disease and decreased cardiac output. Findings were consistent with Takotsubo cardiomyopathy complicated with cardiogenic shock, acute mitral regurgitation, and sinus node dysfunction. Management of this patient required the use of a mechanical device intra-aortic balloon pump, and pacemaker insertion for persistent symptomatic arrhythmia. This case highlights the challenging management of potentially fatal acute complications of Takotsubo cardiomyopathy and inadequate data on how to approach them.
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Koh Y, Voskoboinik A, Neil C. Arrhythmias and Their Electrophysiological Mechanisms in Takotsubo Syndrome: A Narrative Review. Heart Lung Circ 2022; 31:1075-1084. [PMID: 35562239 DOI: 10.1016/j.hlc.2022.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/19/2022] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Takotsubo syndrome (TTS), an acute and usually reversible condition, is associated with both tachy- and bradyarrhythmias. Such arrhythmias can be life-threatening, e.g. ventricular tachycardia and fibrillation, and associated with cardiac arrest. Others, such as atrioventricular block, persist and require long-term device therapy. In this narrative review, we aim to provide a summary of the current literature on arrhythmias in TTS and their clinical sequelae. METHODS PubMed and Medline databases were searched with various permutations of TTS, arrhythmias and beta-adrenoceptors. After application of exclusion criteria and review, 84 articles were included. RESULTS Although there are no specific electrocardiograph (ECG) findings in TTS to differentiate it from ST-elevation myocardial infarction, suggestive patterns include small QRS amplitude, ST segment elevation without reciprocal ST depression and prolonged QT interval. Atrial tachyarrhythmias (incidence of 5-15%) are associated with a more unwell patient cohort. Ventricular arrhythmias (incidence 4-14%) are often associated with prolonged QT interval and are a cause of sudden death in TTS. Bradyarrhythmias are less common (incidence 1.3-2.5%), but have been reported with TTS, and usually persist beyond the acute phase. CONCLUSIONS Takotsubo syndrome, though considered primarily a disease of the myocardium, carries multiple arrhythmic manifestations that affect short- and long-term prognosis. The management of such arrhythmias represents a constantly evolving area of research.
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Affiliation(s)
- Y Koh
- Department of Cardiology, Western Health, Melbourne, Vic, Australia.
| | - A Voskoboinik
- Department of Cardiology, Western Health, Melbourne, Vic, Australia
| | - C Neil
- Department of Cardiology, Western Health, Melbourne, Vic, Australia
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12
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Bairashevskaia AV, Belogubova SY, Kondratiuk MR, Rudnova DS, Sologova SS, Tereshkina OI, Avakyan EI. Update of Takotsubo cardiomyopathy: Present experience and outlook for the future. IJC HEART & VASCULATURE 2022; 39:100990. [PMID: 35281752 PMCID: PMC8913320 DOI: 10.1016/j.ijcha.2022.100990] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/24/2022] [Accepted: 03/01/2022] [Indexed: 11/21/2022]
Abstract
Takotsubo cardiomyopathy (TTS) has become a recognised clinical entity since the Japanese scientist Sato first described it in 1990. Despite an increasing number of confirmed cases, especially during the COVID-19 pandemic, its pathophysiology remains incompletely understood, and decision-making differs in the diagnosis and treatment. In addition, it is not evident whether a significant increase in TTS is due to better understanding among practitioners and widespread access to coronary angiography, or if it is a reflection of an actual increase in incidence. We analysed a series of international research studies from 1990 to 2021. Beyond epidemiology and clinical presentation, we evaluated and summarised fundamental knowledge about various predisposing factors, with particular attention to the iatrogenic impact of certain drugs, namely antidepressants, chemotherapy, and antiarrhythmics. Furthermore, we highlighted the main pathophysiological theories to date. In addition, based on published studies and clinical cases, we investigated the role of numerous diagnostic approaches in the differential diagnosis of TTS and identified predictors of TTS complications, such as cardiogenic shock, ventricular fibrillation, and left ventricular thrombi. Accordingly, we sought to propose a diagnostic algorithm and further treatment management of TTS under the presence of possible complications to help practitioners make more informed decisions, as the initial presentation continues to pose a challenge due to its close similarity to acute coronary syndrome with ST-elevation. In conclusion, this article examines Takotsubo cardiomyopathy from different perspectives and, along with future systematic reviews and meta-analyses, can be of particular interest to practising cardiologists and researchers in developing clinical guidelines.
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Affiliation(s)
- Anastasiia V Bairashevskaia
- Department of Paediatrics, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia
| | - Sofiya Y Belogubova
- Department of Faculty Therapy, Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia.,AMEE International Networking Centre, Sechenov First Moscow State Medical University (Sechenov University), 123242 Moscow, Russia
| | - Mikhail R Kondratiuk
- Department of Faculty Therapy, Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia
| | - Daria S Rudnova
- International School "Medicine of the Future", Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia
| | - Susanna S Sologova
- Department of Pharmacology, Institute of Pharmacy, Sechenov First Moscow State Medical University (Sechenov University), 119571 Moscow, Russia
| | - Olga I Tereshkina
- Department of Pharmacology, Institute of Pharmacy, Sechenov First Moscow State Medical University (Sechenov University), 119571 Moscow, Russia
| | - Esma I Avakyan
- Department of Faculty Therapy, Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia.,AMEE International Networking Centre, Sechenov First Moscow State Medical University (Sechenov University), 123242 Moscow, Russia
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Vavilis G, Y‐Hassan S. Atrio‐ventricular block and takotsubo syndrome: A review illustrated with two case reports. Clin Case Rep 2022; 10:e05417. [PMID: 35223010 PMCID: PMC8847407 DOI: 10.1002/ccr3.5417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/04/2022] [Accepted: 01/25/2022] [Indexed: 11/09/2022] Open
Abstract
Takotsubo syndrome (TS) can be complicated by life‐threatening arrhythmias. Data on the association of AV‐block, pacemaker implantation, and TS are scarce. We describe two cases of AV‐block associated with TS. AV‐block persisted despite the recovery of left ventricular dysfunction during follow‐up. A review of AV‐block and TS association is provided.
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Affiliation(s)
- Georgios Vavilis
- Departement of Medicine Karolinska Institute Huddinge, Stockholm Sweden
- Coronary Artery Disease Area Heart and Vascular Theme Karolinska University Hospital Stockholm Sweden
| | - Shams Y‐Hassan
- Coronary Artery Disease Area Heart and Vascular Theme Karolinska University Hospital Stockholm Sweden
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van der Lingen ALC, Woudstra J, Becker MA, Mol MA, van Rossum AC, Rijnierse MT, Allaart CP. Recurrent Ventricular Arrhythmias and Mortality in Cardiac Arrest Survivors with a Reversible Cause With and Without an Implantable Cardioverter Defibrillator: a Systematic Review. Resuscitation 2022; 173:76-90. [DOI: 10.1016/j.resuscitation.2022.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 02/17/2022] [Accepted: 02/20/2022] [Indexed: 12/15/2022]
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Montone RA, La Vecchia G, Buono MGD, Abbate A, Sanna T, Pedicino D, Niccoli G, Antonelli M, Crea F. Takotsubo Syndrome in Intensive Cardiac Care Unit: Challenges in Diagnosis and Management. Curr Probl Cardiol 2021; 47:101084. [PMID: 34942270 DOI: 10.1016/j.cpcardiol.2021.101084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 12/15/2021] [Indexed: 01/02/2023]
Abstract
Takotsubo syndrome (TTS) is an acute reversible form of myocardial dysfunction that is often associated with serious adverse in-hospital complications, including acute heart failure, cardiogenic shock and life-threatening arrythmias. In the absence of randomized clinical trials, its management in the acute phase is based on empirical supportive pharmacological and non-pharmacological measures.In this review article, we aimed at providing an overview of the acute clinical manifestations of patients presenting with TTS, highlighting the predictors of a worse short-term outcome, along with the challenges in therapeutic management of TTS-related complications in the acute care setting.
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Affiliation(s)
- Rocco Antonio Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Giulia La Vecchia
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Marco Giuseppe Del Buono
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond
| | - Antonio Abbate
- Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond
| | - Tommaso Sanna
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Daniela Pedicino
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giampaolo Niccoli
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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16
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Omerovic E, Citro R, Bossone E, Redfors B, Backs J, Bruns B, Ciccarelli M, Couch LS, Dawson D, Grassi G, Iacoviello M, Parodi G, Schneider B, Templin C, Ghadri JR, Thum T, Chioncel O, Tocchetti CG, Van Der Velden J, Heymans S, Lyon AR. Pathophysiology of Takotsubo Syndrome - a joint scientific statement from the Heart Failure Association Takotsubo Syndrome Study Group and Myocardial Function Working Group of the European Society of Cardiology - Part 1: Overview and the central role for catecholamines and sympathetic nervous system. Eur J Heart Fail 2021; 24:257-273. [PMID: 34907620 DOI: 10.1002/ejhf.2400] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/04/2021] [Accepted: 12/07/2021] [Indexed: 11/11/2022] Open
Abstract
This is the first part of a scientific statement from the Heart Failure Association of the European Society of Cardiology focused upon the pathophysiology of Takotsubo syndrome and is complimentary to the previous HFA Position Statement on Takotsubo syndrome which focused upon clinical management. In part 1 we provide an overview of the pathophysiology of Takotsubo syndrome and fundamental questions to consider. We then review and discuss the central role of catecholamines and the sympathetic nervous system in the pathophysiology, and the direct effects of high surges in catecholamines upon myocardial biology including β-adrenergic receptor signaling, G protein coupled receptor kinases, cardiomyocyte calcium physiology, myofilament physiology, cardiomyocyte gene expression, myocardial electrophysiology and arrhythmogenicity, myocardial inflammation, metabolism and energetics. The integrated effects upon ventricular haemodynamics are discussed and integrated into the pathophysiological model. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital and Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Rodolfo Citro
- Heart Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Eduardo Bossone
- Division of Cardiology, A. Cardarelli Hospital, Naples, Italy
| | - Bjorn Redfors
- Department of Cardiology, Sahlgrenska University Hospital and Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Johannes Backs
- Institute of Experimental Cardiology, Heidelberg University, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Germany
| | - Bastian Bruns
- Institute of Experimental Cardiology, Heidelberg University, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Germany.,Department of General Internal Medicine and Psychosomatics, University of Heidelberg, Heidelberg, Germany
| | - Michele Ciccarelli
- Department of Medicine, Surgery, and Dentistry, University of Salerno, Salerno, Italy
| | - Liam S Couch
- National Heart and Lung Institute, Imperial College, London, UK
| | - Dana Dawson
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland, UK
| | - Guido Grassi
- Clinica Medica, University of Milano Bicocca, Milan, Italy
| | - Massimo Iacoviello
- University Cardiology Unit, Cardiothoracic Department, University Hospital, Bari, Italy
| | - Guido Parodi
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
| | | | - Christian Templin
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Jelena R Ghadri
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Thum
- Hannover Medical School, Institute of Molecular and Translational Therapeutic Strategies, Hannover, Germany
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania and University of Medicine Carol Davila, Bucharest, Romania
| | - C Gabriele Tocchetti
- Department of Translational Medical Sciences and Interdepartmental Center for Clinical and Translational Research (CIRCET), Federico II University, Naples, Italy
| | | | - Stephane Heymans
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, The Netherlands and Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology and Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Alexander R Lyon
- National Heart and Lung Institute, Imperial College, London, UK.,Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
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17
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Topf A, Mirna M, Bacher N, Paar V, Motloch LJ, Ohnewein B, Larbig R, Grueninger J, Hoppe UC, Lichtenauer M, Pistulli R. Analysis of Selected Cardiovascular Biomarkers in Takotsubo Cardiomyopathy and the Most Frequent Cardiomyopathies. Front Cardiovasc Med 2021; 8:700169. [PMID: 34805296 PMCID: PMC8597641 DOI: 10.3389/fcvm.2021.700169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 09/27/2021] [Indexed: 12/22/2022] Open
Abstract
Introduction: Among the causes of de novo diagnosed cardiomyopathy, Takotsubo cardiomyopathy (TTC) plays a minor role, with an occurrence of 50,000–100,000 cases per annum in the United States. In clinical practice, a differentiation of a TTC toward an ischemic cardiomyopathy (ICMP) or a dilatative cardiomyopathy (DCMP) appears to be challenging, especially in a subacute setting or in atypical types of TTC. Methods: To investigate this issue, we analyzed serum levels of sST2, GDF-15, suPAR, HFABP, and clinical parameters including echocardiography in 51 patients with TTC, 52 patients with ischemic cardiomyopathy (ICMP) and 65 patients with dilated cardiomyopathy (DCMP). Results: sST-2 seemed to be the most promising biomarker for prediction of a TTC in differential diagnosis to an ICMP (AUC: 0.879, p = < 0.001, Cut off values: 12,140.5 pg/ml) or to a DCMP (AUC: 0.881, p = < 0.001, cut off value: 14521.9 pg/ml). GDF-15 evidenced a slightly lower AUC for prediction of a TTC in differential diagnosis to an ICMP (AUC: 0.626, p = 0.028) and to a DCMP (AUC: 0.653, p = 0.007). A differential diagnostic value was found for H-FABP in the prediction of a DCMP compared to TTC patients (AUC: 0.686, p = < 0.001). In propensity score matching for left ventricular ejection fraction, sex, and cardiovascular risk factors, differences in the plasma levels of sST2 and H-FABP in the matched cohort of TTC vs. DCMP remained statistically significant. In the matched cohort of TTC vs. ICMP, differences in sST2 also remained statistically significant Conclusion: As medical therapy, long term prognosis, interval of follow-ups, rehabilitation program and recommendations differ completely between TTC and ICMP/DCMP, biomarkers for differential diagnosis, or rather for confirmation of diagnosis, are warranted in cases of cardiomyopathies with unsure origin. sST-2, GDF-15 and H-FABP might facilitate the classification.
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Affiliation(s)
- Albert Topf
- Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Moritz Mirna
- Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Nina Bacher
- Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Vera Paar
- Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Lukas J Motloch
- Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Bernhard Ohnewein
- Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Robert Larbig
- Devision of Cardiology, Hospital Maria Hilf Moenchengladbach, Moenchengladbach, Germany
| | - Janine Grueninger
- Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Uta C Hoppe
- Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Michael Lichtenauer
- Department of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Rudin Pistulli
- Devision of Cardiology, University Hospital of Muenster, Muenster, Germany
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Braschi A, Frasheri A, Lombardo RM, Abrignani MG, Lo Presti R, Vinci D, Traina M. Association between Tpeak-Tend/QT and major adverse cardiovascular events in patients with Takotsubo syndrome. Acta Cardiol 2021; 76:732-738. [PMID: 32527206 DOI: 10.1080/00015385.2020.1776012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Conflicting results have been described in the scientific literature regarding the relationship between electrocardiographic parameters and complications in patients with Takotsubo syndrome (TTS). Aim of the present study was to investigate whether there is an association between markers of ventricular repolarization and major adverse cardiovascular events (MACE) during hospitalisation. METHODS A retrospective chart review was conducted on a sample of patients with diagnosis of TTS, based on the fulfilment of the revised Mayo Clinic criteria. MACE included acute heart failure, cardiogenic shock, sustained ventricular tachycardia, ventricular fibrillation, and death. The following parameters, assessed on the admission electrocardiogram, were analysed: ST-segment elevation, ST-segment depression, T wave inversion, presence of Q waves, QT interval, QT interval corrected for heart rate, QT-dispersion, Tpeak-Tend (Tpe) interval, Tpe dispersion, Tpe/QT ratio, and QTpeak/QT ratio. RESULTS Patients with MACE, compared to patients without MACE, showed more commonly anterior ST-segment elevation and had significantly higher values of Tpe/QT ratio. Low ejection fraction and Tpe/QT ratio > 0.27 identified a sub-population of patients more likely to have MACE during hospitalisation. CONCLUSIONS Tpe/QT ratio represents a useful electrocardiographic parameter in the acute phase of TTS.
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Affiliation(s)
- Annabella Braschi
- Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo, Italy
| | - Arian Frasheri
- Coronary Care Unit and Catheterization Laboratory, S. Antonio Abate Hospital, Trapani, Italy
| | - Renzo M. Lombardo
- Coronary Care Unit and Catheterization Laboratory, S. Antonio Abate Hospital, Trapani, Italy
| | - Maurizio G. Abrignani
- Coronary Care Unit and Catheterization Laboratory, S. Antonio Abate Hospital, Trapani, Italy
| | - Rosalia Lo Presti
- Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo, Italy
| | - Daniele Vinci
- Coronary Care Unit and Catheterization Laboratory, S. Antonio Abate Hospital, Trapani, Italy
| | - Marcello Traina
- Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo, Italy
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19
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Madias JE. Takotsubo Cardiomyopathy: Current Treatment. J Clin Med 2021; 10:3440. [PMID: 34362223 PMCID: PMC8347171 DOI: 10.3390/jcm10153440] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023] Open
Abstract
Management of takotsubo syndrome (TTS) is currently empirical and supportive, via extrapolation of therapeutic principles worked out for other cardiovascular pathologies. Although it has been emphasized that such non-specific therapies for TTS are consequent to its still elusive pathophysiology, one wonders whether it does not necessarily follow that the absence of knowledge of TTS' pathophysiological underpinnings should prevent us for searching, designing, or even finding, therapies efficacious for its management. Additionally, it is conceivable that therapy for TTS may be in response to pathophysiological/pathoanatomic/pathohistological consequences (e.g., "myocardial stunning/reperfusion injury"), common to both TTS and coronary artery disease, or other cardiovascular disorders). The present review outlines the whole range of management principles of TTS during its acute phase and at follow-up, including considerations pertaining to the recurrence of TTS, and commences with the idea that occasionally management of TTS should consist of mere observation along the "first do no harm" principle, while self-healing is under way. Finally, some new therapeutic hypotheses (i.e., large doses of insulin infusions in association with the employment of intravenous short- and ultrashort-acting β-blockers) are being entertained, based on previous extensive animal work and limited application in patients with neurogenic cardiomyopathy and TTS.
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Affiliation(s)
- John E. Madias
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; ; Tel.: +1-(718)-334-5005; Fax: +1-(718)-334-5990
- Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY 11373, USA
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20
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Permanent Pacemaker Implantation in a Patient with Takotsubo Cardiomyopathy and Complete Atrioventricular Block. Case Rep Cardiol 2021; 2021:6637720. [PMID: 33868730 PMCID: PMC8035013 DOI: 10.1155/2021/6637720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/20/2021] [Accepted: 03/18/2021] [Indexed: 11/19/2022] Open
Abstract
This case report presents a patient with Takotsubo cardiomyopathy (TCM) and complete atrioventricular (AV) block who was treated with permanent pacemaker implantation. A 78-year-old woman with a history of hypertension presented with a 6-month history of palpitations. On initial evaluation, her heart rate was 40 beats/minute. Electrocardiography revealed a complete AV block and T-wave inversion in these leads: I, II, aVL, aVF, and V3–6. Echocardiography showed akinesis from the midventricle to the apex and hyperkinesis on the basal segments. The patient was diagnosed with TCM and complete AV block. Because improvement of TCM may subsequently improve the AV node dysfunction associated with TCM, the patient was admitted for treatment of heart failure without pacemaker implantation. The left ventricular (LV) abnormal wall motion improved gradually; however, the AV block persisted intermittently. On hospital day 14, a pause of 5–6 seconds without LV contraction was observed, and permanent pacemaker implantation was performed. On day 92, echocardiography revealed normal LV wall motion. However, electrocardiography revealed that the pacemaker rhythm with atrial sensing and ventricular pacing remained. Although specific degree of damage that may result from AV block associated with TCM is unknown, some of these patients require pacemaker implantation, despite improvement of abnormality in LV wall motion.
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21
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Zeijlon R, Chamat J, Enabtawi I, Jha S, Mohammed MM, Wågerman J, Le V, Shekka Espinosa A, Nyman E, Omerovic E, Redfors B. Risk of in-hospital life-threatening ventricular arrhythmia or death after ST-elevation myocardial infarction vs. the Takotsubo syndrome. ESC Heart Fail 2021; 8:1314-1323. [PMID: 33511788 PMCID: PMC8006718 DOI: 10.1002/ehf2.13208] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/23/2020] [Accepted: 12/28/2020] [Indexed: 01/14/2023] Open
Abstract
AIMS The risk of life-threatening ventricular arrhythmias (LTVA) has been reported to be lower in Takotsubo syndrome (TS) compared with ST-elevation myocardial infarction (STEMI). However, the extent to which these differences relate to the fact that most patients with TS are women (who have a lower risk of LTVA) and a relatively larger proportion of patients with STEMI are men is incompletely understood. We aimed to investigate the risk of LTVA or death in sex-matched and age-matched patients with TS, anterior STEMI, and non-anterior STEMI. METHODS AND RESULTS We systematically reviewed the charts of all patients with TS who were treated at Sahlgrenska University Hospital (Gothenburg, Sweden) between 2008 and 2019. A total of 155 patients with confirmed TS (according to the European Society of Cardiology diagnostic criteria for TS) were sex-matched and age-matched 1:1:1 to patients with anterior and non-anterior STEMI. Baseline characteristics and in-hospital outcomes were recorded directly from the patient charts for all patients, and all admission electrocardiographs were analysed. The primary outcome was the composite of death or LTVA [defined as sustained ventricular tachycardia (>30 s) or ventricular fibrillation] within 72 h. The risk of LTVA or death within 72 h after admission was considerably lower in TS (2.6%) vs. anterior STEMI (14%; P = 0.002) and non-anterior STEMI (9.0%; P = 0.02), despite similar or greater risks of acute heart failure, and similar risks of cardiogenic shock. Compared with STEMI, TS was associated with a lower risk of sustained and non-sustained ventricular tachycardia and ventricular fibrillation. CONCLUSIONS In a predominantly female age-matched and sex-matched cohort of patients with TS, anterior STEMI, and non-anterior STEMI, the adjusted risk of in-hospital LTVA or death was considerably lower in TS compared with STEMI, despite similar or greater risk of acute heart failure and similar risk of cardiogenic shock.
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Affiliation(s)
- Rickard Zeijlon
- Department of CardiologySahlgrenska University Hospital/SGothenburgSweden
- Department of Internal MedicineSahlgrenska University Hospital/SGothenburgSweden
- Wallenberg Laboratory, Institute of MedicineUniversity of GothenburgGothenburgSweden
| | - Jasmina Chamat
- Department of CardiologySahlgrenska University Hospital/ÖGothenburgSweden
- Wallenberg Laboratory, Institute of MedicineUniversity of GothenburgGothenburgSweden
| | - Israa Enabtawi
- Wallenberg Laboratory, Institute of MedicineUniversity of GothenburgGothenburgSweden
| | - Sandeep Jha
- Department of CardiologySahlgrenska University Hospital/SGothenburgSweden
- Department of Internal MedicineKungälvs HospitalKungälvSweden
- Wallenberg Laboratory, Institute of MedicineUniversity of GothenburgGothenburgSweden
| | - Mohammed Munir Mohammed
- Department of Internal MedicineNorra Älvsborgs LänssjukhusTrollhättanSweden
- Wallenberg Laboratory, Institute of MedicineUniversity of GothenburgGothenburgSweden
| | - Johan Wågerman
- Wallenberg Laboratory, Institute of MedicineUniversity of GothenburgGothenburgSweden
| | - Vina Le
- Wallenberg Laboratory, Institute of MedicineUniversity of GothenburgGothenburgSweden
| | - Aaron Shekka Espinosa
- Department of CardiologySahlgrenska University Hospital/SGothenburgSweden
- Wallenberg Laboratory, Institute of MedicineUniversity of GothenburgGothenburgSweden
| | - Erik Nyman
- Wallenberg Laboratory, Institute of MedicineUniversity of GothenburgGothenburgSweden
| | - Elmir Omerovic
- Department of CardiologySahlgrenska University Hospital/SGothenburgSweden
- Wallenberg Laboratory, Institute of MedicineUniversity of GothenburgGothenburgSweden
| | - Björn Redfors
- Department of CardiologySahlgrenska University Hospital/SGothenburgSweden
- Wallenberg Laboratory, Institute of MedicineUniversity of GothenburgGothenburgSweden
- Clinical Trial CenterCardiovascular Research FoundationNew YorkNYUSA
- Department of CardiologyNew York‐Presbyterian Hospital/Columbia University Medical CenterNew YorkNYUSA
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22
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Pelargonio G, La Rosa G, Di Stasio E, Narducci ML, Rocco E, Angelini A, Pinnacchio G, Bencardino G, Perna F, Comerci G, Catania F, Crea F. Ventricular arrhythmias in Takotsubo Syndrome: incidence, predictors and clinical outcomes. J Cardiovasc Med (Hagerstown) 2021; 22:180-189. [PMID: 32890232 DOI: 10.2459/jcm.0000000000001106] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIMS To investigate predictors of the occurrence of subacute ventricular arrhythmias (VAs), defined as any VAs presenting after 48 h from admission in patients with Takotsubo Syndrome (TTS), and to evaluate the related in-hospital mortality. METHODS This is a retrospective single-center study enrolling patients admitted between 2012 and 2017 with TTS according to International Takotsubo diagnostic criteria. Data collection included ECG on admission and at 48 h, telemetry monitoring and transthoracic echocardiogram. RESULTS We enrolled 93 patients; during in-hospital stay (mean 14 ± 16 days) subacute VAs occurred in 25% of patients (VAs group). Life-threatening VAs occurred in 6% of patients (3 sustained ventricular tachycardia, 1 torsade de pointes, 1 ventricular fibrillation) and not life-threatening VAs in 19% (6 non-sustained ventricular tachycardia and 12 premature ventricular contractions > 2000 in 24 h). Mortality was higher in the VAs than in the non-VAs group (P = 0.03), without differences in terms of life-threatening and not life-threatening subacute VAs (P = 0.65) and VAs on admission (P = 0.25). Logistic regression identified the following independent predictors of subacute VAs occurrence: VAs on admission {odds ratio [OR] 22.5 (3.9-131.8), P = 0.001]}, New York Heart Association (NYHA) class III-IV on admission [OR 6.7 (1.3- 34.0), P = 0.021] and QTc at 48 h [OR 1.01 (1.00-1.03), P = 0.046]. CONCLUSION TTS patients with VAs and NYHA class III-IV on admission and higher QTc at 48 h are at increased risk of subacute VAs occurrence, associated with higher in-hospital mortality. Awareness of this potential complication is critical for proper patients management.
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Affiliation(s)
- Gemma Pelargonio
- Dipartimento di Scienze Cardiovascolari e Toraciche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, Rome, Italy.,Istituto di Cardiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giulio La Rosa
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area. Madrid, Spain
| | - Enrico Di Stasio
- Dipartimento di Scienze di Laboratorio ed Infettivologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS.,Istituto di Biochimica e Biochimica Clinica, Università Cattolica del Sacro Cuore, Largo F. Vito 1, Rome, Italy
| | - Maria Lucia Narducci
- Dipartimento di Scienze Cardiovascolari e Toraciche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, Rome, Italy
| | - Erica Rocco
- Dipartimento di Scienze Cardiovascolari e Toraciche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, Rome, Italy
| | - Alessio Angelini
- Dipartimento di Scienze Cardiovascolari e Toraciche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, Rome, Italy
| | - Gaetano Pinnacchio
- Dipartimento di Scienze Cardiovascolari e Toraciche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, Rome, Italy
| | - Gianluigi Bencardino
- Dipartimento di Scienze Cardiovascolari e Toraciche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, Rome, Italy
| | - Francesco Perna
- Dipartimento di Scienze Cardiovascolari e Toraciche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, Rome, Italy
| | - Gianluca Comerci
- Dipartimento di Scienze Cardiovascolari e Toraciche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, Rome, Italy
| | - Fiammetta Catania
- Dipartimento di Scienze Cardiovascolari e Toraciche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, Rome, Italy
| | - Filippo Crea
- Dipartimento di Scienze Cardiovascolari e Toraciche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, Rome, Italy.,Istituto di Cardiologia, Università Cattolica del Sacro Cuore, Rome, Italy
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23
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Revilla-Martí P, Cueva-Recalde JF, Linares-Vicente JA, Río-Sánchez S, Ruiz-Arroyo JR. High-degree atrioventricular block. An unusual presentation of Takotsubo cardiomyopathy: a case report. Egypt Heart J 2021; 73:18. [PMID: 33630189 PMCID: PMC7907396 DOI: 10.1186/s43044-021-00144-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/08/2021] [Indexed: 01/24/2023] Open
Abstract
Background Takotsubo cardiomyopathy is a non-ischemic cardiomyopathy characterized by acute left ventricular systolic dysfunction with transient wall motion abnormalities without a culprit coronary stenosis or other concurrent diagnoses. Its coexistence with transient high-degree AV block is very infrequent. Case presentation A 61-year-old man presented with a new onset of high degree AV block without ST segment deviations developing an anterior and apical dyskinesia with a low left ventricular ejection fraction in the absence of coronary artery disease. Conclusion Atrioventricular block is an uncommon presentation of Takotsubo syndrome. The management of patients with relevant conduction disorders in this scenario is a challenge for the clinician. In case of persistence of advanced conduction disorders, it seems appropriate to implant a pacemaker.
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Affiliation(s)
- Pablo Revilla-Martí
- Cardiology Department, Hospital Clínico Universitario "Lozano Blesa", Av. San Juan Bosco 15, 50009, Zaragoza, Spain.
| | - Juan F Cueva-Recalde
- Cardiology Department, Hospital Clínico Universitario "Lozano Blesa", Av. San Juan Bosco 15, 50009, Zaragoza, Spain
| | - Jose A Linares-Vicente
- Cardiology Department, Hospital Clínico Universitario "Lozano Blesa", Av. San Juan Bosco 15, 50009, Zaragoza, Spain
| | - Sara Río-Sánchez
- Cardiology Department, Hospital Clínico Universitario "Lozano Blesa", Av. San Juan Bosco 15, 50009, Zaragoza, Spain
| | - Jose R Ruiz-Arroyo
- Cardiology Department, Hospital Clínico Universitario "Lozano Blesa", Av. San Juan Bosco 15, 50009, Zaragoza, Spain
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Santoro F, Mallardi A, Leopizzi A, Vitale E, Rawish E, Stiermaier T, Eitel I, Brunetti ND. Current Knowledge and Future Challenges in Takotsubo Syndrome: Part 2-Treatment and Prognosis. J Clin Med 2021; 10:jcm10030468. [PMID: 33530545 PMCID: PMC7866173 DOI: 10.3390/jcm10030468] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 01/21/2021] [Accepted: 01/23/2021] [Indexed: 12/15/2022] Open
Abstract
Takotsubo syndrome (TTS) represents a form of acute heart failure featured by reversible left ventricular systolic dysfunction. The management during the acute phase is mainly performed with supportive pharmacological (diuretics, ACE-inhibitors/angiotensin-receptor blockers (ARBs), anticoagulants, antiarrhythmics, non-catecholamine inotropics (levosimendan), and non-pharmacological (mechanical circulatory and respiratory support) therapy, due to the wide clinical presentation and course of the disease. However, there is a gap in evidence and there are no randomized and adequately powered studies on clinical effectiveness of therapeutic approaches. Some evidence supports the use ACE-inhibitors/ARBs at long-term. A tailored approach based on cardiovascular and non-cardiovascular risk factors is strongly suggested for long-term management. The urgent need for evidence-based treatment approaches is also reflected by the prognosis following TTS. The acute phase of the disease can be accompanied by various cardiovascular complications. In addition, long term outcome of TTS patients is also related to non-cardiovascular comorbidities. Physical triggers such as hypoxia and acute neurological disorders in TTS are associated with a poor outcome.
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Affiliation(s)
- Francesco Santoro
- Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (A.M.); (A.L.); (E.V.); (N.D.B.)
- Correspondence: ; Tel.: +39-380-2695183; Fax: +39-0881-745424
| | - Adriana Mallardi
- Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (A.M.); (A.L.); (E.V.); (N.D.B.)
| | - Alessandra Leopizzi
- Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (A.M.); (A.L.); (E.V.); (N.D.B.)
| | - Enrica Vitale
- Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (A.M.); (A.L.); (E.V.); (N.D.B.)
| | - Elias Rawish
- Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Heart Center, 23552 Lübeck, Germany; (E.R.) (T.S.); (I.E.)
- German Center for Cardiovascular Research (DZHK), 23552 Lübeck, Germany
| | - Thomas Stiermaier
- Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Heart Center, 23552 Lübeck, Germany; (E.R.) (T.S.); (I.E.)
- German Center for Cardiovascular Research (DZHK), 23552 Lübeck, Germany
| | - Ingo Eitel
- Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Heart Center, 23552 Lübeck, Germany; (E.R.) (T.S.); (I.E.)
| | - Natale D. Brunetti
- Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (A.M.); (A.L.); (E.V.); (N.D.B.)
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Prokudina ES, Kurbatov BK, Zavadovsky KV, Vrublevsky AV, Naryzhnaya NV, Lishmanov YB, Maslov LN, Oeltgen PR. Takotsubo Syndrome: Clinical Manifestations, Etiology and Pathogenesis. Curr Cardiol Rev 2021; 17:188-203. [PMID: 31995013 PMCID: PMC8226199 DOI: 10.2174/1573403x16666200129114330] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/02/2019] [Accepted: 12/12/2019] [Indexed: 12/15/2022] Open
Abstract
The purpose of the review is the analysis of clinical and experimental data on the etiology and pathogenesis of takotsubo syndrome (TS). TS is characterized by contractile dysfunction, which usually affects the apical region of the heart without obstruction of coronary artery, moderate increase in myocardial necrosis markers, prolonged QTc interval (in 50% of patients), sometimes elevation of ST segment (in 19% of patients), increase N-Terminal Pro-B-Type Natriuretic Peptide level, microvascular dysfunction, sometimes spasm of the epicardial coronary arteries (in 10% of patients), myocardial edema, and life-threatening ventricular arrhythmias (in 11% of patients). Stress cardiomyopathy is a rare disease, it is observed in 0.6 - 2.5% of patients with acute coronary syndrome. The occurrence of takotsubo syndrome is 9 times higher in women, who are aged 60-70 years old, than in men. The hospital mortality among patients with TS corresponds to 3.5% - 12%. Physical or emotional stress do not precede disease in all patients with TS. Most of patients with TS have neurological or mental illnesses. The level of catecholamines is increased in patients with TS, therefore, the occurrence of TS is associated with excessive activation of the adrenergic system. The negative inotropic effect of catecholamines is associated with the activation of β2 adrenergic receptors. An important role of the adrenergic system in the pathogenesis of TS is confirmed by studies which were performed using 125I-metaiodobenzylguanidine (125I -MIBG). TS causes edema and inflammation of the myocardium. The inflammatory response in TS is systemic. TS causes impaired coronary microcirculation and reduces coronary reserve. There is a reason to believe that an increase in blood viscosity may play an important role in the pathogenesis of microcirculatory dysfunction in patients with TS. Epicardial coronary artery spasm is not obligatory for the occurrence of TS. Cortisol, endothelin-1 and microRNAs are challengers for the role of TS triggers. A decrease in estrogen levels is a factor contributing to the onset of TS. The central nervous system appears to play an important role in the pathogenesis of TS.
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Affiliation(s)
- Ekaterina S Prokudina
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the RAS, Tomsk, Russian Federation
| | - Boris K Kurbatov
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the RAS, Tomsk, Russian Federation
| | - Konstantin V Zavadovsky
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the RAS, Tomsk, Russian Federation
| | - Alexander V Vrublevsky
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the RAS, Tomsk, Russian Federation
| | - Natalia V Naryzhnaya
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the RAS, Tomsk, Russian Federation
| | - Yuri B Lishmanov
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the RAS, Tomsk, Russian Federation
| | - Leonid N Maslov
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the RAS, Tomsk, Russian Federation
| | - Peter R Oeltgen
- Department of Pathology, University of Kentucky College of Medicine, Lexington, KY 40506, United States
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26
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Habedank D, Thieme R, Bublak A, Heinemann F, Spencker S, Atmowihardjo I. Ventricular fibrillation and Takotsubo cardiomyopathy triggered by media panic on COVID‐19: A case report. Clin Case Rep 2021; 9:72-76. [PMID: 33362931 PMCID: PMC7753670 DOI: 10.1002/ccr3.3423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 09/30/2020] [Accepted: 10/06/2020] [Indexed: 11/16/2022] Open
Abstract
Takotsubo cardiomyopathy has potentially lethal complications and can be caused by a media‐induced diffuse atmosphere of life threatening and panic in preconditioned patients.
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Affiliation(s)
- Dirk Habedank
- DRK Kliniken Berlin Köpenick Medizinische Klinik Kardiologie Berlin Germany
| | - Roland Thieme
- DRK Kliniken Berlin Köpenick Medizinische Klinik Kardiologie Berlin Germany
| | - Angelika Bublak
- DRK Kliniken Berlin Köpenick Medizinische Klinik Kardiologie Berlin Germany
| | - Felix Heinemann
- DRK Kliniken Berlin Köpenick Medizinische Klinik Kardiologie Berlin Germany
| | - Sebastian Spencker
- DRK Kliniken Berlin Köpenick Medizinische Klinik Kardiologie Berlin Germany
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27
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Prokudina ES, Kurbatov BK, Maslov LN. [Clinical Manifestation of Stressful Cardiomyopathy (Takotsubo Syndrome) and the Problem of Differential Diagnosis with Acute Myocardial Infarction]. ACTA ACUST UNITED AC 2020; 60:777. [PMID: 33487160 DOI: 10.18087/cardio.2020.11.n777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/28/2019] [Accepted: 01/09/2020] [Indexed: 11/18/2022]
Abstract
The presented data show that tacotsubo syndrome (TS) is characterized by the absence of coronary artery obstruction, cardiac contractile dysfunction, apical ballooning, and heart failure, and in some patients, ST-segment elevation and prolongation of the QTc interval. Every tenth patient with TS develops ventricular arrhythmias. Most of TS patients have elevated markers of necrosis (troponin I, troponin Т, and creatine kinase МВ (CK-МВ), which are considerably lower than in patients with acute myocardial infarction (AMI) with ST-segment elevation. The level of N-terminal pro-B-type natriuretic peptide (NT-proBNP), in contrast, is considerably higher in patients with TS than with AMI. Differential diagnosis of TS and AMI should be based on a multifaceted approach using coronary angiography, echocardiography, analysis of ECG, magnetic resonance imaging, single-photon emission computed tomography, and measurement of troponins, CK-MB, and NT-proBNP.
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Affiliation(s)
- E S Prokudina
- Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - B K Kurbatov
- Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - L N Maslov
- Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
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28
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Malanchini G, Del Corral M, De Filippo P, Ferrari P, Solomon A, Krepp J. Cardiac arrhythmias and In-hospital mortality amongst patients with takotsubo cardiomyopathy: A retrospective study in an Italian population. IJC HEART & VASCULATURE 2020; 31:100608. [PMID: 32923578 PMCID: PMC7475186 DOI: 10.1016/j.ijcha.2020.100608] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/27/2020] [Indexed: 01/14/2023]
Abstract
Takotsubo cardiomyopathy was more common in women and the mortality rate was 2.2%. Ventricular arrhythmias were the strongest predictor of mortality. Age was associated with increased mortality in women with takotsubo cardiomyopathy.
Background Methods Results Conclusion
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29
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Gili S, Cammann VL, Schlossbauer SA, Kato K, D'Ascenzo F, Di Vece D, Jurisic S, Micek J, Obeid S, Bacchi B, Szawan KA, Famos F, Sarcon A, Levinson R, Ding KJ, Seifert B, Lenoir O, Bossone E, Citro R, Franke J, Napp LC, Jaguszewski M, Noutsias M, Münzel T, Knorr M, Heiner S, Katus HA, Burgdorf C, Schunkert H, Thiele H, Bauersachs J, Tschöpe C, Pieske BM, Rajan L, Michels G, Pfister R, Cuneo A, Jacobshagen C, Hasenfuß G, Karakas M, Koenig W, Rottbauer W, Said SM, Braun-Dullaeus RC, Banning A, Cuculi F, Kobza R, Fischer TA, Vasankari T, Airaksinen KEJ, Opolski G, Dworakowski R, MacCarthy P, Kaiser C, Osswald S, Galiuto L, Crea F, Dichtl W, Empen K, Felix SB, Delmas C, Lairez O, El-Battrawy I, Akin I, Borggrefe M, Gilyarova E, Shilova A, Gilyarov M, Horowitz JD, Kozel M, Tousek P, Widimský P, Winchester DE, Ukena C, Gaita F, Di Mario C, Wischnewsky MB, Bax JJ, Prasad A, Böhm M, Ruschitzka F, Lüscher TF, Ghadri JR, Templin C. Cardiac arrest in takotsubo syndrome: results from the InterTAK Registry. Eur Heart J 2020; 40:2142-2151. [PMID: 31098611 PMCID: PMC6612368 DOI: 10.1093/eurheartj/ehz170] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 09/11/2018] [Accepted: 03/12/2019] [Indexed: 12/27/2022] Open
Abstract
AIMS We aimed to evaluate the frequency, clinical features, and prognostic implications of cardiac arrest (CA) in takotsubo syndrome (TTS). METHODS AND RESULTS We reviewed the records of patients with CA and known heart rhythm from the International Takotsubo Registry. The main outcomes were 60-day and 5-year mortality. In addition, predictors of mortality and predictors of CA during the acute TTS phase were assessed. Of 2098 patients, 103 patients with CA and known heart rhythm during CA were included. Compared with patients without CA, CA patients were more likely to be younger, male, and have apical TTS, atrial fibrillation (AF), neurologic comorbidities, physical triggers, and longer corrected QT-interval and lower left ventricular ejection fraction on admission. In all, 57.1% of patients with CA at admission had ventricular fibrillation/tachycardia, while 73.7% of patients with CA in the acute phase had asystole/pulseless electrical activity. Patients with CA showed higher 60-day (40.3% vs. 4.0%, P < 0.001) and 5-year mortality (68.9% vs. 16.7%, P < 0.001) than patients without CA. T-wave inversion and intracranial haemorrhage were independently associated with higher 60-day mortality after CA, whereas female gender was associated with lower 60-day mortality. In the acute phase, CA occurred less frequently in females and more frequently in patients with AF, ST-segment elevation, and higher C-reactive protein on admission. CONCLUSIONS Cardiac arrest is relatively frequent in TTS and is associated with higher short- and long-term mortality. Clinical and electrocardiographic parameters independently predicted mortality after CA.
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Affiliation(s)
- Sebastiano Gili
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland.,Division of Cardiology, Department of Medical Sciences, AOU Citta della Salute e della Scienza, University of Turin, Turin, Italy
| | - Victoria L Cammann
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Susanne A Schlossbauer
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Ken Kato
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, AOU Citta della Salute e della Scienza, University of Turin, Turin, Italy
| | - Davide Di Vece
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Stjepan Jurisic
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Jozef Micek
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Slayman Obeid
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Beatrice Bacchi
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Konrad A Szawan
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Flurina Famos
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Annahita Sarcon
- Keck School of Medicine, University of Southern California, Los Angeles CA, USA
| | - Rena Levinson
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland.,Division of Biological Sciences, University of California San Diego, San Diego, CA, USA
| | - Katharina J Ding
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Burkhardt Seifert
- Division of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Olivia Lenoir
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Eduardo Bossone
- Division of Cardiology 'Antonio Cardarelli' Hospital, Naples, Italy
| | - Rodolfo Citro
- Heart Department, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Jennifer Franke
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | - L Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Milosz Jaguszewski
- First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Michel Noutsias
- Division of Cardiology, Department of Internal Medicine III, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Halle (Saale), Germany
| | - Thomas Münzel
- Center for Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany
| | - Maike Knorr
- Center for Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany
| | - Susanne Heiner
- Center for Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany
| | - Hugo A Katus
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Heribert Schunkert
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, University of Leipzig-Heart Center, Leipzig, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Carsten Tschöpe
- Department of Cardiology, Charité, Campus Rudolf Virchow, Berlin, Germany
| | - Burkert M Pieske
- Department of Cardiology, Charité, Campus Rudolf Virchow, Berlin, Germany
| | | | - Guido Michels
- Department of Internal Medicine III, Heart Center University of Cologne, Cologne, Germany
| | - Roman Pfister
- Department of Internal Medicine III, Heart Center University of Cologne, Cologne, Germany
| | - Alessandro Cuneo
- Krankenhaus 'Maria Hilf' Medizinische Klinik, Stadtlohn, Germany
| | - Claudius Jacobshagen
- Clinic for Cardiology and Pneumology, Georg August University Goettingen, Goettingen, Germany
| | - Gerd Hasenfuß
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Mahir Karakas
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Wolfgang Rottbauer
- Department of Internal Medicine II-Cardiology, University of Ulm, Medical Center, Ulm, Germany
| | - Samir M Said
- Internal Medicine/Cardiology, Angiology, and Pneumology, Magdeburg University, Magdeburg, Germany
| | | | - Adrian Banning
- Department of Cardiology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Florim Cuculi
- Department of Cardiology, Kantonsspital Lucerne, Lucerne, Switzerland
| | - Richard Kobza
- Department of Cardiology, Kantonsspital Lucerne, Lucerne, Switzerland
| | - Thomas A Fischer
- Department of Cardiology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Tuija Vasankari
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Grzegorz Opolski
- Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Rafal Dworakowski
- Department of Cardiology, Kings College Hospital, Kings Health Partners, London, UK
| | - Philip MacCarthy
- Department of Cardiology, Kings College Hospital, Kings Health Partners, London, UK
| | - Christoph Kaiser
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Stefan Osswald
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Leonarda Galiuto
- Department of Cardiovascular Sciences, Catholic University of the Sacred Heart Rome, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular Sciences, Catholic University of the Sacred Heart Rome, Rome, Italy
| | - Wolfgang Dichtl
- University Hospital for Internal Medicine III (Cardiology and Angiology), Medical University Innsbruck, Innsbruck, Austria
| | - Klaus Empen
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany
| | - Stephan B Felix
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany
| | - Clément Delmas
- Department of Cardiology and Cardiac Imaging Center, University Hospital of Rangueil, Toulouse, France
| | - Olivier Lairez
- Department of Cardiology and Cardiac Imaging Center, University Hospital of Rangueil, Toulouse, France
| | - Ibrahim El-Battrawy
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM) University of Heidelberg, Mannheim, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM) University of Heidelberg, Mannheim, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM) University of Heidelberg, Mannheim, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Ekaterina Gilyarova
- Intensive coronary care Unit, Moscow City Hospital # 1 named after N. Pirogov, Moscow, Russia
| | - Alexandra Shilova
- Intensive coronary care Unit, Moscow City Hospital # 1 named after N. Pirogov, Moscow, Russia
| | - Mikhail Gilyarov
- Intensive coronary care Unit, Moscow City Hospital # 1 named after N. Pirogov, Moscow, Russia
| | - John D Horowitz
- Discipline of Medicine, Queen Elizabeth Hospital, University of Adelaide, Adelaide, Australia
| | - Martin Kozel
- Third Medical Faculty, Charles University in Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Petr Tousek
- Third Medical Faculty, Charles University in Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Petr Widimský
- Third Medical Faculty, Charles University in Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - David E Winchester
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Christian Ukena
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Fiorenzo Gaita
- Division of Cardiology, Department of Medical Sciences, AOU Citta della Salute e della Scienza, University of Turin, Turin, Italy
| | - Carlo Di Mario
- Structural Interventional Cardiology, University Hospital Careggi, Florence, Italy
| | | | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Abhiram Prasad
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Thomas F Lüscher
- Center for Molecular Cardiology, Schlieren Campus, University of Zurich, Zurich, Switzerland.,Royal Brompton and Harefield Hospitals Trust and Imperial College, London, UK
| | - Jelena R Ghadri
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Christian Templin
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
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Vélez-Leal JL, Caballero-Arenas RA. Arritmias graves en el síndrome de takotsubo: ¿cuándo dar de alta? REVISTA COLOMBIANA DE CARDIOLOGÍA 2020. [DOI: 10.1016/j.rccar.2019.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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31
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Alfano G, Ciervo D, Migliore T, Sorbo A, Ariello M, Vitale A, Laukkanen MO, Del Gaudio S. Mortal consequences of a cooperative action between Takotsubo syndrome and increased intracranial pressure. ESC Heart Fail 2020; 7:1095-1100. [PMID: 32142222 PMCID: PMC7261570 DOI: 10.1002/ehf2.12601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/07/2019] [Accepted: 11/28/2019] [Indexed: 12/20/2022] Open
Abstract
An elderly patient with head injury was registered to the emergency room. Because the patient arrived to the hospital unconscious, her cranial, cerebrovascular, and cardiac function was studied. The cardiac function measurements were (i) heart rate, (ii) blood pressure, (iii) oxygen saturation level, (iv) electrocardiogram (ECG), (v) coronary angiogram, (vi) chest computerized tomography (CT), and (vii) echocardiogram. The head damage was studied by cerebral CT and magnetic resonance imaging (MRI). The serum ischemia and inflammatory biomarkers were analysed. For the immediate treatment, the patient received cardiovascular system supporting medication. The cardiac diagnostic results were (i) the ECG suggested an elevation in the left ventricular systolic function, (ii) the blood test showed neutrophilia, increased creatine and increased troponin I kinase values, and (iii) the coronary angiogram and ECG analysis demonstrated a lack of a myocardial infarction but identified apical akinesia. The patient did not have previous symptoms of cardiovascular disease. The brain imaging demonstrated (iv) an acute ischemia in the left occipital area and (v) increased intracranial pressure. Brain MRI indicated (vi) aqueductal stenosis and (vii) multiple gliomatotic foci demonstrating hydrocephalus caused by gliomatosis cerebri. A chest CT indicated (viii) chronic obstructive pulmonary disease (COPD). One week later, the patient died because of cardiac arrest. The diagnosis was Takotsubo syndrome enforced by gliomatosis cerebri and COPD. To our knowledge, this is the first reported case in which the cardiac dysfunction of the patient is associated with gliomatosis cerebri-derived hydrocephalus and increased intracranial pressure that together with COPD may have enhanced the negative clinical outcome.
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Affiliation(s)
- Gennaro Alfano
- Department of Cardiology, Pineta Grande Hospital, Caserta, 81030, Italy
| | - Deasy Ciervo
- Department of Emergency Medicine, Pineta Grande Hospital, Caserta, 81030, Italy
| | - Teresa Migliore
- Department of Emergency Medicine, Pineta Grande Hospital, Caserta, 81030, Italy
| | - Antonia Sorbo
- Department of Radiology, Pineta Grande Hospital, Caserta, 81030, Italy
| | - Manuela Ariello
- Department of Emergency Medicine, Pineta Grande Hospital, Caserta, 81030, Italy
| | - Andrea Vitale
- Clinical Research Center, Pineta Grande Hospital, Caserta, 81030, Italy
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32
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Di Filippo C, Bacchi B, Di Mario C. Novel Aspects of Classification, Prognosis and Therapy in Takotsubo Syndrome. Eur Cardiol 2020; 14:191-196. [PMID: 31933691 PMCID: PMC6950358 DOI: 10.15420/ecr.2019.27.3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/05/2019] [Indexed: 12/20/2022] Open
Abstract
Takotsubo syndrome (TTS) can be considered a transient form of acute heart failure that mimics an acute coronary syndrome. Although many hypotheses have been formulated, the precise physiopathology of TTS remains unknown. TTS is associated with a heterogeneous clinical course, which ranges from benign to poor outcome, comprising life-threatening phenotypes. In the acute phase, TTS patients may experience complications including left ventricular outflow tract obstruction, cardiogenic shock, arrhythmias and thromboembolic events. Furthermore, after the acute episode, physiological abnormalities can persist and some patients continue to suffer cardiac symptoms. To recognise patients at higher risk earlier, many variables have been proposed and risk stratifications suggested. There is no solid evidence regarding specific therapy and the proper management of TTS patients, either in the acute phase or long term. This review describes the current knowledge regarding diagnostic criteria, prognosis and therapy in TTS.
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Takotsubo syndrome and cardiac implantable electronic device therapy. Sci Rep 2019; 9:16559. [PMID: 31719584 PMCID: PMC6851377 DOI: 10.1038/s41598-019-52929-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 10/26/2019] [Indexed: 12/27/2022] Open
Abstract
Recent studies have reported that takotsubo syndrome (TTS) patients are suffering from life-threatening arrhythmias. The aim of our study was to understand the short and long-term usefulness of cardiac implantable electronic devices in TTS patients.We constituted a collective of 142 patients in a bi-centric study diagnosed with TTS between 2003 and 2017. The patient groups, divided according to the treatment with (n = 9, 6.3%) or without cardiac devices (n = 133, 93.7%), were followed-up to determine the importance of devices and its complications. One patient was treated with a permanent pacemaker, five patients with a wearable cardioverter defibrillator, two patients with a subcutaneous defibrillator and one patient with a transvenous defibrillator. Regular device check-up was documented in all patients, presenting an ongoing high-degree AV-block. Neither device complications nor life-threatening tachyarrhythmias were documented after acute TTS event. However, patients comprising the device group suffered significantly more often from a highly reduced EF (30 ± 7.7% versus 39.1 ± 9.7%; p < 0.05), cardiogenic shock with use of inotropic agents (66.6% versus 16.6%; p < 0.05) and cardiopulmonary resuscitation (44.4% versus 5.3%; p < 0.05). Our data confirm the usefulness of pacemaker in TTS patients. However, the cardioverter defibrillator including wearable cardioverter defibrillator may not be recommended.
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Prevalence, management, and outcome of adverse rhythm disorders in takotsubo syndrome: insights from the international multicenter GEIST registry. Heart Fail Rev 2019; 25:505-511. [DOI: 10.1007/s10741-019-09856-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Affiliation(s)
- Ilan S Wittstein
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Quevedo HC, Khoueiry G. Recurrent admission with ventricular fibrillation in the context of Takotsubo cardiomyopathy. HeartRhythm Case Rep 2019; 5:237-239. [PMID: 30997343 PMCID: PMC6453150 DOI: 10.1016/j.hrcr.2018.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
| | - Georges Khoueiry
- Heart Clinic of Hammond, Hammond, Louisiana
- Address reprint requests and correspondence: Dr Georges Khoueiry, 16033 Doctor’s Blvd, Hammond, LA 70403.
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Zhang AN, Sacchi T, Altschul R, Guss D, Mohanty SR, Notar-Francesco V. A case of esophagogastroduodenoscopy induced Takotsubo cardiomyopathy with complete heart block. Clin J Gastroenterol 2019; 12:296-300. [PMID: 30904984 DOI: 10.1007/s12328-019-00967-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 01/31/2019] [Indexed: 12/27/2022]
Abstract
Takotsubo cardiomyopathy (TC) describes a reversible left ventricular dysfunction characterized by apical ballooning and basal hyperkinesis, commonly triggered by emotional or physical distress. TC associated with an esophagogastroduodenoscopy (EGD) has rarely been reported. We report a case of TC with complete heart block (CHB) in a patient receiving an EGD, who had no underlying cardiac disease, had previously tolerated both local and general anesthesia, and who had previously undergone similar endoscopic procedures without complications. The concurrence of both TC and CHB is unique in this case pertaining to a patient with no significant risk factors. The incidence, mechanism and prognosis of TC-associated arrhythmias are also reviewed.
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Affiliation(s)
- Allison Naiquan Zhang
- Division of Gastroenterology and Hepatobiliary Diseases, New York-Presbyterian Brooklyn Methodist Hospital, 506 6th Street, Brooklyn, NY, 11215, USA.
| | - Terrence Sacchi
- Division of Cardiovascular Diseases, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, 11215, USA
| | - Rebecca Altschul
- Division of Cardiovascular Diseases, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, 11215, USA
| | - Debra Guss
- Division of Gastroenterology and Hepatobiliary Diseases, New York-Presbyterian Brooklyn Methodist Hospital, 506 6th Street, Brooklyn, NY, 11215, USA
| | - Smruti Ranjan Mohanty
- Division of Gastroenterology and Hepatobiliary Diseases, New York-Presbyterian Brooklyn Methodist Hospital, 506 6th Street, Brooklyn, NY, 11215, USA
| | - Vincent Notar-Francesco
- Division of Gastroenterology and Hepatobiliary Diseases, New York-Presbyterian Brooklyn Methodist Hospital, 506 6th Street, Brooklyn, NY, 11215, USA
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Jha S, Zeijlon R, Shekka Espinosa A, Alkhoury J, Oras J, Omerovic E, Redfors B. Clinical management in the takotsubo syndrome. Expert Rev Cardiovasc Ther 2018; 17:83-93. [DOI: 10.1080/14779072.2019.1556098] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Sandeep Jha
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Laboratory, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Internal Medicine, Kungälv Hospital, Kungälv, Sweden
| | - Rickard Zeijlon
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Laboratory, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Aaron Shekka Espinosa
- Wallenberg Laboratory, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Jessica Alkhoury
- Wallenberg Laboratory, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Jonatan Oras
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Laboratory, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Laboratory, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Laboratory, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Clinical Trial Center, Cardiovascular Research Foundation, New York, NY, USA
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Imori Y, Iwasaki YK, Takano H, Shimizu W. Takotsubo syndrome with severe bradycardia initiated by seizure: Is the implantation of a permanent pacemaker necessary? BMJ Case Rep 2018; 2018:bcr-2018-226480. [PMID: 30317208 PMCID: PMC6194446 DOI: 10.1136/bcr-2018-226480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Although arrhythmias are frequent in patients with Takotsubo syndrome (TTS), data on sick sinus syndrome remain elusive. Here, we report a case of TTS initiated by a seizure as a physical trigger that led to sinus arrest. The patient presented with cardiogenic shock and bradycardia which required intensive cardiovascular care. However, in the subacute phase of TTS, the sinus function recovered significantly, and pacemaker implantation was deferred.
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Affiliation(s)
- Yoichi Imori
- Department of Cardiovascular Medicine, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Yu-Ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Hitoshi Takano
- Department of Cardiovascular Medicine, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
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Möller C, Eitel C, Thiele H, Eitel I, Stiermaier T. Ventricular arrhythmias in patients with Takotsubo syndrome. J Arrhythm 2018; 34:369-375. [PMID: 30167007 PMCID: PMC6111471 DOI: 10.1002/joa3.12029] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/23/2017] [Indexed: 01/15/2023] Open
Abstract
Takotsubo syndrome (TTS) is a unique nonischemic cardiac disease characterized by acute myocardial dysfunction of the left and/or right ventricle. Patients are predominantly postmenopausal women and usually present with symptoms indistinguishable from acute coronary syndrome. Although the exact pathomechanisms of TTS remain elusive, increasing evidence suggests that sympathetic overdrive and catecholamine excess might play a central role. Despite the complete recovery of ventricular dysfunction within several days to weeks, patients with TTS exhibit considerable short- and long-term mortality rates and ventricular arrhythmias have been identified as key contributor to morbidity and mortality. This article summarizes the prevalence, underlying mechanisms, therapeutic strategies, and prognostic implications of ventricular arrhythmias in TTS. Furthermore, the need for implantable cardioverter-defibrillators is discussed in view of the transient character of the disease.
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Affiliation(s)
- Christian Möller
- Department of Cardiology, Angiology and Intensive Care MedicineMedical Clinic IIUniversity Heart Center LübeckLübeckGermany
- German Center for Cardiovascular Research (DZHK)Partner Site Hamburg/Kiel/LübeckLübeckGermany
| | - Charlotte Eitel
- Department of Cardiology, Angiology and Intensive Care MedicineMedical Clinic IIUniversity Heart Center LübeckLübeckGermany
- German Center for Cardiovascular Research (DZHK)Partner Site Hamburg/Kiel/LübeckLübeckGermany
| | - Holger Thiele
- Department of Cardiology, Angiology and Intensive Care MedicineMedical Clinic IIUniversity Heart Center LübeckLübeckGermany
- German Center for Cardiovascular Research (DZHK)Partner Site Hamburg/Kiel/LübeckLübeckGermany
| | - Ingo Eitel
- Department of Cardiology, Angiology and Intensive Care MedicineMedical Clinic IIUniversity Heart Center LübeckLübeckGermany
- German Center for Cardiovascular Research (DZHK)Partner Site Hamburg/Kiel/LübeckLübeckGermany
| | - Thomas Stiermaier
- Department of Cardiology, Angiology and Intensive Care MedicineMedical Clinic IIUniversity Heart Center LübeckLübeckGermany
- German Center for Cardiovascular Research (DZHK)Partner Site Hamburg/Kiel/LübeckLübeckGermany
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Ghadri JR, Wittstein IS, Prasad A, Sharkey S, Dote K, Akashi YJ, Cammann VL, Crea F, Galiuto L, Desmet W, Yoshida T, Manfredini R, Eitel I, Kosuge M, Nef HM, Deshmukh A, Lerman A, Bossone E, Citro R, Ueyama T, Corrado D, Kurisu S, Ruschitzka F, Winchester D, Lyon AR, Omerovic E, Bax JJ, Meimoun P, Tarantini G, Rihal C, Y.-Hassan S, Migliore F, Horowitz JD, Shimokawa H, Lüscher TF, Templin C. International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management. Eur Heart J 2018; 39:2047-2062. [PMID: 29850820 PMCID: PMC5991205 DOI: 10.1093/eurheartj/ehy077] [Citation(s) in RCA: 475] [Impact Index Per Article: 79.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 11/23/2017] [Accepted: 04/11/2018] [Indexed: 02/07/2023] Open
Abstract
The clinical expert consensus statement on takotsubo syndrome (TTS) part II focuses on the diagnostic workup, outcome, and management. The recommendations are based on interpretation of the limited clinical trial data currently available and experience of international TTS experts. It summarizes the diagnostic approach, which may facilitate correct and timely diagnosis. Furthermore, the document covers areas where controversies still exist in risk stratification and management of TTS. Based on available data the document provides recommendations on optimal care of such patients for practising physicians.
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Affiliation(s)
- Jelena-Rima Ghadri
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Ilan Shor Wittstein
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Abhiram Prasad
- Division of Cardiovascular Diseases Mayo Clinic, Rochester, MN, USA
| | - Scott Sharkey
- Cardiovascular Research Division, Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Keigo Dote
- Department of Cardiology, Hiroshima City Asa Hospital, Hiroshima, Japan
| | - Yoshihiro John Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Victoria Lucia Cammann
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Filippo Crea
- Department of Cardiovascular Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Leonarda Galiuto
- Department of Cardiovascular Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Walter Desmet
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Tetsuro Yoshida
- Department of Cardiovascular Medicine, Onga Nakama Medical Association Onga Hospital, Fukuoka, Japan
| | - Roberto Manfredini
- Clinica Medica, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Ingo Eitel
- University Heart Center Luebeck, Medical Clinic II, Department of Cardiology, Angiology and Intensive Care Medicine, University of Luebeck, Luebeck, Germany
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Holger M Nef
- Department of Cardiology, University Hospital Giessen, Giessen, Germany
| | | | - Amir Lerman
- Division of Cardiovascular Diseases Mayo Clinic, Rochester, MN, USA
| | - Eduardo Bossone
- Heart Department, University Hospital “San Giovanni di Dio e Ruggi d'Aragona”, Salerno, Italy
| | - Rodolfo Citro
- Heart Department, University Hospital “San Giovanni di Dio e Ruggi d'Aragona”, Salerno, Italy
| | - Takashi Ueyama
- Department of Anatomy and Cell Biology, Wakayama Medical University School of Medicine, Wakayama, Japan
| | - Domenico Corrado
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua Medical School, Padova, Italy
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Frank Ruschitzka
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - David Winchester
- Division of Cardiovascular Disease, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Alexander R Lyon
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Patrick Meimoun
- Department of Cardiology and Intensive Care, Centre Hospitalier de Compiegne, Compiegne, France
| | - Guiseppe Tarantini
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua Medical School, Padova, Italy
| | - Charanjit Rihal
- Division of Cardiovascular Diseases Mayo Clinic, Rochester, MN, USA
| | - Shams Y.-Hassan
- Department of Cardiology, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Federico Migliore
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua Medical School, Padova, Italy
| | - John D Horowitz
- Department of Cardiology, Basil Hetzel Institute, Queen Elizabeth Hospital, University of Adelaide, Adelaide, Australia
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Thomas Felix Lüscher
- Center for Molecular Cardiology, Schlieren Campus, University of Zurich, Zurich, Switzerland
- Department of Cardiology, Royal Brompton & Harefield Hospital and Imperial College, London, UK
| | - Christian Templin
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
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42
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Jesel L, Berthon C, Messas N, Lim HS, Girardey M, Marzak H, Marchandot B, Trinh A, Ohlmann P, Morel O. Ventricular arrhythmias and sudden cardiac arrest in Takotsubo cardiomyopathy: Incidence, predictive factors, and clinical implications. Heart Rhythm 2018; 15:1171-1178. [PMID: 29627435 DOI: 10.1016/j.hrthm.2018.04.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Indexed: 10/17/2022]
Abstract
BACKGROUND Takotsubo cardiomyopathy (TTC) is a stress-related transient cardiomyopathy. Life-threatening arrhythmias (LTA) can occur and worsen prognosis. OBJECTIVE The purpose of this study was to assess the incidence and outcome of LTA in TTC, as well as its predictive factors and clinical implications. METHODS We studied 214 consecutive cases of TTC over 8 years. The study cohort was divided into 2 groups: those with LTA (LTA group) and those without (non-LTA group). LTA was defined as ventricular tachycardia, ventricular fibrillation, or cardiac arrest. RESULTS LTA occurred in 23 (10.7%) of patients mainly in the first 24 hours of hospitalization: ventricular tachycardia (n = 2), ventricular fibrillation (n = 11), cardiac arrest (n = 10: 5 asystole, 3 complete heart block, and 2 sinoatrial block). LTAs were associated with lower left ventricular ejection fraction (LVEF) and a high rate of conduction disturbances. In-hospital (39.1% vs 8.9%; P < .001) and 1-year mortality (47.8% vs 14.1%; P < .001) rates were significantly increased in the LTA group. LVEF and QRS duration >105 ms were independent predictors of LTA. In cases where a device was implanted, conduction disturbances persisted after the index event despite complete recovery of LVEF. There was no ventricular arrhythmia recurrence during follow-up. CONCLUSION LTAs occur early in patients presenting with TTC and are associated with significantly worse short- and long-term prognosis. Left ventricular impairment and QRS duration >105 ms are independent predictors of LTA. Ventricular arrhythmias occurred in the acute phase without further recurrence recorded in hospital survivors, whereas severe conduction disorders persisted during long-term follow-up. These findings may have implications on the choice of device therapy for this specific patient subgroup.
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Affiliation(s)
- Laurence Jesel
- Department of Cardiology, University Hospital of Strasbourg, Strasbourg, France.
| | - Charlotte Berthon
- Department of Cardiology, University Hospital of Strasbourg, Strasbourg, France
| | - Nathan Messas
- Department of Cardiology, University Hospital of Strasbourg, Strasbourg, France
| | - Han S Lim
- Department of Cardiology, Austin and Northern Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Mélanie Girardey
- Department of Cardiology, University Hospital of Strasbourg, Strasbourg, France
| | - Halim Marzak
- Department of Cardiology, University Hospital of Strasbourg, Strasbourg, France
| | - Benjamin Marchandot
- Department of Cardiology, University Hospital of Strasbourg, Strasbourg, France
| | - Annie Trinh
- Department of Cardiology, University Hospital of Strasbourg, Strasbourg, France
| | - Patrick Ohlmann
- Department of Cardiology, University Hospital of Strasbourg, Strasbourg, France
| | - Olivier Morel
- Department of Cardiology, University Hospital of Strasbourg, Strasbourg, France
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43
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Madias JE. Dissecting the pathophysiology of complete heart block in takotsubo syndrome. Indian Pacing Electrophysiol J 2018; 18:87. [PMID: 29510244 PMCID: PMC5998690 DOI: 10.1016/j.ipej.2018.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 03/01/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- John E Madias
- Icahn School of Medicine at Mount Sinai, New York, NY, USA; Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, USA.
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44
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Rathore A, Banavalikar B, Shenthar J, Acharya D, Parvez J, Setty Srinivasa KH. An unusual case of complete atrioventricular block causing Takotsubo syndrome. Indian Pacing Electrophysiol J 2018; 18:123-125. [PMID: 29325979 PMCID: PMC5986300 DOI: 10.1016/j.ipej.2018.01.002] [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] [Received: 11/02/2017] [Revised: 01/05/2018] [Accepted: 01/08/2018] [Indexed: 11/17/2022] Open
Abstract
Complete atrioventricular (AV) block in association with Takotsubo syndrome (TS) has been well recognized, but the cause and effect relationship has not been elucidated. We describe a 78-year-old female who presented with complete AV block but one week later developed new-onset, diffuse T-wave inversions, QT prolongation, and acceleration of junctional escape rate. Left ventriculogram revealed features typical of TS. One year after permanent pacemaker implantation, complete AV block persisted despite the reversal of wall motion defects implying that conduction abnormality was the trigger of TS rather than its consequence.
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Affiliation(s)
- Abhishek Rathore
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Bharatraj Banavalikar
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India.
| | - Jayaprakash Shenthar
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Debashish Acharya
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Javed Parvez
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
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A Rare Association of Takotsubo Cardiomyopathy with High-Degree Atrioventricular Block. Case Rep Cardiol 2017; 2017:6989438. [PMID: 29085680 PMCID: PMC5632486 DOI: 10.1155/2017/6989438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 08/15/2017] [Indexed: 12/18/2022] Open
Abstract
Here we present a case of a patient who got trapped in an elevator; on initial evaluation patient was found with bradycardia; on further evaluation electrocardiogram (EKG) showed new onset 2nd-degree Mobitz type 2 AV block. On admission patient developed ischemic changes on EKG and troponin elevation. Transthoracic echocardiogram showed reduced ejection fraction as well as apical inferior, anterior, lateral, and septal hypokinesia. Coronary angiography showed nonobstructive coronary artery disease and ventriculogram demonstrated anterolateral and apical hypokinesia suggesting takotsubo cardiomyopathy (TCM). Atrioventricular block (AV) is rarely seen as initial presentation of TCM and has a prevalence of about 2.9%. AV block during early presentation of TCM poses a therapeutic dilemma with regard to the timing and the need to place a temporary or permanent pacemaker. The decision to place a permanent pacemaker may be on a case-by-case basis and more research is needed on formulating standardized recommendations in patients with TCM and conduction tissue abnormalities.
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46
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WITHDRAWN: Ventricular Arrhythmias in Patients with Takotsubo Syndrome. J Arrhythm 2017. [DOI: 10.1016/j.joa.2017.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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47
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Inayat F, Virk HUH, Ullah W, Riaz I. Takotsubo cardiomyopathy-related complete heart block and torsades de pointes. BMJ Case Rep 2017; 2017:bcr-2016-218017. [PMID: 28710299 DOI: 10.1136/bcr-2016-218017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Takotsubo cardiomyopathy (TCM) is a relatively recently recognised clinical entity. It frequently mimics acute coronary syndrome and is accompanied by reversible left ventricular apical ballooning in the absence of angiographically significant coronary artery stenosis. TCM is a reversible condition, and the prognosis is usually well. However, in rare instances, it can be associated with life-threatening arrhythmic complications. Herein, we report the case of a patient with TCM who developed complete atrioventricular block followed by QT prolongation and torsades de pointes. Furthermore, we undertook a literature review of this rare complication of TCM and discussed the formidable therapeutic challenge encountered in such patients.
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Affiliation(s)
- Faisal Inayat
- New York-Presbyterian Hospital, Weill Cornell Medical College, New York City, New York, USA
| | | | | | - Iqra Riaz
- Mayo Hospital, King Edward Medical University, Lahore, Pakistan
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48
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Barraud J, Cautela J, Orabona M, Pinto J, Missenard O, Laine M, Thuny F, Paganelli F, Bonello L, Peyrol M. Wearable cardioverter defibrillator: Bridge or alternative to implantation? World J Cardiol 2017; 9:531-538. [PMID: 28706588 PMCID: PMC5491470 DOI: 10.4330/wjc.v9.i6.531] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 03/04/2017] [Accepted: 04/20/2017] [Indexed: 02/06/2023] Open
Abstract
The implantable cardioverter-defibrillator (ICD) is effective to prevent sudden cardiac death (SCD) in selected patients with heart disease known to be at high risk for ventricular arrhythmia. Nevertheless, this invasive and definitive therapy is not indicated in patients with potentially transient or reversible causes of sudden death, or in patients with temporary contra-indication for ICD placement. The wearable cardioverter defibrillator (WCD) is increasingly used for SCD prevention both in patients awaiting ICD implantation or with an estimated high risk of ventricular arrhythmia though to be transient. We conducted a review of current clinical uses and benefits of the WCD, and described its technical aspects, limitations and perspectives.
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Madias JE. To the Editor- Implantation of permanent devices in patients with Takotsubo syndrome. Heart Rhythm 2016; 13:e328. [PMID: 27477996 DOI: 10.1016/j.hrthm.2016.07.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Indexed: 11/29/2022]
Affiliation(s)
- John E Madias
- Icahn School of Medicine at Mount Sinai New York, New York; Division of Cardiology Elmhurst Hospital Center Elmhurst, New York.
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Stiermaier T, Thiele H, Eitel I. Reply to the Editor- Implantation of permanent devices in patients with Takotsubo syndrome. Heart Rhythm 2016; 13:e329. [PMID: 27498278 DOI: 10.1016/j.hrthm.2016.07.027] [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] [Received: 07/21/2016] [Indexed: 11/15/2022]
Affiliation(s)
- Thomas Stiermaier
- Department of Cardiology, Angiology, Intensive Care Medicine, Medical Clinic II University Heart Center Lübeck, Lübeck, Germany, and German Center for Cardiovascular Research (DZHK) Partner site Hamburg/Kiel/Lübeck Lübeck, Germany
| | - Holger Thiele
- Department of Cardiology, Angiology, Intensive Care Medicine, Medical Clinic II University Heart Center Lübeck, Lübeck, Germany, and German Center for Cardiovascular Research (DZHK) Partner site Hamburg/Kiel/Lübeck Lübeck, Germany
| | - Ingo Eitel
- Department of Cardiology, Angiology, Intensive Care Medicine, Medical Clinic II University Heart Center Lübeck, Lübeck, Germany, and German Center for Cardiovascular Research (DZHK) Partner site Hamburg/Kiel/Lübeck Lübeck, Germany.
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