1
|
Schweiger V, Di Vece D, Cammann VL, Koleva I, Würdinger M, Gilhofer T, Rajman K, Szawan KA, Niederseer D, Citro R, Vecchione C, Bossone E, Gili S, Neuhaus M, Franke J, Meder B, Jaguszewski M, Noutsias M, Knorr M, Jansen T, D'Ascenzo F, Bruno F, De Filippo O, Stefanini G, Campo G, Wanha W, Raposeiras Roubin S, Dichtl W, von Lewinski D, Burgdorf C, Kherad B, Tschöpe C, Sarcon A, Shinbane J, Rajan L, Michels G, Pfister R, Cuneo A, Jacobshagen C, Karakas M, Koenig W, Pott A, Meyer P, Roffi M, Banning A, Wolfrum M, Cuculi F, Kobza R, Fischer TA, Vasankari T, Airaksinen KEJ, Napp LC, Dworakowski R, MacCarthy P, Kaiser C, Osswald S, Galiuto L, Chan C, Bridgman P, Beug D, Delmas C, Lairez O, Gilyarova E, Shilova A, Gilyarov M, El-Battrawy I, Akin I, Poledniková K, Toušek P, Winchester DE, Massoomi M, Galuszka J, Ukena C, Poglajen G, Carrilho-Ferreira P, Hauck C, Paolini C, Bilato C, Kobayashi Y, Kato K, Ishibashi I, Himi T, Din J, Al-Shammari A, Prasad A, Rihal CS, Liu K, Schulze PC, Bianco M, Jörg L, Rickli H, Pestana G, Nguyen TH, Böhm M, Maier LS, Pinto FJ, Widimský P, Felix SB, Braun-Dullaeus RC, Rottbauer W, Hasenfuß G, Pieske BM, Schunkert H, Budnik M, Opolski G, Thiele H, Bauersachs J, Horowitz JD, Di Mario C, Kong W, Dalakoti M, Imori Y, Münzel T, Bax JJ, Lüscher TF, Crea F, Ruschitzka F, Ghadri JR, Templin C. Cardiac biomarkers for diagnosing Takotsubo syndrome. Eur Heart J 2024; 45:2254-2258. [PMID: 38717630 DOI: 10.1093/eurheartj/ehae231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 03/08/2024] [Accepted: 03/25/2024] [Indexed: 07/10/2024] Open
Affiliation(s)
- Victor Schweiger
- Department of Cardiology, University Heart Center, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Davide Di Vece
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
- Internal Medicine B, University Medicine Greifswald, Greifswald, Germany
| | - Victoria L Cammann
- Department of Cardiology, University Heart Center, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Iva Koleva
- Department of Cardiology, University Heart Center, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Michael Würdinger
- Department of Cardiology, University Heart Center, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Thomas Gilhofer
- Department of Cardiology, University Heart Center, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Katja Rajman
- Department of Cardiology, University Heart Center, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Konrad A Szawan
- Department of Cardiology, University Heart Center, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - David Niederseer
- Department of Cardiology, University Heart Center, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Rodolfo Citro
- Heart Department, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
- Department of Vascular Physiopathology, IRCCS Neuromed, Pozzilli, Italy
| | - Carmine Vecchione
- Department of Vascular Physiopathology, IRCCS Neuromed, Pozzilli, Italy
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Eduardo Bossone
- Division of Cardiology, 'Antonio Cardarelli' Hospital, Naples, Italy
| | | | - Michael Neuhaus
- Department of Cardiology, Kantonsspital Frauenfeld, Frauenfeld, Switzerland
| | - Jennifer Franke
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Benjamin Meder
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Miłosz Jaguszewski
- First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Michel Noutsias
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Maike Knorr
- Center for Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany
| | - Thomas Jansen
- Center for Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Francesco Bruno
- Division of Cardiology, Department of Medical Sciences, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
- Royal Brompton and Harefield Hospitals Trust and Imperial College, London, UK
| | - Ovidio De Filippo
- Royal Brompton and Harefield Hospitals Trust and Imperial College, London, UK
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Gianluca Campo
- Azienda Ospedaliero-Universitaria di Ferrara, University of Ferrara, Italy
| | | | | | - Wolfgang Dichtl
- University Hospital for Internal Medicine III (Cardiology and Angiology), Medical University Innsbruck, Innsbruck, Austria
| | | | | | - Behrouz Kherad
- Department of Cardiology, Charité, Campus Rudolf Virchow, Berlin, Germany
| | - Carsten Tschöpe
- Department of Cardiology, Charité, Campus Rudolf Virchow, Berlin, Germany
| | - Annahita Sarcon
- Section of Cardiac Electrophysiology, Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Jerold Shinbane
- University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | | | - Guido Michels
- Klinik für Akut- und Notfallmedizin, St.-Antonius-Hospital gGmbH, Akademisches Lehrkrankenhaus der RWTH Aachen, Eschweiler, 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
- Vincentius-Diakonissen Hospital, Karlsruhe, Germany
| | - Mahir Karakas
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 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
| | - Alexander Pott
- Department of Internal Medicine II-Cardiology, University of Ulm, Medical Center, Ulm, Germany
| | - Philippe Meyer
- Service de cardiologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Marco Roffi
- Service de cardiologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Adrian Banning
- Department of Cardiology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Mathias Wolfrum
- Department of Cardiology, Kantonsspital Lucerne, Lucerne, Switzerland
| | - 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
| | | | - L Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | | | - Christoph Kaiser
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Stefan Osswald
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Leonarda Galiuto
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Christina Chan
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Paul Bridgman
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Daniel Beug
- Department of Cardiology and Internal Medicine B, University Medicine 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
| | - Ekaterina Gilyarova
- Intensive Coronary Care Unit, Pirogov Clinical City Hospital No. 1, Moscow, Russia
| | - Alexandra Shilova
- Intensive Coronary Care Unit, Pirogov Clinical City Hospital No. 1, Moscow, Russia
| | - Mikhail Gilyarov
- Intensive Coronary Care Unit, Pirogov Clinical City Hospital No. 1, Moscow, Russia
| | - 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
| | - Karolina Poledniková
- Cardiocenter, Third Faculty of Medicine, Charles University in Prague and University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Petr Toušek
- Cardiocenter, Third Faculty of Medicine, Charles University in Prague and University Hospital Královské Vinohrady, Prague, Czech Republic
| | - David E Winchester
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Michael Massoomi
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jan Galuszka
- Department of Internal Medicine I-Cardiology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Christian Ukena
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Gregor Poglajen
- Advanced Heart Failure and Transplantation Center, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Pedro Carrilho-Ferreira
- Santa Maria University Hospital, CHULN, Center of Cardiology of the University of Lisbon, Lisbon School of Medicine, Lisbon Academic Medical Center, Lisboa, Portugal
| | - Christian Hauck
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Carla Paolini
- Local Health Unit n.8, Cardiology Unit, Arzignano, Vicenza, Italy
| | - Claudio Bilato
- Local Health Unit n.8, Cardiology Unit, Arzignano, Vicenza, Italy
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Ken Kato
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Iwao Ishibashi
- Department of Cardiology, Chiba Emergency Medical Center, Chiba, Japan
| | - Toshiharu Himi
- Division of Cardiology, Kimitsu Central Hospital, Kisarazu, Japan
| | - Jehangir Din
- Dorset Heart Centre, Royal Bournemouth Hospital, Bournemouth, UK
| | - Ali Al-Shammari
- Dorset Heart Centre, Royal Bournemouth Hospital, Bournemouth, UK
| | - Abhiram Prasad
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Kan Liu
- Division of Cardiology, Heart and Vascular Center, University of Iowa, Iowa City, IA, USA
| | - P Christian Schulze
- Department of Internal Medicine I, University Hospital Jena, Friedrich-Schiller-University Jena, Jena, Germany
| | - Matteo Bianco
- Division of Cardiology, A.O.U San Luigi Gonzaga, Orbassano, Turin, Italy
| | - Lucas Jörg
- Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Hans Rickli
- Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Gonçalo Pestana
- Department of Cardiology, Centro Hospitalar Universitário de São João, E.P.E., Porto, Portugal
| | - Thanh H Nguyen
- Department of Cardiology, Basil Hetzel Institute, Queen Elizabeth Hospital, University of Adelaide, Adelaide, Australia
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Lars S Maier
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Fausto J Pinto
- Santa Maria University Hospital, CHULN, Center of Cardiology of the University of Lisbon, Lisbon School of Medicine, Lisbon Academic Medical Center, Lisboa, Portugal
| | - Petr Widimský
- Cardiocenter, Third Faculty of Medicine, Charles University in Prague and University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Stephan B Felix
- Department of Cardiology and Internal Medicine B, University Medicine Greifswald, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Greifswald, Greifswald, Germany
| | | | - Wolfgang Rottbauer
- Department of Internal Medicine II-Cardiology, University of Ulm, Medical Center, Ulm, Germany
| | - Gerd Hasenfuß
- Clinic for Cardiology and Pneumology, Georg August University Goettingen, Goettingen, Germany
| | - Burkert M Pieske
- Department of Cardiology, Charité, Campus Rudolf Virchow, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Monika Budnik
- Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Opolski
- Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig-University Hospital, Leipzig, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - John D Horowitz
- Department of Cardiology, Basil Hetzel Institute, Queen Elizabeth Hospital, University of Adelaide, Adelaide, Australia
| | - Carlo Di Mario
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | - William Kong
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Mayank Dalakoti
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Yoichi Imori
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Thomas Münzel
- Center for Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Thomas F Lüscher
- Royal Brompton and Harefield Hospitals Trust and Imperial College, London, UK
- Center for Molecular Cardiology, Schlieren Campus, University of Zurich, Zurich, Switzerland
| | - Filippo Crea
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Jelena R Ghadri
- Center for Molecular Cardiology, Schlieren Campus, University of Zurich, Zurich, Switzerland
| | - Christian Templin
- Department of Cardiology, University Heart Center, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Swiss CardioVascularClinic, Private Hospital Bethanien, Zurich, Switzerland
| |
Collapse
|
2
|
Zulfaj E, Nejat A, Haamid A, Elmahdy A, Espinosa A, Redfors B, Omerovic E. Animal models of Takotsubo syndrome: bridging the gap to the human condition. Front Cardiovasc Med 2024; 11:1351587. [PMID: 38841261 PMCID: PMC11152046 DOI: 10.3389/fcvm.2024.1351587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/18/2024] [Indexed: 06/07/2024] Open
Abstract
Modelling human diseases serves as a crucial tool to unveil underlying mechanisms and pathophysiology. Takotsubo syndrome (TS), an acute form of heart failure resembling myocardial infarction, manifests with reversible regional wall motion abnormalities (RWMA) of the ventricles. Despite its mortality and clinical similarity to myocardial infarction, TS aetiology remains elusive, with stress and catecholamines playing central roles. This review delves into current animal models of TS, aiming to assess their ability to replicate key clinical traits and identifying limitations. An in-depth evaluation of published animal models reveals a variation in the definition of TS among studies. We notice a substantial prevalence of catecholamine-induced models, particularly in rodents. While these models shed light on TS, there remains potential for refinement. Translational success in TS research hinges on models that align with human TS features and exhibit the key features, including transient RWMA. Animal models should be comprehensively evaluated regarding the various systemic changes of the applied trigger(s) for a proper interpretation. This review acts as a guide for researchers, advocating for stringent TS model standards and enhancing translational validity.
Collapse
Affiliation(s)
- Ermir Zulfaj
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - AmirAli Nejat
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Abdulhussain Haamid
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ahmed Elmahdy
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Aaron Espinosa
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Björn Redfors
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
- Core Facilities - Experimental Biomedicine, Sahlgrenska Academy, Gothenburg, Sweden
| | - Elmir Omerovic
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
- Core Facilities - Experimental Biomedicine, Sahlgrenska Academy, Gothenburg, Sweden
| |
Collapse
|
3
|
Ryazantsev D, Shustinskiy M, Sheshil A, Titov A, Grudtsov V, Vechorko V, Kitiashvili I, Puchnin K, Kuznetsov A, Komarova N. A Portable Readout System for Biomarker Detection with Aptamer-Modified CMOS ISFET Array. SENSORS (BASEL, SWITZERLAND) 2024; 24:3008. [PMID: 38793863 PMCID: PMC11125907 DOI: 10.3390/s24103008] [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: 04/15/2024] [Revised: 05/04/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024]
Abstract
Biosensors based on ion-sensitive field effect transistors (ISFETs) combined with aptamers offer a promising and convenient solution for point-of-care testing applications due to the ability for fast and label-free detection of a wide range of biomarkers. Mobile and easy-to-use readout devices for the ISFET aptasensors would contribute to further development of the field. In this paper, the development of a portable PC-controlled device for detecting aptamer-target interactions using ISFETs is described. The device assembly allows selective modification of individual ISFETs with different oligonucleotides. Ta2O5-gated ISFET structures were optimized to minimize trapped charge and capacitive attenuation. Integrated CMOS readout circuits with linear transfer function were used to minimize the distortion of the original ISFET signal. An external analog signal digitizer with constant voltage and superimposed high-frequency sine wave reference voltage capabilities was designed to increase sensitivity when reading ISFET signals. The device performance was demonstrated with the aptamer-driven detection of troponin I in both reference voltage setting modes. The sine wave reference voltage measurement method reduced the level of drift over time and enabled a lowering of the minimum detectable analyte concentration. In this mode (constant voltage 2.4 V and 10 kHz 0.1Vp-p), the device allowed the detection of troponin I with a limit of detection of 3.27 ng/mL. Discrimination of acute myocardial infarction was demonstrated with the developed device. The ISFET device provides a platform for the multiplexed detection of different biomarkers in point-of-care testing.
Collapse
Affiliation(s)
- Dmitriy Ryazantsev
- Scientific-Manufacturing Complex Technological Centre, 1–7 Shokin Square, Zelenograd, Moscow 124498, Russia
- Institute of Nanotechnology of Microelectronics of the Russian Academy of Sciences, 32A Leninsky Prospekt, Moscow 119334, Russia
| | - Mark Shustinskiy
- Institute of Nanotechnology of Microelectronics of the Russian Academy of Sciences, 32A Leninsky Prospekt, Moscow 119334, Russia
| | - Andrey Sheshil
- Scientific-Manufacturing Complex Technological Centre, 1–7 Shokin Square, Zelenograd, Moscow 124498, Russia
- Institute of Nanotechnology of Microelectronics of the Russian Academy of Sciences, 32A Leninsky Prospekt, Moscow 119334, Russia
| | - Alexey Titov
- Scientific-Manufacturing Complex Technological Centre, 1–7 Shokin Square, Zelenograd, Moscow 124498, Russia
| | - Vitaliy Grudtsov
- Scientific-Manufacturing Complex Technological Centre, 1–7 Shokin Square, Zelenograd, Moscow 124498, Russia
- Institute of Nanotechnology of Microelectronics of the Russian Academy of Sciences, 32A Leninsky Prospekt, Moscow 119334, Russia
| | - Valerii Vechorko
- Municipal Clinical Hospital No.15 Named after O.M. Filatov, 23 Veshnyakovskaya St, Moscow 111539, Russia
| | - Irakli Kitiashvili
- Municipal Clinical Hospital No.15 Named after O.M. Filatov, 23 Veshnyakovskaya St, Moscow 111539, Russia
| | - Kirill Puchnin
- Scientific-Manufacturing Complex Technological Centre, 1–7 Shokin Square, Zelenograd, Moscow 124498, Russia
- Institute of Nanotechnology of Microelectronics of the Russian Academy of Sciences, 32A Leninsky Prospekt, Moscow 119334, Russia
| | - Alexander Kuznetsov
- Scientific-Manufacturing Complex Technological Centre, 1–7 Shokin Square, Zelenograd, Moscow 124498, Russia
- Institute of Nanotechnology of Microelectronics of the Russian Academy of Sciences, 32A Leninsky Prospekt, Moscow 119334, Russia
| | - Natalia Komarova
- Scientific-Manufacturing Complex Technological Centre, 1–7 Shokin Square, Zelenograd, Moscow 124498, Russia
- Institute of Nanotechnology of Microelectronics of the Russian Academy of Sciences, 32A Leninsky Prospekt, Moscow 119334, Russia
| |
Collapse
|
4
|
Couch LS, Garrard JW, Henry JA, Kotronias RA, Alaour B, De Maria GL, Channon KM, Banning AP, Lyon AR, Marber M, Kaier TE. Comparison of troponin and natriuretic peptides in Takotsubo syndrome and acute coronary syndrome: a meta-analysis. Open Heart 2024; 11:e002607. [PMID: 38508657 PMCID: PMC10952941 DOI: 10.1136/openhrt-2024-002607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 01/16/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVE Takotsubo syndrome (TTS) is an acute heart failure syndrome which resembles acute coronary syndrome (ACS) at presentation. Differentiation requires coronary angiography, but where this does not occur immediately, cardiac biomarkers may provide additional utility. We performed a meta-analysis to compare troponin and natriuretic peptides (NPs) in TTS and ACS to determine if differences in biomarker profile can aid diagnosis. METHODS We searched five literature databases for studies reporting NPs (Brain NP (BNP)/NT-pro-BNP) or troponin I/T in TTS and ACS, identifying 28 studies for troponin/NPs (5618 and 1145 patients, respectively). RESULTS Troponin was significantly lower in TTS than ACS (standardised mean difference (SMD) -0.86; 95% CI, -1.08 to -0.64; p<0.00001), with an absolute difference of 75 times the upper limit of normal (×ULN) higher in ACS than TTS. Conversely, NPs were significantly higher in TTS (SMD 0.62; 95% CI, 0.44 to 0.80; p<0.00001) and 5.8×ULN greater absolutely. Area under the curve (AUC) for troponin in ACS versus TTS was 0.82 (95% CI, 0.70 to 0.93), and 0.92 (95% CI, 0.80 to 1.00) for ST-segment elevation myocardial infarction versus TTS. For NPs, AUC was 0.69 (95% CI, 0.48 to 0.89). Combination of troponin and NPs with logistic regression did not improve AUC. Recursive Partitioning and Regression Tree analysis calculated a troponin threshold ≥26×ULN that identified 95% cases as ACS where and specificity for ACS were 85.71% and 53.57%, respectively, with 94.32% positive predictive value and 29.40% negative predictive value. CONCLUSIONS Troponin is lower and NPs higher in TTS versus ACS. Troponin had greater power than NPs at discriminating TTS and ACS, and with troponin ≥26×ULN patients are far more likely to have ACS.
Collapse
Affiliation(s)
- Liam Steven Couch
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, London, UK
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - James W Garrard
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - John A Henry
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Rafail A Kotronias
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Bashir Alaour
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, London, UK
| | - Giovanni Luigi De Maria
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Keith M Channon
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Adrian P Banning
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | | | - Michael Marber
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, London, UK
| | - Thomas Edward Kaier
- King's College London BHF Centre, The Rayne Institute, St Thomas' Hospital, London, UK
| |
Collapse
|
5
|
Rallidis LS, Iordanidis D, Papathanasiou KA, Simitsis P, Varounis C, Simou A, Kosmas N. NT-proBNP/cardiac troponin T ratio >7.5 on the second day of admission can differentiate Takotsubo from acute coronary syndrome with good accuracy. Hellenic J Cardiol 2024; 76:22-30. [PMID: 37269943 DOI: 10.1016/j.hjc.2023.05.010] [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: 02/08/2023] [Revised: 05/01/2023] [Accepted: 05/28/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Takotsubo syndrome (TTS) is not usually diagnosed until patients with suspected acute coronary syndrome (ACS) and echocardiographically detected apical aneurysm are found to have "normal" coronary angiography (CA). Our aim was to explore whether cardiac biomarkers can contribute to the early diagnosis of TTS. METHODS Ratios of N-terminal-pro brain natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (cTnT) both expressed in pg/mL [admission and the 3 following days] were compared in 38 patients with TTS and 114 ACS patients of whom 58 had non-ST-elevation myocardial infarction (NSTEMI). RESULTS NT-proBNP/cTnT ratio at admission and during the following 3 days was significantly higher in TTS compared to patients with ACS [18.4 (8.7-41.7) vs 2.9 (0.8-6.8), 29.6 (14.3-53.7) vs 1.2 (0.5-2.7), 30.0 (11.6-50.9) vs 1.7 (0.5-3.0), 27.8 (11.3-42.6) vs 1.4 (0.6-2.8), respectively, all <0.001]. Βest discrimination of TTS from ACS was possible with the ratio of NT-proBNP/cTnT on the 2nd day. A cut-off value of NT-proBNP/cTnT ratio >7.5 had a sensitivity of 97.3%, a specificity of 95.4% and an accuracy of ∼96% in detecting TTS as opposed to ACS. Furthermore, the ratio of NT-proBNP/cTnT preserved its discriminatory value in the subgroup of patients with NSTEMI. In particular, an NT-proBNP/cTnT ratio >7.5 on the 2nd day had a sensitivity of 97.3%, a specificity of 91.4%, and an accuracy of 93.7% in differentiating TTS from NSTEMI. CONCLUSIONS An NT-proBNP/cTnT ratio >7.5 on the 2nd day of admission can be useful for the early identification of TTS among selected patients initially presenting with ACS, a ratio more clinically useful in the setting of NSTEMI.
Collapse
Affiliation(s)
- Loukianos S Rallidis
- Second Department of Cardiology, National & Kapodistrian University of Athens, School of Medicine, University General Hospital ATTIKON, Athens, 12462, Greece
| | - Dimitrios Iordanidis
- Second Department of Cardiology, National & Kapodistrian University of Athens, School of Medicine, University General Hospital ATTIKON, Athens, 12462, Greece
| | - Konstantinos A Papathanasiou
- Second Department of Cardiology, National & Kapodistrian University of Athens, School of Medicine, University General Hospital ATTIKON, Athens, 12462, Greece.
| | - Panagiotis Simitsis
- Second Department of Cardiology, National & Kapodistrian University of Athens, School of Medicine, University General Hospital ATTIKON, Athens, 12462, Greece
| | - Christos Varounis
- Second Department of Cardiology, National & Kapodistrian University of Athens, School of Medicine, University General Hospital ATTIKON, Athens, 12462, Greece
| | - Aggeliki Simou
- Second Department of Cardiology, National & Kapodistrian University of Athens, School of Medicine, University General Hospital ATTIKON, Athens, 12462, Greece
| | - Nikolaos Kosmas
- Second Department of Cardiology, National & Kapodistrian University of Athens, School of Medicine, University General Hospital ATTIKON, Athens, 12462, Greece
| |
Collapse
|
6
|
Celeski M, Nusca A, De Luca VM, Antonelli G, Cammalleri V, Melfi R, Mangiacapra F, Ricottini E, Gallo P, Cocco N, Rinaldi R, Grigioni F, Ussia GP. Takotsubo Syndrome and Coronary Artery Disease: Which Came First-The Chicken or the Egg? J Cardiovasc Dev Dis 2024; 11:39. [PMID: 38392253 PMCID: PMC10889783 DOI: 10.3390/jcdd11020039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Takotsubo syndrome (TTS) is a clinical condition characterized by temporary regional wall motion anomalies and dysfunction that extend beyond a single epicardial vascular distribution. Various pathophysiological mechanisms, including inflammation, microvascular dysfunction, direct catecholamine toxicity, metabolic changes, sympathetic overdrive-mediated multi-vessel epicardial spasms, and transitory ischemia may cause the observed reversible myocardial stunning. Despite the fact that TTS usually has an acute coronary syndrome-like pattern of presentation, the absence of culprit atherosclerotic coronary artery disease is often reported at coronary angiography. However, the idea that coronary artery disease (CAD) and TTS conditions are mutually exclusive has been cast into doubt by numerous recent studies suggesting that CAD may coexist in many TTS patients, with significant clinical and prognostic repercussions. Whether the relationship between CAD and TTS is a mere coincidence or a bidirectional cause-and-effect is still up for debate, and misdiagnosis of the two disorders could lead to improper patient treatment with unfavourable outcomes. Therefore, this review seeks to provide a profound understanding of the relationship between CAD and TTS by analyzing potential common underlying pathways, addressing challenges in differential diagnosis, and discussing medical and procedural techniques to treat these conditions appropriately.
Collapse
Affiliation(s)
- Mihail Celeski
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Annunziata Nusca
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Valeria Maria De Luca
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Giorgio Antonelli
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Valeria Cammalleri
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Rosetta Melfi
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Fabio Mangiacapra
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Elisabetta Ricottini
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Paolo Gallo
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Nino Cocco
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Raffaele Rinaldi
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Francesco Grigioni
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Gian Paolo Ussia
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| |
Collapse
|
7
|
Guler A, Turkmen I, Atmaca S, Karakurt H, Kahraman S, Aydin S, Sevinc S, Tukenmez Karakurt S, Turkvatan Cansever A, Erturk M, Babur Guler G. Influence of cardiac biomarkers on predicting significant coronary artery disease in hypertrophic cardiomyopathy patients. Heart Vessels 2023; 38:1329-1336. [PMID: 37414867 DOI: 10.1007/s00380-023-02287-0] [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: 04/27/2023] [Accepted: 06/29/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND In this study, our aim was to investigate the role of cardiac biomarkers in predicting the presence of significant coronary artery disease in hypertrophic cardiomyopathy (HCM) patients. METHODS The study population was composed of hypertrophic cardiomyopathy patients who underwent coronary angiography at a single center between June 2021 and March 2023, and whose cardiac biomarkers were evaluated before the procedure. HCM patients were screened retrospectively. Significant CAD was defined as > 50% stenosis of the left main coronary artery or > 70% stenosis in a major coronary vessel. Demographic, echocardiographic and cardiac biomarker values were compared between the two groups. RESULTS A total of 123 patients were evaluated. Significant CAD was detected in 39 (31.7%) patients. Patients with significant CAD had higher CK-MB values than those without CAD [2.8 (2.1-4.0) vs. 3.4 (2.8-4.6), p = 0.036], and a higher level of high-sensitivity troponin T (hs-TnT) than those without CAD (24 vs. 17.8, p = 0.022). the NT-proBNP/hs-TnT ratio was found to be significantly lower in patients with CAD than in those with CAD (31.4 vs. 21.4, p = 0.019). In multivariate anaylsis, NT-proBNP/hs-TnT was determined as an independent predictor for significant CAD. In ROC analysis, NT-proBNP/hs-TnT ratio lower than the cut-off value of 30.7 could detect the presence of significant CAD with 76.9% sensitivity and 53.6% specificity (AUC: 0.632, 95% CI: 0.528-0.736, p = 0.019). CONCLUSION To sum up, we suggest that cardiac biomarkers were valuable and simple parameters in terms of significant CAD in HCM patients.
Collapse
Affiliation(s)
- Arda Guler
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey.
| | - Irem Turkmen
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey
| | - Sezgin Atmaca
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey
| | - Huseyin Karakurt
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey
| | - Serkan Kahraman
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey
| | - Sinem Aydin
- Department of Radiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Samet Sevinc
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey
| | - Seda Tukenmez Karakurt
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey
| | - Aysel Turkvatan Cansever
- Department of Radiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Mehmet Erturk
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey
| | - Gamze Babur Guler
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istasyon Mahallesi, Turgut Ozal Bulvarı, No: 11, Küçükçekmece/Istanbul, Turkey
| |
Collapse
|
8
|
Sonaglioni A, Lombardo M, Grasso E, Nicolosi GL, Foti N, Lonati C, Harari S. Presumed Takotsubo syndrome is associated with high in-hospital mortality in very elderly frail females: a case series. Aging Clin Exp Res 2023; 35:2851-2856. [PMID: 37581859 DOI: 10.1007/s40520-023-02517-5] [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: 07/18/2023] [Accepted: 07/23/2023] [Indexed: 08/16/2023]
Abstract
Given the aging of general population, very elderly females with Takotsubo syndrome (TTS) are not rarely encountered in clinical practice. Although coronary angiography with left ventriculography is the gold standard diagnostic tool to exclude or confirm TTS, currently, this invasive procedure is less frequently performed in older patients with several comorbidities, such as renal failure, anemia, infections, neurological disorders, malignancy, and severe frailty. In these patients, a "presumed" TTS is diagnosed on the basis of clinical presentation, electrocardiogram, cardiac biomarkers, and echocardiographic findings without coronary angiography. While, in younger patients, TTS is generally a benign condition, in very elderly females, it is associated with higher in-hospital mortality and poor prognosis. Herein, we present four cases of ultra-octogenarian females diagnosed with "presumed TTS", who did not undergo coronary angiography due to severe frailty and multiple comorbidities and who exhibited poor outcome. This could arise the question if an early more aggressive approach could have changed final results. Probably, the solution could only be a personalized decision deriving from a profound and detailed discussion of each case through a multidisciplinary team approach.
Collapse
Affiliation(s)
| | | | - Enzo Grasso
- Division of Cardiology, MultiMedica IRCCS, Milan, Italy
| | | | - Nicolò Foti
- Division of Internal Medicine, MultiMedica IRCCS, Milan, Italy
| | - Chiara Lonati
- Division of Internal Medicine, MultiMedica IRCCS, Milan, Italy.
- Department of Clinical Sciences and Community Health, Università di Milano, Milan, Italy.
| | - Sergio Harari
- Division of Internal Medicine, MultiMedica IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, Università di Milano, Milan, Italy
| |
Collapse
|
9
|
Couch LS, Channon K, Thum T. Molecular Mechanisms of Takotsubo Syndrome. Int J Mol Sci 2022; 23:12262. [PMID: 36293121 PMCID: PMC9603071 DOI: 10.3390/ijms232012262] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/07/2022] [Accepted: 10/10/2022] [Indexed: 12/04/2022] Open
Abstract
Takotsubo syndrome (TTS) is a severe but reversible acute heart failure syndrome that occurs following high catecholaminergic stress. TTS patients are similar to those with acute coronary syndrome, with chest pain, dyspnoea and ST segment changes on electrocardiogram, but are characterised by apical akinesia of the left ventricle, with basal hyperkinesia in the absence of culprit coronary artery stenosis. The pathophysiology of TTS is not completely understood and there is a paucity of evidence to guide treatment. The mechanisms of TTS are thought to involve catecholaminergic myocardial stunning, microvascular dysfunction, increased inflammation and changes in cardiomyocyte metabolism. Here, we summarise the available literature to focus on the molecular basis for the pathophysiology of TTS to advance the understanding of the condition.
Collapse
Affiliation(s)
- Liam S. Couch
- Department of Cardiovascular Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Keith Channon
- Department of Cardiovascular Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies, Hannover Medical School, 30625 Hannover, Germany
- Fraunhofer Institute of Toxicology and Experimental Medicine, 30625 Hannover, Germany
| |
Collapse
|
10
|
The Octopus Trap of Takotsubo and Stroke: Genetics, Biomarkers and Clinical Management. J Pers Med 2022; 12:jpm12081244. [PMID: 36013193 PMCID: PMC9410002 DOI: 10.3390/jpm12081244] [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: 06/14/2022] [Revised: 07/24/2022] [Accepted: 07/25/2022] [Indexed: 11/16/2022] Open
Abstract
Takotsubo cardiomyopathy (TC) is a reversible cardiomyopathy mimicking an acute coronary syndrome, usually observed in response to acute stress situations. The association between acute ischemic stroke and TC is already known, since it has been previously reported that ischemic stroke can be both a consequence and a potential cause of TC. However, the precise pathophysiological mechanism linking the two conditions is still poorly understood. The aim of our review is to expand insights regarding the genetic susceptibility and available specific biomarkers of TC and to investigate the clinical profile and outcomes of patients with TC and stroke. Since evidence and trials on TC and stroke are currently lacking, this paper aims to fill a substantial gap in the literature about the relationship between these pathologies.
Collapse
|
11
|
Angelini P, Postalian A, Hernandez-Vila E, Uribe C, Costello B. COVID-19 and the Heart: Could Transient Takotsubo Cardiomyopathy Be Related to the Pandemic by Incidence and Mechanisms? Front Cardiovasc Med 2022; 9:919715. [PMID: 35833183 PMCID: PMC9271702 DOI: 10.3389/fcvm.2022.919715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/19/2022] [Indexed: 12/19/2022] Open
Abstract
Typical emergency hospital care during the COVID-19 pandemic has centered on pulmonary-focused services. Nonetheless, patients with COVID-19 frequently develop complications associated with the dysfunction of other organs, which may greatly affect prognosis. Preliminary evidence suggests that cardiovascular involvement is relatively frequent in COVID-19 and that it correlates with significant worsening of clinical status and mortality in infected patients. In this article, we summarize current knowledge on the cardiovascular effects of COVID-19. In particular, we focus on the association between COVID-19 and transient takotsubo cardiomyopathy (TTC)—two conditions that preliminarily seem epidemiologically associated—and we highlight cardiovascular changes that may help guide future investigations toward full discovery of this new, complex disease entity. We hypothesize that coronary endothelial dysfunction, along with septic state, inflammatory storm, hypercoagulability, endothelial necrosis, and small-vessel clotting, may represent a fundamental hidden link between COVID-19 and TTC. Furthermore, given the likelihood that new genetic mutations of coronaviruses or other organisms will cause similar pandemics and endemics in the future, we must be better prepared so that a substantial complication such as TTC can be more accurately recognized, its pathophysiology better understood, and its treatment made more justifiable, timely, and effective.
Collapse
|
12
|
Barmore W, Patel H, Harrell S, Garcia D, Calkins Jr JB. Takotsubo cardiomyopathy: A comprehensive review. World J Cardiol 2022; 14:355-362. [PMID: 35979181 PMCID: PMC9258224 DOI: 10.4330/wjc.v14.i6.355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/24/2022] [Accepted: 05/23/2022] [Indexed: 02/06/2023] Open
Abstract
Takotsubo cardiomyopathy (TCM), also known as stress cardiomyopathy, occurs in the setting of catecholamine surge from an acute stressor. This cardiomyopathy mimics acute myocardial infarction in the absence of coronary disease. The classic feature of TCM is regional wall motion abnormalities with characteristic ballooning of the left ventricle. The etiology of the stressor is often physical or emotional stress, however iatrogenic causes of TCM have been reported in the literature. In our review, we discuss medications, primarily the exogenous administration of catecholamines, and a wide array of procedures with subsequent development of iatrogenic cardiomyopathy. TCM is unique in that it is transient and has favorable outcomes in most individuals. Classically, beta-blockers and ACE-inhibitors have been prescribed in individuals with cardiomyopathy; however, unique to TCM, no specific treatment is required other than temporary supportive measures as this process is transient. Additionally, no improvement in mortality or recurrence have been reported in patients on these drugs. The aim of this review is to elucidate on the iatrogenic causes of TCM, allowing for prompt recognition and management by clinicians.
Collapse
Affiliation(s)
- Walker Barmore
- Department of Internal Medicine, Augusta University Medical Center, Augusta, GA 30912, United States
| | - Himax Patel
- Department of Internal Medicine, Augusta University Medical Center, Augusta, GA 30912, United States
| | - Sean Harrell
- Department of Cardiovascular Medicine, Augusta University Medical Center, Augusta, GA 30912, United States
| | - Daniel Garcia
- Department of Internal Medicine, Augusta University Medical Center, Augusta, GA 30912, United States
| | - Joe B Calkins Jr
- Department of Cardiovascular Medicine, Augusta University Medical Center, Augusta, GA 30912, United States
| |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
Gabarre P, Ruiz P, Chenevier-Gobeaux C, Charpentier E, Soulat-Dufour L, Cohen A, Monnier-Cholley L, Chemali L, François H, Kerneis M, Lefèvre G, Boissan M. Inverted Takotsubo Syndrome With HELLP Syndrome: A Case Report. Front Cardiovasc Med 2022; 9:832098. [PMID: 35433851 PMCID: PMC9008274 DOI: 10.3389/fcvm.2022.832098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/03/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundTakotsubo syndrome is an acute cardiac condition involving sudden, transient apical ballooning of the left ventricle of the heart that may be triggered by emotional stress and some non-cardiac conditions. Its diagnosis is based on clinical presentation, electrocardiogram, cardiac imaging and biomarkers.Case SummaryHere, we present a novel and original case report of a patient presenting very soon in the post-partum period with an unusual form of Takotsubo syndrome without clinical symptoms of cardiac disease and accompanied by HELLP syndrome. The overall dynamics of the changes in troponin I, troponin T and NT-proBNP levels after delivery were generally similar, but the amount of troponin I was much greater than that of troponin T and troponin I was already elevated before delivery. NT-proBNP levels peaked around the same time as the troponins and the peak concentration was within the same range as that of troponin I.DiscussionOur findings indicate that assaying circulating cardiac biomarkers, especially troponin I and NT-proBNP, may be a useful complement to non-invasive cardiac imaging including transthoracic echocardiography and cardiovascular magnetic resonance imaging, in the diagnosis of Takotsubo syndrome. They illustrate the importance of cardiac biomarkers in assisting diagnosis of this disease.
Collapse
Affiliation(s)
- Paul Gabarre
- AP-HP, Hôpital Tenon, Soins Intensifs Néphrologiques et Rein Aigu (SINRA), Paris, France
| | - Pablo Ruiz
- AP-HP, Hôpital Tenon, Laboratoire de Biochimie, Paris, France
| | - Camille Chenevier-Gobeaux
- AP-HP-Centre Université de Paris, Hôpital Cochin, Department of Automated Biological Diagnostic, Paris, France
| | - Etienne Charpentier
- AP-HP, Groupe Hospitalier Pitié Salpêtrière, Unité d'Imagerie Cardiovasculaire et Thoracique ICT, Institut de Cardiologie, Paris, France
| | - Laurie Soulat-Dufour
- AP-HP, Hôpital Saint-Antoine-Tenon, Service de Cardiologie, Paris, France
- Sorbonne Université, Inserm, Unité de Recherche sur les Maladies Cardiovasculaires, le Métabolisme et la Nutrition, ICAN, Paris, France
| | - Ariel Cohen
- AP-HP, Hôpital Saint-Antoine-Tenon, Service de Cardiologie, Paris, France
- Sorbonne Université, Inserm, Unité de Recherche sur les Maladies Cardiovasculaires, le Métabolisme et la Nutrition, ICAN, Paris, France
| | | | - Lotfi Chemali
- AP-HP, Hôpital Tenon, Laboratoire de Biochimie, Paris, France
| | - Hélène François
- AP-HP, Hôpital Tenon, Soins Intensifs Néphrologiques et Rein Aigu (SINRA), Paris, France
- Sorbonne Université, Inserm, UMR_S1155, Paris, France
| | - Mathieu Kerneis
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie (AP-HP), Paris, France
| | | | - Mathieu Boissan
- AP-HP, Hôpital Tenon, Laboratoire de Biochimie, Paris, France
- Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine, CRSA, Paris, France
- *Correspondence: Mathieu Boissan
| |
Collapse
|
15
|
Moady G, Atar S. Stress-Induced Cardiomyopathy—Considerations for Diagnosis and Management during the COVID-19 Pandemic. Medicina (B Aires) 2022; 58:medicina58020192. [PMID: 35208516 PMCID: PMC8875249 DOI: 10.3390/medicina58020192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 12/12/2022] Open
Abstract
The novel coronavirus disease 2019 (COVID-19) is associated with several cardiovascular manifestations including myocardial injury, myocarditis, arrhythmia, and pulmonary embolism. Rare cases of stress-induced cardiomyopathy, or takotsubo syndrome have also been reported during the acute infection, and secondary to stress following lockdown and self-isolation. Diagnosis in the setting of the acute infection is challenging since conventional imaging modalities such as transthoracic echocardiography and coronary angiography should be restricted to minimize physician-patient contact until the patients is tested negative for COVID-19. The use of point of care hand-held ultrasound is appropriate for this purpose. The overall course of the disease seems to be similar to takotsubo in the general population. Physicians should be familiar with the clinical presentation, possible complications, and management of takotsubo during COVID-19 outbreak. Here, we review the special considerations in the diagnosis and management of takotsubo syndrome during the current pandemic.
Collapse
Affiliation(s)
- Gassan Moady
- Department of Cardiology, Galilee Medical Center, Nahariya 2221006, Israel;
- Azrieli Faculty of Medicine, Bar Ilan University, Safed 5290002, Israel
- Correspondence: ; Tel.: +972-4-9107273
| | - Shaul Atar
- Department of Cardiology, Galilee Medical Center, Nahariya 2221006, Israel;
- Azrieli Faculty of Medicine, Bar Ilan University, Safed 5290002, Israel
| |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
Kinno R, Ono K. Takotsubo Syndrome: Optimizing Care with a Multidisciplinary Approach. J Multidiscip Healthc 2021; 14:2487-2499. [PMID: 34531661 PMCID: PMC8439972 DOI: 10.2147/jmdh.s283667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 08/23/2021] [Indexed: 12/19/2022] Open
Abstract
Symptoms of takotsubo syndrome (TTS) include acute and transient regional systolic dysfunction of the left ventricle, as well as a variety of wall-motion abnormalities. The clinical features of TTS, including initial symptoms, cardiac biomarkers, and electrocardiogram (ECG) changes, are similar to those of acute coronary syndrome, with the exception that TTS patients typically have no obstructive coronary artery disease. TTS primarily affects elderly women, and emotional or physical stress is a common cause of the disease. Exaggerated sympathetic stimulation associated with dysfunction of the limbic system has also been reported to be related to TTS occurrence. Cancer also induces emotional and physical stress. Therefore, optimization of TTS care should involve cardiac, neurological, psychiatric, and oncological approaches. The first step in optimizing TTS care is to diagnose it by cardiac means. Multimodality imaging, including ECG, echocardiogram, angiography, ventriculography, and cardiac magnetic resonance imaging, is indispensable for diagnosis, therapy management, and the evaluation of prognosis in the acute and chronic phases of TTS. The current cardiac approach during the acute phase is primarily supportive, with the goal of preventing life-threatening complications. As central nervous system diseases frequently trigger TTS, a neurological approach is also required. Appropriate psychiatric medication may reduce the risk of TTS recurrence, as not only psychiatric disorders themselves but also psychiatric medications can be the trigger for TTS. Several conditions are associated with TTS, including the novel coronavirus disease 2019. We present current knowledge of TTS in this review and describe how to optimize TTS care through a multidisciplinary approach.
Collapse
Affiliation(s)
- Ryuta Kinno
- Division of Neurology, Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama City, Kanagawa, 224-8503, Japan
| | - Kenjiro Ono
- Division of Neurology, Department of Medicine, Showa University School of Medicine, Tokyo, 142-8555, Japan
| |
Collapse
|
18
|
Ali A, Redfors B, Alkhoury J, Oras J, Henricsson M, Boren J, Björnson E, Espinosa A, Levin M, Gan LM, Omerovic E. Sacubitril/valsartan decreases mortality in the rat model of the isoprenaline-induced takotsubo-like syndrome. ESC Heart Fail 2021; 8:4130-4138. [PMID: 34463049 PMCID: PMC8497381 DOI: 10.1002/ehf2.13530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/06/2021] [Accepted: 07/08/2021] [Indexed: 12/11/2022] Open
Abstract
Aims Takotsubo syndrome (TTS) is an acute potentially reversible cardiac syndrome characterized by variable regional myocardial akinesia that cannot be attributed to a culprit coronary artery occlusion. TTS is an important differential diagnosis of acute heart failure where brain natriuretic peptides are elevated. Sacubitril/valsartan is a novel and effective pharmacological agent for the treatment of patients with heart failure. Our aim was to explore whether treatment with sacubitril/valsartan could prevent isoprenaline‐induced takotsubo‐like phenotype in rats. Methods and results A total number of 186 Sprague–Dawley male rats were randomized to receive pretreatment with water (CONTROL, n = 62), valsartan (VAL, n = 62), or sacubitril/valsartan (SAC/VAL, n = 62) before receiving isoprenaline for induction of TTS. We recorded heart rate and blood pressure invasively. Cardiac morphology and function were evaluated by high‐resolution echocardiography 90 min after the administration of isoprenaline. We documented the survival rate at the time of echocardiography. Compared with the CONTROL group, the SAC/VAL group had less pronounced TTS‐like cardiac dysfunction and lower mortality rate, while the VAL group did not differ. Heart rate and blood pressure were not significantly different between the groups. Analysis of cardiac lipids was performed with mass spectrometry. The VAL and SAC/VAL groups had significantly higher levels of lysophosphatidylcholine (LPC), in particular LPC 18:1 and LPC 16:0. Conclusions Pretreatment with sacubitril/valsartan but not with valsartan reduces mortality and attenuates isoprenaline‐induced apical akinesia in the TTS‐like model in rats. Sacubitril/valsartan could be a potential treatment option in patients with TTS in humans.
Collapse
Affiliation(s)
- Anwar Ali
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Björn Redfors
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jessica Alkhoury
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jonatan Oras
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Marcus Henricsson
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan Boren
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Elias Björnson
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Aaron Espinosa
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Malin Levin
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Li-Ming Gan
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Elmir Omerovic
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
19
|
Khan H, Gamble D, Mezincescu A, Abbas H, Rudd A, Dawson D. A systematic review of biomarkers in Takotsubo syndrome: A focus on better understanding the pathophysiology. IJC HEART & VASCULATURE 2021; 34:100795. [PMID: 34095448 PMCID: PMC8164033 DOI: 10.1016/j.ijcha.2021.100795] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The diagnosis of Takotsubo syndrome is made based on clinical presentation, ECG, biomarker, imaging and coronary angiography. There is a lack of diagnostic biomarkers that can discriminate patients with Takotsubo syndrome from those with acute myocardial infarction (AMI) and provide clinical monitoring and prognostic information in the long-term. METHODS A literature search of published Takotsubo syndrome biomarkers from PubMed was performed. All studies that included numerical biomarker data on Takotsubo syndrome was included. Exclusion criteria was any study without an AMI cohort for comparison in the acute phase biomarkers or due to the absence of numerical values. The results were tabulated in table form with results expressed as either mean ± SD or median (interquartile range). RESULTS The literature search produced 14 relevant studies that met search criteria. The results showed; high sensitivity Troponin I (3.21 ± 4.4 vs 34.4 ± 37 ng/ml), BNP [972 (578.5-1671.0) pg/L vs 358 (50.5-688.0) pg/L in NSTEMI and vs 381 (106.0-934.0) pg/L in STEMI] and BNP/Troponin I ratio [642 (331.8-1226.5) vs 184.5 (50.5-372.3) pg/ug in NSTEMI and 7.5 (2.0-29.6) pg/ug in STEMI] patients. DISCUSSION This study is limited by many studies being retrospective cohort studies. This data shows that acutely troponin is raised in Takotsubo syndrome but not enough to be discriminating from AMI. BNP level is significantly raised in Takotsubo syndrome compared to AMI. CONCLUSION Current specificity of acute and chronic biomarkers for Takotsubo syndrome is lacking and further work is needed to address the gap in knowledge.
Collapse
Affiliation(s)
- Hilal Khan
- Cardiology Research Group, Aberdeen Cardiovascular and Diabetes Centre, School of Medicine and Dentistry, University of Aberdeen, Foresterhill Aberdeen AB25 2ZD, United Kingdom
| | - David Gamble
- Cardiology Research Group, Aberdeen Cardiovascular and Diabetes Centre, School of Medicine and Dentistry, University of Aberdeen, Foresterhill Aberdeen AB25 2ZD, United Kingdom
| | - Alice Mezincescu
- Cardiology Research Group, Aberdeen Cardiovascular and Diabetes Centre, School of Medicine and Dentistry, University of Aberdeen, Foresterhill Aberdeen AB25 2ZD, United Kingdom
| | - Hassan Abbas
- Cardiology Research Group, Aberdeen Cardiovascular and Diabetes Centre, School of Medicine and Dentistry, University of Aberdeen, Foresterhill Aberdeen AB25 2ZD, United Kingdom
| | - Amelia Rudd
- Cardiology Research Group, Aberdeen Cardiovascular and Diabetes Centre, School of Medicine and Dentistry, University of Aberdeen, Foresterhill Aberdeen AB25 2ZD, United Kingdom
| | - Dana Dawson
- Cardiology Research Group, Aberdeen Cardiovascular and Diabetes Centre, School of Medicine and Dentistry, University of Aberdeen, Foresterhill Aberdeen AB25 2ZD, United Kingdom
| |
Collapse
|
20
|
Taggart C, Wereski R, Mills NL, Chapman AR. Diagnosis, Investigation and Management of Patients with Acute and Chronic Myocardial Injury. J Clin Med 2021; 10:2331. [PMID: 34073539 PMCID: PMC8199345 DOI: 10.3390/jcm10112331] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/14/2021] [Accepted: 05/20/2021] [Indexed: 12/16/2022] Open
Abstract
The application of high-sensitivity cardiac troponins in clinical practice has led to an increase in the recognition of elevated concentrations in patients without myocardial ischaemia. The Fourth Universal Definition of Myocardial Infarction encourages clinicians to classify such patients as having an acute or chronic myocardial injury based on the presence or absence of a rise or a fall in cardiac troponin concentrations. Both conditions may be caused by a variety of cardiac and non-cardiac conditions, and evidence suggests that clinical outcomes are worse than patients with myocardial infarction due to atherosclerotic plaque rupture, with as few as one-third of patients alive at 5 years. Major adverse cardiovascular events are comparable between populations, and up to three-fold higher than healthy individuals. Despite this, no evidence-based strategies exist to guide clinicians in the investigation of non-ischaemic myocardial injury. This review explores the aetiology of myocardial injury and proposes a simple framework to guide clinicians in early assessment to identify those who may benefit from further investigation and treatment for those with cardiovascular disease.
Collapse
Affiliation(s)
- Caelan Taggart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK; (C.T.); (R.W.); (N.L.M.)
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK; (C.T.); (R.W.); (N.L.M.)
| | - Nicholas L. Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK; (C.T.); (R.W.); (N.L.M.)
- Usher Institute, University of Edinburgh, Edinburgh EH16 4UX, UK
| | - Andrew R. Chapman
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SA, UK; (C.T.); (R.W.); (N.L.M.)
| |
Collapse
|
21
|
Barnicle R, Bracey A, Secko M. Early Identification of Takotsubo syndrome in the emergency department using point-of-care echocardiography: A case series. JOURNAL OF CLINICAL ULTRASOUND : JCU 2021; 49:413-419. [PMID: 32924171 DOI: 10.1002/jcu.22918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/23/2020] [Accepted: 09/03/2020] [Indexed: 06/11/2023]
Abstract
Takotsubo syndrome (TS) is an incompletely understood, transient dysfunction of the left ventricle. While acute coronary syndrome must be at the forefront of the differential diagnosis and ruled out appropriately, the possibility of TS can be identified early with point-of-care ultrasonography. The formal diagnostic criteria for TS rely on invasive diagnostic procedures and resolution of symptoms, typically relegating it to a diagnosis of exclusion. However, the acute complications are potentially lethal, and rapid identification is therefore beneficial because these patients can be risk-stratified to higher levels of care. Our case series of three patients, each with early suspected and subsequently confirmed TS, explores how early emergency department ultrasonography can suggest the diagnosis during the emergent workup, and potentially influence disposition decisions, subsequent interventions, and possibly even outcomes.
Collapse
Affiliation(s)
- Ryan Barnicle
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Alexander Bracey
- Department of Emergency Medicine, Albany Medical Center, Albany, New York, USA
| | - Michael Secko
- Division Chief, Emergency and Clinical Ultrasound, Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York, USA
| |
Collapse
|
22
|
Rawish E, Stiermaier T, Santoro F, Brunetti ND, Eitel I. Current Knowledge and Future Challenges in Takotsubo Syndrome: Part 1-Pathophysiology and Diagnosis. J Clin Med 2021; 10:jcm10030479. [PMID: 33525539 PMCID: PMC7865728 DOI: 10.3390/jcm10030479] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/08/2021] [Accepted: 01/15/2021] [Indexed: 02/06/2023] Open
Abstract
First recognized in 1990, takotsubo syndrome (TTS) constitutes an acute cardiac condition that mimics acute myocardial infarction commonly in the absence of obstructive coronary artery disease; it is characterized by temporary left ventricular dysfunction, regularly in a circumferential apical, midventricular, or basal distribution. Considering its acute clinical presentation, coronary angiography with left ventriculography constitutes the gold standard diagnostic tool to exclude or confirm TTS. Frequently, TTS is related to severe emotional or physical stress and a subsequent increased adrenergic stimulation affecting cardiac function. Beyond clinical presentation, epidemiology, and novel diagnostic biomarkers, this review draws attention to potential pathophysiological mechanisms for the observed reversible myocardial dysfunction such as sympathetic overdrive-mediated multi-vessel epicardial spasms, microvascular dysfunction, the direct toxicity of catecholamines, lipotoxicity, and inflammation. Considering the long-term prognosis, further experimental and clinical research is indispensable to elucidate further pathophysiological mechanisms underlying TTS before randomized control trials with evidence-based therapeutic management can be performed.
Collapse
Affiliation(s)
- Elias Rawish
- Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine) University Heart Center, 23538 Lübeck, Germany; (E.R.); (T.S.)
- DZHK (German Centre for Cardiovascular Research), 23538 Lübeck, Germany
| | - Thomas Stiermaier
- Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine) University Heart Center, 23538 Lübeck, Germany; (E.R.); (T.S.)
- DZHK (German Centre for Cardiovascular Research), 23538 Lübeck, Germany
| | - Francesco Santoro
- Department of Medical & Surgery Sciences, University of Foggia, 71121 Foggia, Italy
| | - Natale D. Brunetti
- Department of Medical & Surgery Sciences, University of Foggia, 71121 Foggia, Italy
| | - Ingo Eitel
- Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine) University Heart Center, 23538 Lübeck, Germany; (E.R.); (T.S.)
- DZHK (German Centre for Cardiovascular Research), 23538 Lübeck, Germany
- Correspondence: ; Tel.: +49-451-500-44501
| |
Collapse
|
23
|
Jothin A, Raj JP, Thiruvenkatarajan V. A simple procedure in a complex patient: perioperative takotsubo cardiomyopathy. BMJ Case Rep 2020; 13:13/12/e233121. [PMID: 33334739 PMCID: PMC7747580 DOI: 10.1136/bcr-2019-233121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Takotsubo cardiomyopathy (TTC) is a rare but life-threatening condition that is still not completely understood. Characterised by rapidly reversible ventricular dysfunction without any prior coronary artery disease, it can imitate a myocardial infarction and lead to death if not managed appropriately. This report examines a case of intraoperative cardiac arrest in a patient with no previous cardiac disease, and discusses the factors that may have precipitated this event, as well as the ways of distinguishing the cause of the arrest based on clinical course and investigations, eventually leading to a diagnosis of TTC.
Collapse
Affiliation(s)
- Arvind Jothin
- Department of Anaesthesia, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - John Prakash Raj
- Department of Intensive Care Medicine, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | | |
Collapse
|
24
|
Linganna RE, Leong RL, Yeom RS, Kopenitz J, Li RQ, Ram H, Dwarakanath S, Vasquez CR, Augoustides JGT. Takotsubo Cardiomyopathy-Navigating the Challenges of Diagnosis and Management in Heart Transplantation. J Cardiothorac Vasc Anesth 2020; 35:944-950. [PMID: 33262040 DOI: 10.1053/j.jvca.2020.10.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 10/28/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Regina E Linganna
- Department of Anesthesiology and Critical Care, Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Ron L Leong
- Department of Anesthesiology and Critical Care, Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Richard S Yeom
- Department of Anesthesiology and Critical Care, Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Jason Kopenitz
- Department of Anesthesiology and Critical Care, Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Rosie Q Li
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Harish Ram
- Department of Anesthesiology, School of Medicine, University of Kentucky, Lexington, KY
| | - Sanjay Dwarakanath
- Department of Anesthesiology, School of Medicine, University of Kentucky, Lexington, KY
| | - Charles R Vasquez
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| |
Collapse
|
25
|
Dagrenat C, Von Hunolstein JJ, Matsushita K, Thebaud L, Greciano S, Tuzin N, Meyer N, Trinh A, Jesel L, Ohlmann P, Morel O. Value of Cardiac Biomarkers in the Early Diagnosis of Takotsubo Syndrome. J Clin Med 2020; 9:E2985. [PMID: 32942758 PMCID: PMC7564647 DOI: 10.3390/jcm9092985] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/25/2020] [Accepted: 09/07/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Bedside diagnosis between Takotsubo syndrome (TTS) and ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction remains challenging. We sought to determine a cardiac biomarker profile to enable their early distinction. METHODS 1100 patients (TTS n = 314, STEMI n = 452, NSTEMI n = 334) were enrolled in two centers. Baseline clinical and biological characteristics were compared between groups. RESULTS At admission, cut-off values of BNP (B-type natriuretic peptide)/TnI (Troponin I) ratio of 54 and 329 distinguished respectively STEMI from NSTEMI, and NSTEMI from TTS. Best differentiation was obtained by the use of BNP/TnI ratio at peak (cut-of values of 6 and 115 discriminated respectively STEMI from NSTEMI, and NSTEMI from TTS). We developed a score including five parameters (age, gender, history of psychiatric disorders, LVEF, and BNP/TnI ratio at admission) enabling good distinction between TTS and STEMI (77% specificity and 92% sensitivity, AUC 0.93). For the distinction between TTS and NSTEMI, a four variables score (gender, history of psychiatric disorders, LVEF, and BNP at admission) achieved a good diagnostic performance (89% sensitivity, 85% specificity, AUC 0.94). CONCLUSION A distinctive cardiac biomarker profile enables at an early stage a differentiation between TTS and ACS. A four (NSTEMI) or five variables score (STEMI) permitted a better discrimination.
Collapse
Affiliation(s)
- Charlotte Dagrenat
- Université de Strasbourg, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, 67091 Strasbourg, France; (J.J.V.H.); (K.M.); (L.T.); (A.T.); (L.J.); (P.O.)
| | - Jean Jacques Von Hunolstein
- Université de Strasbourg, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, 67091 Strasbourg, France; (J.J.V.H.); (K.M.); (L.T.); (A.T.); (L.J.); (P.O.)
| | - Kensuke Matsushita
- Université de Strasbourg, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, 67091 Strasbourg, France; (J.J.V.H.); (K.M.); (L.T.); (A.T.); (L.J.); (P.O.)
| | - Lucie Thebaud
- Université de Strasbourg, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, 67091 Strasbourg, France; (J.J.V.H.); (K.M.); (L.T.); (A.T.); (L.J.); (P.O.)
| | - Stéphane Greciano
- Department of Cardiology, Centre Hospitalier de Colmar, 68000 Colmar, France;
| | - Nicolas Tuzin
- Department of Biostatistics, University of Strasbourg, 67091 Strasbourg, France; (N.T.); (N.M.)
| | - Nicolas Meyer
- Department of Biostatistics, University of Strasbourg, 67091 Strasbourg, France; (N.T.); (N.M.)
| | - Annie Trinh
- Université de Strasbourg, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, 67091 Strasbourg, France; (J.J.V.H.); (K.M.); (L.T.); (A.T.); (L.J.); (P.O.)
| | - Laurence Jesel
- Université de Strasbourg, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, 67091 Strasbourg, France; (J.J.V.H.); (K.M.); (L.T.); (A.T.); (L.J.); (P.O.)
- UMR INSERM 1230 Regenerative Nanomedicine, University of Strasbourg, 67000 Strasbourg, France
| | - Patrick Ohlmann
- Université de Strasbourg, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, 67091 Strasbourg, France; (J.J.V.H.); (K.M.); (L.T.); (A.T.); (L.J.); (P.O.)
| | - Olivier Morel
- Université de Strasbourg, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, 67091 Strasbourg, France; (J.J.V.H.); (K.M.); (L.T.); (A.T.); (L.J.); (P.O.)
- UMR INSERM 1230 Regenerative Nanomedicine, University of Strasbourg, 67000 Strasbourg, France
| |
Collapse
|
26
|
Agarwal S, Sanghvi C, Odo N, Castresana MR. Perioperative takotsubo cardiomyopathy: Implications for anesthesiologist. Ann Card Anaesth 2020; 22:309-315. [PMID: 31274495 PMCID: PMC6639891 DOI: 10.4103/aca.aca_71_18] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Takotsubo cardiomyopathy (TCM) is characterized by transient ventricular dysfunction in the absence of obstructive coronary artery disease that may be triggered by an acute medical illness or intense physical or emotional stress. TCM is often confused with acute myocardial infarction given the similar electrocardiographic changes, cardiac enzymes, hemodynamic perturbations, and myocardial wall motion abnormalities. In the perioperative setting, the clinical picture may be more confusing because of the effect of anesthesia as well as hemodynamic changes related to the surgery itself. However, awareness of various other diagnostic modalities may enable clinicians to distinguish between the two, more systematically and with greater certainty. Despite the large body of literature, there still seems to be an overall paucity in our understanding of the etiopathogenesis, clinical characteristics, natural history, and management of this syndrome, especially in the perioperative setting. This narrative review seeks to present and synthesize the most recent literature on TCM and to identify gaps in current knowledge which can become the basis for future research.
Collapse
Affiliation(s)
- Shvetank Agarwal
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Chinar Sanghvi
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Nadine Odo
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Manuel R Castresana
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| |
Collapse
|
27
|
An Update on Cardiac Magnetic Resonance Imaging in Takotsubo Cardiomyopathy. CURRENT CARDIOVASCULAR IMAGING REPORTS 2020. [DOI: 10.1007/s12410-020-09536-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Abstract
Purpose of Review
To provide an update on the use of cardiac magnetic resonance imaging in the diagnosis of Takotsubo cardiomyopathy.
Recent Findings
Long-term prognosis of Takotsubo cardiomyopathy may not be as clear-cut as previously thought. Cardiac magnetic resonance imaging not only allows differentiation between reversible and nonreversible changes but has an emerging role in identifying cellular level changes associated with prognostic indicators such as myocardial energetics using 31P-CMR spectroscopy and detection of myocardial inflammation overlying myocardial oedema, using ultrasmall paramagnetic iron oxide particle uptake in macrophages.
Summary
Takotsubo cardiomyopathy is a non-ischemic acute heart failure syndrome. It is commonly triggered by emotional or physical stress and is possibly the strongest psychosomatic interaction seen in medicine. While clinically its presentation mimics a myocardial infarction, the acute imaging characteristics are critical in correctly identifying the disease entity.
Collapse
|
28
|
Ciutac AM, Dawson D. The role of inflammation in stress cardiomyopathy. Trends Cardiovasc Med 2020; 31:225-230. [PMID: 32276825 DOI: 10.1016/j.tcm.2020.03.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 02/25/2020] [Accepted: 03/12/2020] [Indexed: 02/08/2023]
Abstract
Stress cardiomyopathy (SC) is an increasingly recognized form of acute heart failure, which has been linked to a wide variety of emotional and physical triggers. The pathophysiological mechanisms of the disease remain incompletely understood, however, inflammation has been recently shown to play a pivotal role. This review summarizes the most notable findings of myocardial inflammation, demonstrated from biopsies and cardiac magnetic resonance imaging in humans. In the acute stage macrophage infiltration appears to represent the substrate for myocardial edema, together defining the local myocardial inflammation. This appears to evolve into a low grade systemic chronic inflammation which could explain the protracted clinical course of these patients and raises hope for finding a specific SC cardiac biomarker as well as a therapeutic breakthrough. As a parallel to the human findings the review covers some of the emerging mechanistic insights from experimental models, which, albeit not proven in the human condition, highlight the possible importance in pursuing distinct paths of investigation such as the beta-receptor signaling, aberrations of nitric oxide generation and signaling and the contribution of the vascular endothelium/permeability to edema and inflammation during the acute stage.
Collapse
Affiliation(s)
- Andra Maria Ciutac
- School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Foresterhill, Aberdeen, Scotland, United Kingdom
| | - Dana Dawson
- School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Foresterhill, Aberdeen, Scotland, United Kingdom.
| |
Collapse
|
29
|
Gue YX, Kanji R, Gati S, Gorog DA. MI with Non-obstructive Coronary Artery Presenting with STEMI: A Review of Incidence, Aetiology, Assessment and Treatment. Eur Cardiol 2020; 15:e20. [PMID: 32419851 PMCID: PMC7215489 DOI: 10.15420/ecr.2019.13] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 02/25/2020] [Indexed: 12/11/2022] Open
Abstract
MI with non-obstructive coronary artery (MINOCA) is a condition previously thought to be benign that has recently been shown to have comparable mortality to that of acute coronary syndrome with obstructive coronary disease. The heterogeneity of the underlying aetiology makes the assessment, investigation and treatment of patients with MINOCA challenging. The majority of patients with MINOCA presenting with ST-segment elevation MI generally have an underlying coronary or myocardial cause, predominantly plaque disruption or myocarditis. In order to make the correct diagnosis, in addition to the cause of the presentation, a meticulous and methodical approach is required, with targeted investigations. Stratification of patients to guide investigations that are more likely to provide the diagnosis will allow the correct treatment to be initiated promptly. In this article, the authors review the contemporary incidence, aetiology, recommended assessment and treatment of patients with MINOCA presenting with ST-segment elevation MI.
Collapse
Affiliation(s)
- Ying X Gue
- University of Hertfordshire Hertfordshire, UK
| | - Rahim Kanji
- National Heart and Lung Institute, Imperial College London, UK
| | - Sabiha Gati
- University of Hertfordshire Hertfordshire, UK
| | - Diana A Gorog
- University of Hertfordshire Hertfordshire, UK
- National Heart and Lung Institute, Imperial College London, UK
| |
Collapse
|
30
|
Keramida K, Backs J, Bossone E, Citro R, Dawson D, Omerovic E, Parodi G, Schneider B, Ghadri JR, Van Laake LW, Lyon AR. Takotsubo syndrome in Heart Failure and World Congress on Acute Heart Failure 2019: highlights from the experts. ESC Heart Fail 2020; 7:400-406. [PMID: 31994355 PMCID: PMC7160490 DOI: 10.1002/ehf2.12603] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/09/2019] [Indexed: 12/29/2022] Open
Affiliation(s)
- Kalliopi Keramida
- Medical School, University of Cyprus, Nicosia, Cyprus.,Cardiology Department, Heart Failure Unit, Attikon University Hospital, Athens, Greece
| | - Johannes Backs
- Institute of Experimental Cardiology, University Hospital Heidelberg, Heidelberg, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
| | - Eduardo Bossone
- Division of Cardiology, A. Cardarelli Hospital, Naples, Italy
| | - Rodolfo Citro
- Cardiovascular Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Dana Dawson
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, UK
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Guido Parodi
- Division of Interventional Cardiology, University Hospital of Sassari, Sassari, Italy
| | | | - Jelena R Ghadri
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Linda W Van Laake
- Department of Cardiology and Regenerative Medicine Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | | |
Collapse
|
31
|
Højagergaard MA, Hassager C, Christensen TE, Bang LE, Gøtze JP, Ostrowski SR, Holmvang L, Frydland M. Biomarkers in patients with Takotsubo cardiomyopathy compared to patients with acute anterior ST-elevation myocardial infarction. Biomarkers 2020; 25:137-143. [PMID: 31902247 DOI: 10.1080/1354750x.2019.1710767] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Takotsubo cardiomyopathy (TTC) is a syndrome of acute non-coronary heart failure with similar symptoms and electrocardiograms to acute anterior ST-elevation myocardial infarction (STEMI). Little is known about the pathophysiology of TTC. We assessed admission plasma concentrations of biomarkers reflecting neuroendocrine response (copeptin, mid-regional-pro-adrenomedullin, pro-atrial-natriuretic-peptide, soluble thrombomodulin (sTM), syndecan-1) and inflammation (suppression-of-tumorigenicity 2 (ST2), high-sensitive C-reactive-protein) in TTC patients and compared to patients with acute anterior STEMI.Materials and methods: Twenty TTC patients were matched with 40 STEMI patients by age, gender and left ventricular ejection fraction. Blood was sampled upon hospital admission immediately before acute coronary angiography.Results: The groups had similar comorbidities. TTC patients had higher plasma concentrations of sTM: 7.94 (5.89;9.61) vs. 6.42 (5.50;7.82)ng/ml, p = 0.04 and ST2 (53 (32;157) vs. 45 (31;55)ng/ml, p = 0.008) and higher heart rate: 101 ([Formula: see text]33) vs. 76([Formula: see text]14)bpm, p = 0.0001, but lower concentrations of copeptin (10.4 (7.6;39) vs. 92.3 (13;197)pmol/l, p < 0.05) and troponin T (348 (98;759) vs. 1190 (261;4105)ng/l, p = 0.04).Conclusion: TTC patients had higher plasma concentrations of sTM and ST2, higher heart rate and lower copeptin and troponin T concentrations compared to acute anterior STEMI patients. This study contributes to the hypothesis that TTC patients have endothelial cell damage and are hemodynamically more stable than patients with acute anterior STEMI on admission.
Collapse
Affiliation(s)
| | - Christian Hassager
- The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Thomas Emil Christensen
- The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lia Evi Bang
- The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jens Peter Gøtze
- Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Sisse Rye Ostrowski
- Department of Clinical Immunology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lene Holmvang
- The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Martin Frydland
- The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
32
|
Moscatelli S, Montecucco F, Carbone F, Valbusa A, Massobrio L, Porto I, Brunelli C, Rosa GM. An Emerging Cardiovascular Disease: Takotsubo Syndrome. BIOMED RESEARCH INTERNATIONAL 2019; 2019:6571045. [PMID: 31781633 PMCID: PMC6875025 DOI: 10.1155/2019/6571045] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/12/2019] [Accepted: 10/03/2019] [Indexed: 12/18/2022]
Abstract
Takotsubo syndrome (TTS) is a recently identified cardiac disease, which is far from being completely known. The aims of this narrative review are to provide a better understanding of the pathophysiological features of TTS and to update clinical findings in order to improve the management of subjects affected by this syndrome (according to the most recent consensus papers issued by the international scientific societies). We based our search on the material obtained via PubMed up to April 2019. The terms used were "Takotsubo Syndrome and Takotsubo cardiomyopathy" in combination with "heart failure, pathophysiology, complications, diagnosis, and treatment." TTS is a reversible form of ventricular dysfunction usually characterized by akinesia of the apex in the absence of obstructive coronary artery disease. In its initial phase, TTS may be indistinguishable from AMI and is usually triggered by a sudden emotional/physical stressor which abruptly increases catecholamine levels. However, the mechanisms by which catecholamines or other unidentified molecules can cause myocardial dysfunction is unknown. In-hospital stay may be hampered by various life-threatening complications, while data on long-term survival remain scarce and unclear. Furthermore, TTS may sometimes recur. We believe that TTS is clearly a much more complex condition than previously thought. Much remains to be discovered about its pathophysiologic mechanisms, the role of the link between the heart and brain and that of triggering factors and gender, and the reasons why this syndrome displays different phenotypes and sometimes recurs. Undoubtedly, preliminary evidence from pathophysiological studies (mainly genetic studies) has shown promising advances. However, prospective randomized clinical trials are still needed in order to identify and to tailor the best medical treatments for TTS patients.
Collapse
Affiliation(s)
- Sara Moscatelli
- Clinic of Cardiovascular Diseases, University of Genoa, 6 Viale Benedetto XV, 16132 Genoa, Italy
| | - Fabrizio Montecucco
- IRCCS Ospedale Policlinico San Martino Genoa–Italian Cardiovascular Network, 10 Largo Benzi, 16132 Genoa, Italy
- First Clinic of Internal Medicine, Department of Internal Medicine, and Centre of Excellence for Biomedical Research (CEBR), University of Genoa, 6 Viale Benedetto XV, 16132 Genoa, Italy
| | - Federico Carbone
- IRCCS Ospedale Policlinico San Martino Genoa–Italian Cardiovascular Network, 10 Largo Benzi, 16132 Genoa, Italy
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 Viale Benedetto XV, 16132 Genoa, Italy
| | - Alberto Valbusa
- IRCCS Ospedale Policlinico San Martino Genoa–Italian Cardiovascular Network, 10 Largo Benzi, 16132 Genoa, Italy
| | - Laura Massobrio
- IRCCS Ospedale Policlinico San Martino Genoa–Italian Cardiovascular Network, 10 Largo Benzi, 16132 Genoa, Italy
| | - Italo Porto
- Clinic of Cardiovascular Diseases, University of Genoa, 6 Viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa–Italian Cardiovascular Network, 10 Largo Benzi, 16132 Genoa, Italy
| | - Claudio Brunelli
- Clinic of Cardiovascular Diseases, University of Genoa, 6 Viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa–Italian Cardiovascular Network, 10 Largo Benzi, 16132 Genoa, Italy
| | - Gian Marco Rosa
- Clinic of Cardiovascular Diseases, University of Genoa, 6 Viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa–Italian Cardiovascular Network, 10 Largo Benzi, 16132 Genoa, Italy
| |
Collapse
|
33
|
Waterbury TM, Tarantini G, Vogel B, Mehran R, Gersh BJ, Gulati R. Non-atherosclerotic causes of acute coronary syndromes. Nat Rev Cardiol 2019; 17:229-241. [DOI: 10.1038/s41569-019-0273-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2019] [Indexed: 12/15/2022]
|
34
|
Kim DH, Lee SH, Kim SC, Kim T, Kang C, Jeong JH, Park YJ, Lim D, Lee SB. The ratio of N-terminal pro-B-type natriuretic peptide to troponin I for differentiating acute coronary syndrome. Am J Emerg Med 2019; 37:1013-1019. [DOI: 10.1016/j.ajem.2018.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/03/2018] [Accepted: 08/11/2018] [Indexed: 10/28/2022] Open
|
35
|
Vaz HA, Guimaraes RB, Dutra O. Challenges in high-sensitive troponin assay interpretation for intensive therapy. Rev Bras Ter Intensiva 2019; 31:93-105. [PMID: 30843948 PMCID: PMC6443313 DOI: 10.5935/0103-507x.20190001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/10/2018] [Indexed: 12/28/2022] Open
Abstract
Cardiac troponins T and I are considered highly sensitive and specific markers for the diagnosis of acute myocardial infarction. Currently, a series of nonprimary cardiac abnormalities may manifest as an elevation in high-sensitive assays. The reduction in their detection limits has allowed earlier diagnosis and the use of evidence-based therapeutic measures; however, this characteristic has increased the spectrum of detectable noncoronary heart diseases, which poses challenges for characterizing acute coronary syndromes and creates a new role for these tests in known disorders in intensive care units, especially sepsis. Management of patients through a greater understanding of how these markers behave should be re-evaluated to ensure their correct interpretation.
Collapse
Affiliation(s)
- Humberto Andres Vaz
- Unidade de Terapia Intensiva, Instituto de Cardiologia do Rio Grande do Sul, Fundação Universitária de Cardiologia - Porto Alegre (RS), Brasil
| | - Raphael Boesche Guimaraes
- Unidade de Terapia Intensiva, Instituto de Cardiologia do Rio Grande do Sul, Fundação Universitária de Cardiologia - Porto Alegre (RS), Brasil
| | - Oscar Dutra
- Unidade de Terapia Intensiva, Instituto de Cardiologia do Rio Grande do Sul, Fundação Universitária de Cardiologia - Porto Alegre (RS), Brasil
| |
Collapse
|
36
|
Abstract
BACKGROUND AND PURPOSE Takotsubo cardiomyopathy (TCM), first reported by Japanese doctors, has gained an overall acknowledgment as an independent malady of international attention. It resembles the presentation of an acute myocardial infarction but lacks ischemic myocardial tissue. The objective of this article is to review the physiology, diagnostics, treatment, and complications of TCM and report a case study of a patient who developed TCM. METHODS Observation through direct patient care allowed for data collection of this unique medical phenomenon. Supporting information was obtained via investigation of scholarly articles on TCM over the past 10 years. CONCLUSIONS Although TCM is usually transient, it is important to quickly differentiate TCM from other more serious medical conditions, such as myocardial infarction, pulmonary embolism, and pheochromocytoma. Typical diagnostic workup includes electrocardiography, cardiac biomarkers, and echocardiography or coronary angiography. Complications include cardiogenic shock, left ventricular wall rupture, and life-threatening arrhythmias. IMPLICATIONS FOR PRACTICE The advanced practice nurse (APN) is instrumental in differentiating between TCM versus acute myocardial infarction, heart failure, pulmonary edema, dynamic outflow obstruction, and cardiogenic shock. Because of these possible acute and critical presentations, prompt recognition and intervention for patients with TCM are priorities for nurse practitioners.
Collapse
|
37
|
Finsterer J, Stollberger C. How Do Depressive Mood or Antidepressants Acutely Increase Serum Catecholamines? Clin Pract Epidemiol Ment Health 2019; 15:1-2. [PMID: 30972133 PMCID: PMC6407655 DOI: 10.2174/1745017901915010001] [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: 08/12/2018] [Revised: 10/09/2018] [Accepted: 12/30/2018] [Indexed: 11/22/2022]
|
38
|
|
39
|
Misumida N, Ogunbayo GO, Kim SM, Abdel-Latif A, Ziada KM, Sorrell VL. Clinical Outcome of Takotsubo Cardiomyopathy Diagnosed With or Without Coronary Angiography. Angiology 2018; 70:56-61. [DOI: 10.1177/0003319718782049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Takotsubo cardiomyopathy (TC) is definitively diagnosed following the exclusion of acute coronary syndrome. We aimed to examine the rate of coronary angiography in patients diagnosed with TC and also the outcome of patients with TC diagnosed with or without coronary angiography. We analyzed the National Inpatient Sample database from 2010 to 2014 and identified patients hospitalized with a primary diagnosis of TC. We compared in-hospital mortality between patients who underwent coronary angiography and those who did not. We also evaluated the association between coronary angiography and in-hospital mortality using a propensity score–adjusted multivariable analysis. Among 22 818 patients diagnosed with TC, 87.4% underwent coronary angiography and 12.6% did not. Patients who did not undergo coronary angiography had a higher in-hospital mortality than those who did (3.0% vs 0.9%; P < .001). Increased mortality in patients who did not undergo coronary angiogram was observed in both male (8.0% vs 2.8%; P = .03) and female patients (2.6% vs 0.7%; P < .001) and in patients 61 to 80 years old and ≥81 years old, but not in patients ≤60 years old. Multivariable analysis demonstrated that the lack of coronary angiography was independently associated with higher in-hospital mortality (adjusted odds ratio: 2.92; 95% confidence interval: 1.52-5.65; P = .001).
Collapse
Affiliation(s)
- Naoki Misumida
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Gbolahan O. Ogunbayo
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Sun Moon Kim
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Ahmed Abdel-Latif
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Khaled M. Ziada
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Vincent L. Sorrell
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| |
Collapse
|
40
|
Stiermaier T, Santoro F, Graf T, Guastafierro F, Tarantino N, De Gennaro L, Caldarola P, Di Biase M, Thiele H, Brunetti ND, Möller C, Eitel I. Prognostic value of N-Terminal Pro-B-Type Natriuretic Peptide in Takotsubo syndrome. Clin Res Cardiol 2018; 107:597-606. [PMID: 29675571 DOI: 10.1007/s00392-018-1227-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 02/27/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Takotsubo syndrome (TTS), a form of acute transient heart failure, has been associated with severe complications and considerable mortality rates. N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP) might serve as a marker to identify high-risk patients but has not yet been investigated regarding prognostic implications in TTS. Aim of this study was to determine the short- and long-term prognostic utility of NT-proBNP in patients with TTS. METHODS The predictive value of admission NT-proBNP was assessed in an international, multicenter study including 177 consecutive TTS patients. Predefined endpoints were 30-day major adverse cardiac events (MACE) consisting of all-cause death, cardiogenic shock, and pulmonary edema as well as long-term mortality in median 2.3 years after the acute event. RESULTS Stratification according to median admission NT-proBNP (4511 pg/ml) resulted in significantly higher 30-day MACE [22.5 versus 9.1%; odds ratio (OR) 2.90, 95% confidence interval (CI) 1.20-6.99 p = 0.015] and long-term mortality rates [16.3 versus 9.4%; hazard ratio (HR) 2.72, 95% CI 1.13-6.56 p = 0.021] in patients > median. The best admission NT-proBNP cutoffs to predict 30-day MACE and long-term mortality were determined at 5560 and 8178 pg/ml respectively, with subsequent improved risk stratification for short-term MACE (OR 3.61, 95% CI 1.49-8.72; p = 0.003) and long-term mortality (HR 4.40; 95% CI 1.85-10.44, p < 0.001). Multivariate regression analysis identified admission NT-proBNP as an independent predictor of 30-day MACE (p < 0.001) and long-term mortality (p = 0.012). CONCLUSIONS Admission NT-proBNP is an independent predictor for short- and long-term adverse events in TTS patients and, therefore, a useful marker for risk stratification immediately at presentation.
Collapse
Affiliation(s)
- Thomas Stiermaier
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Francesco Santoro
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Tobias Graf
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | | | - Nicola Tarantino
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | | | | | - Matteo Di Biase
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, University Hospital, Leipzig, Germany
| | - Natale D Brunetti
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Christian Möller
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Ingo Eitel
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany. .,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany.
| |
Collapse
|
41
|
Abstract
Takotsubo cardiomyopathy is described as a transient reversible cardiomyopathy which typically occurs in older women after emotional or physical stress. This cardiomyopathy is also recognized as a "syndrome" because it develops in conjunction with various diseases. Since the clinical presentation of takotsubo syndrome (TTS) is similar to acute coronary syndrome (ACS), TTS should be distinguished from ischemic heart disease. Although the pathophysiology of TTS has not well been established, a number of its specific features have been suggested. The predictor of mortality in TTS is still unknown. In this review article, we describe a series of treatment decisions in TTS.
Collapse
Affiliation(s)
- Mika Watanabe
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine
| |
Collapse
|
42
|
Izumo M, Akashi YJ. Role of echocardiography for takotsubo cardiomyopathy: clinical and prognostic implications. Cardiovasc Diagn Ther 2018; 8:90-100. [PMID: 29541614 PMCID: PMC5835647 DOI: 10.21037/cdt.2017.07.03] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 06/28/2017] [Indexed: 12/26/2022]
Abstract
Takotsubo cardiomyopathy (TTC) is newly-described secondary cardiomyopathy characterized by transient left ventricular (LV) dysfunction, which is increasingly recognized in the field of cardiology. TTC occurs in approximately 2% of the patients with acute coronary syndrome. Its onset is rare; however, its specific features play a crucial role in diagnosing the chest pain in clinical practice. TTC has generally favorable outcome with rapid recovery of LV function; however, an increasing evidence suggests that it should be regarded as a more serious acute cardiac disorder with a variety of complications. Owing to its widespread availability, even in emergency settings, transthoracic echocardiography plays a key role in the diagnostic assessment of TTC and contributes to an increased number of disease detection and incidence reports in contemporary clinical practice. This review focuses on the role of echocardiography in understanding the clinical prognostic implications in patients with TTC.
Collapse
Affiliation(s)
- Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| |
Collapse
|
43
|
Gopalakrishnan P, Zaidi R, Sardar MR. Takotsubo cardiomyopathy: Pathophysiology and role of cardiac biomarkers in differential diagnosis. World J Cardiol 2017; 9:723-730. [PMID: 29081904 PMCID: PMC5633535 DOI: 10.4330/wjc.v9.i9.723] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 05/10/2017] [Accepted: 05/24/2017] [Indexed: 02/06/2023] Open
Abstract
Takotsubo cardiomyopathy (TC) is characterized by reversible ventricular dysfunction, not limited to the distribution of an epicardial coronary artery. A disease primarily afflicting post-menopausal women, it is frequently mistaken for acute anterior wall myocardial infarction. Alternatively called Stress Cardiomyopathy, physical or emotional triggers are identified in only three fourths of TC patients. Long considered a benign condition, recent findings suggest poor short term prognosis similar to acute coronary syndrome (ACS). Despite the widely recognized pathophysiological role of catecholamine excess, its diagnostic role is uncertain. TC is suspected based on typical wall motion abnormalities in ventriculogram or echocardiogram. Several additional electrocardiographic, laboratory and imaging parameters have been studied with the goal of clinical diagnosis of TC. While several clinical clues differentiate it from ACS, a clinical diagnosis is often elusive leading to avoidable cardiac catheterizations. Natriuretic peptides (NPs), a family of peptide hormones released primarily in response to myocardial stretch, play a significant role in pathophysiology, diagnosis as well as treatment of congestive heart failure. TC with its prominent ventricular dysfunction is associated with a significant elevation of NPs. NPs are elevated in ACS as well but the degree of elevation is typically lesser than in TC. Markers of myocardial injury such as troponin are usually elevated to a higher degree in ACS than in TC. This differential elevation of NPs and markers of myocardial injury may play a role in early clinical recognition of TC.
Collapse
Affiliation(s)
| | - Ramsha Zaidi
- Division of Cardiology, Department of Medicine, Aultman Hospital, Canton, OH 44710, United States
| | - Muhammad Rizwan Sardar
- Division of Cardiology, Department of Medicine, Aultman Hospital, Canton, OH 44710, United States
| |
Collapse
|
44
|
Abstract
Originally described by Japanese authors in the 1990s, Takotsubo syndrome (TTS) generally presents as an acute myocardial infarction characterized by severe left ventricular dysfunction. TTS, however, differs from an acute coronary syndrome because patients have generally a normal coronary angiogram and left ventricular dysfunction, which extends beyond the territory subtended by a single coronary artery and recovers within days or weeks. The prognosis was initially thought to be benign, but subsequent studies have demonstrated that both short-term mortality and long-term mortality are higher than previously recognized. Indeed, mortality reported during the acute phase in hospitalized patients is ≈4% to 5%, a figure comparable to that of ST-segment-elevation myocardial infarction in the era of primary percutaneous coronary interventions. Despite extensive research, the cause and pathogenesis of TTS remain incompletely understood. The aim of the present review is to discuss the pathophysiology of TTS with particular emphasis on the role of the central and autonomic nervous systems. Different emotional or psychological stressors have been identified to precede the onset of TTS. The anatomic structures that mediate the stress response are found in both the central and autonomic nervous systems. Acute stressors induce brain activation, increasing bioavailability of cortisol and catecholamine. Both circulating epinephrine and norepinephrine released from adrenal medullary chromaffin cells and norepinephrine released locally from sympathetic nerve terminals are significantly increased in the acute phase of TTS. This catecholamine surge leads, through multiple mechanisms, that is, direct catecholamine toxicity, adrenoceptor-mediated damage, epicardial and microvascular coronary vasoconstriction and/or spasm, and increased cardiac workload, to myocardial damage, which has a functional counterpart of transient apical left ventricular ballooning. The relative preponderance among postmenopausal women suggests that estrogen deprivation may play a facilitating role, probably mediated by endothelial dysfunction. Despite the substantial improvement in our understanding of the pathophysiology of TTS, a number of knowledge gaps remain.
Collapse
Affiliation(s)
- Francesco Pelliccia
- From Department of Cardiovascular Sciences, Sapienza University, Rome, Italy (F.P.); Molecular and Clinical Sciences Research Institute, St George's, University of London, UK (J.C.K.); Institute of Cardiology, Catholic University, Rome, Italy (F.C.); and Vita-Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Juan Carlos Kaski
- From Department of Cardiovascular Sciences, Sapienza University, Rome, Italy (F.P.); Molecular and Clinical Sciences Research Institute, St George's, University of London, UK (J.C.K.); Institute of Cardiology, Catholic University, Rome, Italy (F.C.); and Vita-Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Filippo Crea
- From Department of Cardiovascular Sciences, Sapienza University, Rome, Italy (F.P.); Molecular and Clinical Sciences Research Institute, St George's, University of London, UK (J.C.K.); Institute of Cardiology, Catholic University, Rome, Italy (F.C.); and Vita-Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Paolo G Camici
- From Department of Cardiovascular Sciences, Sapienza University, Rome, Italy (F.P.); Molecular and Clinical Sciences Research Institute, St George's, University of London, UK (J.C.K.); Institute of Cardiology, Catholic University, Rome, Italy (F.C.); and Vita-Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.).
| |
Collapse
|
45
|
Dawson DK. Acute stress-induced (takotsubo) cardiomyopathy. Heart 2017; 104:96-102. [PMID: 28824005 DOI: 10.1136/heartjnl-2017-311579] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 07/11/2017] [Accepted: 07/20/2017] [Indexed: 12/27/2022] Open
Abstract
Acute stress-induced (takotsubo) cardiomyopathy has a dramatic clinical presentation, mimicking an acute myocardial infarction and is triggered by intense emotional or physical stress. In this paper, we review the current state of knowledge of the mechanistic physiology underlying the left ventricular ballooning. The pathophysiology of the recovery from this acute heart failure syndrome is presented. The short-term and long-term outlook puts this new syndrome on a different perspective compared with recently held views. Current knowledge on susceptibility and predisposition already define distinctive characteristics of patients with takotsubo compared with myocardial infarction. Gaps in knowledge and future directions of research are identified in order to best direct efforts for identifying specific therapies for this condition, in the acute setting, to mitigate postacute symptoms or to prevent recurrences, none of which exist.
Collapse
|
46
|
Ansari U, El-Battrawy I. The Clinical Manifestations, Diagnosis and Management of Takotsubo Syndrome. Interv Cardiol 2017. [DOI: 10.5772/68037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
|
47
|
Pirlet C, Pierard L, Legrand V, Gach O. Ratio of high-sensitivity troponin to creatine kinase-MB in takotsubo syndrome. Int J Cardiol 2017; 243:300-305. [PMID: 28595746 DOI: 10.1016/j.ijcard.2017.05.107] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 05/21/2017] [Accepted: 05/29/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Takotsubo syndrome (TT) and myocardial infarction (MI) share numerous similarities in clinical presentation, ECG modifications and biomarker elevation. We sought to determine whether the ratio of high-sensitivity cardiac troponin T (hs-TnT) to the myocardial fraction of creatine kinase (CKMB) could be a potent discriminator between TT and MI patients. METHODS We separately present analysis of data from retrospective files and prospectively recruited patients presenting with TT (35 retrospective and 42 prospective), NSTEMI (48 retrospective and 75 prospective) and STEMI (20 retrospective and 39 prospective). We compared ratios of hs-TnT to CKMB on admission to the hospital between TT, NSTEMI and STEMI patients. Receiver operating characteristic (ROC) curves were analysed to determine optimal cut-off values. RESULTS On admission, hs-TnT/CKMB ratio was significantly higher in TT patients than in NSTEMI and STEMI patients in both the retrospective phase (median and interquartile range, TT 0.024 [0.018-0.047] vs NSTEMI 0.009 [0.006-0.022], p<0.0001; TT vs STEMI 0.011 [0.006-0.016], p=0.0002) and the prospective cohort (median and interquartile range, TT 0.032 [0.018-0.040] vs NSTEMI 0.009 [0.006-0.015], p<0.0001; TT vs STEMI 0.009 [0.005-0.017], p<0.0001). A cut-off hs-TnT/CKMB ratio of 0.015 distinguished TT from MI with a sensitivity of 85.7% and a specificity of 67.6% (AUC 0.796; 95%CI: 0.71-0.89) in the retrospective phase. In the prospective phase, a ratio of 0.017 distinguished TT from MI with a sensitivity of 83.3% and a specificity of 78.1% (AUC 0.88; 95%CI: 0.83-0.94). CONCLUSION hs-TnT/CKMB ratio is a novel, readily available parameter that could be used alongside clinical risk scores, other biomarkers and ECG findings to discriminate between TT and MI.
Collapse
Affiliation(s)
- Charles Pirlet
- CHU de Liège, avenue de l'hôpital, 1, Liège 4000, Belgium.
| | - Luc Pierard
- CHU de Liège, avenue de l'hôpital, 1, Liège 4000, Belgium
| | - Victor Legrand
- CHU de Liège, avenue de l'hôpital, 1, Liège 4000, Belgium
| | - Olivier Gach
- CHU de Liège, avenue de l'hôpital, 1, Liège 4000, Belgium
| |
Collapse
|
48
|
|
49
|
Budnik M, Kochanowski J, Piatkowski R, Wojtera K, Peller M, Gaska M, Glowacka P, Karolczak P, Ochijewicz D, Opolski G. Simple markers can distinguish Takotsubo cardiomyopathy from ST segment elevation myocardial infarction. Int J Cardiol 2016; 219:417-20. [PMID: 27367474 DOI: 10.1016/j.ijcard.2016.06.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/12/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Takotsubo cardiomyopathy (TTC) is a clinical condition mimicking acute myocardial infarction. A specific biomarker for TTC screening is required, but until now, no single biomarker has been established for the early diagnosis of TTC and differentiation from ST-segment elevation myocardial infarction (STEMI). In our study we focused on the simple markers that are available in every hospital. METHODS In 66 consecutive patients (pts) who were hospitalized with TTC and 66 pts with STEMI, cardiac biomarkers, such as NT-proBNP, TnI, CK and CKMB mass were determined during 12h from admission and compared with demographic, clinical and echocardiographic findings. RESULTS The concentration of NTproBNP was greater in pts with TTC than STEMI (4702pg/ml vs 2138pg/ml). The concentration of TnI and CKMB mass was greater in the STEMI group than in the TTC group (TnI: 2.1ng/ml and CK MB mass: 9.5ng/ml in pts with TTC vs TnI: 19ng/ml and CK MB mass: 73.3ng/ml in pts with STEMI). The NTproBNP/TnI ratio and NTproBNP/CKMB mass ratio were, respectively, 2235.2 and 678.2 in pts with TTC and 81.6 and 27.5 in pts with STEMI (p<0.001). Moreover, the NTproBNP/EF ratio was also statistically significant (110.4 in TTC group and 39.4 in STEMI group). CONCLUSIONS NTproBNP/TnI, NTproBNP/CKMB mass and NTproBNP/EF ratios can distinguish TTC from STEMI at an early stadium. The most accurate marker is the NTproBNP/TnI ratio.
Collapse
Affiliation(s)
- Monika Budnik
- 1st Department of Cardiology, Medical University of Warsaw, 1a Banacha Street, 02-097 Warsaw, Poland.
| | - Janusz Kochanowski
- 1st Department of Cardiology, Medical University of Warsaw, 1a Banacha Street, 02-097 Warsaw, Poland
| | - Radoslaw Piatkowski
- 1st Department of Cardiology, Medical University of Warsaw, 1a Banacha Street, 02-097 Warsaw, Poland
| | - Karolina Wojtera
- 1st Department of Cardiology, Medical University of Warsaw, 1a Banacha Street, 02-097 Warsaw, Poland
| | - Michal Peller
- 1st Department of Cardiology, Medical University of Warsaw, 1a Banacha Street, 02-097 Warsaw, Poland
| | - Maria Gaska
- 1st Department of Cardiology, Medical University of Warsaw, 1a Banacha Street, 02-097 Warsaw, Poland
| | - Paulina Glowacka
- 1st Department of Cardiology, Medical University of Warsaw, 1a Banacha Street, 02-097 Warsaw, Poland
| | - Paulina Karolczak
- 1st Department of Cardiology, Medical University of Warsaw, 1a Banacha Street, 02-097 Warsaw, Poland
| | - Dorota Ochijewicz
- 1st Department of Cardiology, Medical University of Warsaw, 1a Banacha Street, 02-097 Warsaw, Poland
| | - Grzegorz Opolski
- 1st Department of Cardiology, Medical University of Warsaw, 1a Banacha Street, 02-097 Warsaw, Poland
| |
Collapse
|
50
|
Suzuki T, Lyon A, Saggar R, Heaney LM, Aizawa K, Cittadini A, Mauro C, Citro R, Limongelli G, Ferrara F, Vriz O, Morley-Smith A, Calabrò P, Bossone E. Editor's Choice-Biomarkers of acute cardiovascular and pulmonary diseases. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 5:416-33. [PMID: 27221957 DOI: 10.1177/2048872616652309] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 05/10/2016] [Indexed: 12/27/2022]
Abstract
Acute cardiothoracic and respiratory diseases frequently remain a challenge to diagnose and differentiate in the emergency setting. The main diseases that manifest with chest pain include ischaemic heart disease, myocarditis, acute pericarditis, aortic dissection/rupture and pulmonary embolism (PE). Diseases that primarily present with dyspnoea include heart failure (HF), acute respiratory distress syndrome (ARDS), pneumonia, asthma exacerbations and chronic obstructive pulmonary disease. Pre-test probabilities of clinical findings play a vital part in diagnostic decisions, and the use of a Bayesian approach to these greatly improves the ability to stratify patients more accurately. However, blood tests (biomarkers) are increasingly used to assist in rapid decision-making in the emergency setting in combination with imaging methods such as chest radiograph, ultrasound and increasingly computed tomography, as well as physiological tests such as the electrocardiogram in addition to physical examination. Specific tests for ischaemic heart disease and myocarditis (cardiac troponins), HF (B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP)), aortic dissection (smooth muscle markers) and PE (D-dimer) have been developed. Surfactant protein-D and interleukin-8 have been developed for ARDS. Additionally, circulating microRNAs have emerged as promising biomarker candidates in cardiovascular disease. With this increasing array of biochemical markers to aid in the diagnosis of chest diseases presenting with chest pain and dyspnoea, we herein review the clinical usefulness of these markers, in particular in differentiating cardiac from pulmonary diseases. A symptom-oriented assessment as necessary for use in the critical setting is described in addition to discussion of individual biomarkers.
Collapse
Affiliation(s)
- Toru Suzuki
- Department of Cardiovascular Medicine, University of Tokyo, Japan Department of Cardiovascular Sciences, University of Leicester, UK NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, UK
| | - Alexander Lyon
- National Heart and Lung Institute, Imperial College, UK NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, UK
| | - Rajeev Saggar
- Advanced Lung Disease Institute, Banner Good Samaritan Hospital, USA
| | - Liam M Heaney
- Department of Cardiovascular Sciences, University of Leicester, UK NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, UK
| | - Kenichi Aizawa
- Department of Cardiovascular Medicine, University of Tokyo, Japan
| | - Antonio Cittadini
- Department of Medical Translational Sciences, 'Federico II' University, Italy
| | - Ciro Mauro
- Division of Cardiology, A.O.R.N. 'A. Cardarelli', Italy
| | - Rodolfo Citro
- Heart Department, University Hospital, Salerno, Italy
| | | | | | - Olga Vriz
- Cardiology and Emergency Department, Sant'Antonio Hospital, Italy
| | - Andrew Morley-Smith
- National Heart and Lung Institute, Imperial College, UK NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, UK
| | - Paolo Calabrò
- Division of Cardiology, Second University of Naples, Italy
| | | |
Collapse
|