Psychiatric Illness in Takotsubo (Stress) Cardiomyopathy: A Review

Takotsubo cardiomyopathy and psychiatric illness- insight from National Inpatient Sample (NIS) and National Re-admission Database (NRD) 2016 to 2018

BACKGROUND

Emotional stress is a common precipitating cause of takotsubo cardiomyopathy (TC). Preexisting psychiatric disorder (PD) was linked to worsening outcomes in patients with TC1,2. However, there is limited data in literature to support this. This study aimed to determine the differences in outcomes in TC patients with and without PD.

METHODS

We identified all patients with a diagnosis of TC using the National Inpatient Sample (NIS) and the National Readmission Database (NRD) data from 2016 to 2018. The patients were separated into TC with PD group and TC without PD group. Multiple variable logistic regression was then performed.

RESULTS

Using NIS 2016-2018, we identified 23,220 patients with TC, and 43.11% had PD. The mean age was 66.73 ± 12.74 years, with 90.42% being female sex. The TC with PD group had a higher 30-readmission rate 1.25 (95% CI:1.06-1.47), Cardiogenic shock [aOR = 7.3 (95%CI 3.97-13.6), Mechanical ventilation [aOR = 4.2 (95%CI 2.4-7.5), Cardiac arrest [aOR = 2.6 (95%CI 1.1-6.3), than TC without PD group.

CONCLUSION

Psychiatric disorders were found in up to 43% of patients with TC. The concomitant PD in TC patients was not associated with increased mortality, AKI, but had higher rates of cardiogenic shock, use of mechanical ventilation and cardiac arrest. The TC group with PD was also associated with increased 30-day readmission, LOS and total charges compared to TC patients without PD.

Exploring Brain and Heart Interactions during Electroconvulsive Therapy with Point-of-Care Ultrasound

BACKGROUND

Electroconvulsive therapy (ECT) is a procedure commonly used to treat a number of severe psychiatric disorders, including pharmacologic refractory depression, mania, and catatonia by purposefully inducing a generalized seizure that results in significant hemodynamic changes as a result of an initial transient parasympathetic response that is followed by a marked sympathetic response from a surge in catecholamine release. While the physiologic response of ECT on classic hemodynamic parameters such as heart rate and blood pressure has been described in the literature, real-time visualization of cardiac function using point-of-care ultrasound (POCUS) during ECT has never been reported. This study utilizes POCUS to examine cardiac function in two patients with different ages and cardiovascular risk profiles undergoing ECT.

METHODS

Two patients, a 74-year-old male with significant cardiovascular risks and a 23-year-old female with no significant cardiovascular risks presenting for ECT treatment, were included in this study. A portable ultrasound device was used to obtain apical four-chamber images of the heart before ECT stimulation, after seizure induction, and 2 min after seizure resolution to assess qualitative cardiac function. Two physicians with expertise in echocardiography reviewed the studies. Hemodynamic parameters, ECT settings, and seizure duration were recorded.

RESULTS

Cardiac standstill was observed in both patients during ECT stimulation. The 74-year-old patient with a significant cardiovascular risk profile exhibited a transient decline in cardiac function during ECT, while the 23-year-old patient showed no substantial worsening of cardiac function. These findings suggest that age and pre-existing cardiovascular conditions may influence the cardiac response to ECT. Other potential contributing factors to the cardiac effects of ECT include the parasympathetic and sympathetic responses, medication regimen, and seizure duration with ECT. This study also demonstrates the feasibility of using portable POCUS for real-time cardiac monitoring during ECT.

CONCLUSION

This study reports for the first time cardiac standstill during ECT stimulation visualized using POCUS imaging. In addition, it reports on the potential differential impact of ECT on cardiac function based on patient-specific factors such as age and cardiovascular risks that may have implications for ECT and perioperative anesthetic management and optimization.

Takotsubo Cardiomyopathy and Autoimmune Disorders: A Systematic Scoping Review of Published Cases

Introduction

Takotsubo cardiomyopathy (TCM) features transient left ventricular apical dysfunction or ballooning. The underlying mechanism remains elusive; however, evidence suggests the role of different physical and psychological stressors. We systematically reviewed patients presenting with TCM and autoimmunity to explore the link between the two conditions.

Methods

We applied the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) to report this review. Using keywords related to autoimmune/immune-mediated diseases and TCM, we searched PubMed, Scopus, and WOS in March 2022. The final results were added to a data extraction sheet. Data were analyzed by SPSS version 26.0.

Results

Our search yielded 121 studies, including 155 patients. Females were considerably predominant. Most patients had a history of autoimmune disease, and almost a third had a history of cardiovascular disease. Dyspnea and chest pain were the most common chief complaints. More than 70% of patients had experienced physical stress. Myasthenia gravis, systemic lupus erythematosus, and multiple sclerosis were the most frequently reported autoimmune diseases.

Conclusion

There were similarities in age and sex compared to classic TCM. TCM should be considered as a differential diagnosis for ACS, especially in patients with a positive background of autoimmunity. A precise reporting system is required for further studies.

Unveiling the Hidden Patterns: Multimodality Cardiac Imaging in Takotsubo Cardiomyopathy Diagnosis

Takotsubo cardiomyopathy, also known as stress cardiomyopathy, is a reversible form of cardiomyopathy characterized by reduced ejection fraction with regional wall motion abnormalities, elevated cardiac enzyme levels, and signs of ischemia on electrocardiogram despite the absence of obstructive epicardial coronary artery disease. It is often preceded by intense emotional or physical illness stressors. This case describes a 65-year-old female patient who likely developed takotsubo cardiomyopathy precipitated by the stress of diverticulitis.

Can longitudinal strain analysis differentiate between Takotsubo syndrome and acute coronary syndrome?

BACKGROUND

Takotsubo syndrome (TTS) is characterized by transient abnormalities of myocardial contractility. Noninvasive tests are currently being sought to differentiate TTS from acute coronary syndrome (ACS).

THE AIM OF THE STUDY

To evaluate the prevalence of TTS and echocardiographic parameters to distinguish apical TTS from acute anterior wall infarction.

MATERIAL AND METHODS

The medical records of patients with suspected TTS, hospitalized in the Department of Cardiology (TTS group n = 18) were analyzed. The control group included patients with STEMI of the left ventricle anterior wall and anterior and lateral wall (STEMI group n = 17). Standard transthoracic echocardiography (TTE) was supplemented with segmental longitudinal strain (LS) assessment with the use of acoustic marker tracking.

RESULTS

A statistically significant difference was observed in the second cardiac troponine I (CTNI) measurement (TTS: 3241.2 ng/L vs. STEMI: 12032.6 ng/L; p < 0.05). A significant difference in left and right ventricular size was observed on TTE. Left ventricular end-diastolic and end-systolic volumes were considerably smaller in TTS group; (86.1 vs. 104 ml and 48.1 vs. 74.1 ml, respectively). LS were significantly higher (in absolute values) in patients with TTS than in those with STEMI in the apical and middle lateral segments, LS in the apical four-chamber view (apSept -14.9 vs. -8.9; apLat -14.8 vs. -6.84; midLat -13.26 vs. -9.11).

CONCLUSIONS

Patients with TTS are characterized by a different LS pattern in the apical segments of the left ventricle compared to patients with STEMI. TTE examination with LS remains insufficient to distinguish TTS from ACS at the early stage of diagnosis.

Broken Heart Syndrome: Evolving Molecular Mechanisms and Principles of Management

Broken Heart Syndrome, also known as Takotsubo Syndrome (TS), is sudden and transient dysfunction of the left and/or right ventricle which often mimics Acute Coronary Syndrome (ACS). Japan was the first country to describe this syndrome in the 1990s, and since then it has received a lot of attention from researchers all around the world. Although TS was once thought to be a harmless condition, recent evidence suggests that it may be linked to serious complications and mortality on par with Acute Coronary Syndrome (ACS). The understanding of TS has evolved over the past few years. However, its exact etiology is still poorly understood. It can be classified into two main types: Primary and Secondary TS. Primary TS occurs when the symptoms of myocardial damage, which is typically preceded by emotional stress, are the reason for hospitalization. Secondary TS is seen in patients hospitalized for some other medical, surgical, obstetric, anesthetic, or psychiatric conditions, and the dysfunction develops as a secondary complication due to the activation of the sympathetic nervous system and the release of catecholamines. The etiopathogenesis is now proposed to include adrenergic hormones/stress, decreased estrogen levels, altered microcirculation, endothelial dysfunction, altered inflammatory response via cardiac macrophages, and disturbances in the brain-heart axis. The role of genetics in disease progression is becoming the focus of several upcoming studies. This review focuses on potential pathophysiological mechanisms for reversible myocardial dysfunction observed in TS, and comprehensively describes its epidemiology, clinical presentation, novel diagnostic biomarkers, and evolving principles of management. We advocate for more research into molecular mechanisms and promote the application of current evidence for precise individualized treatment.

[Is Tako-tsubo cardiomyopathy really reversible ?]

Tako-tsubo cardiomyopathy is characterized by a total reversibility of wall motion abnormalities of the left ventricle (LV) as well as normalization of LV ejection fraction after the acute phase. However, recent studies have shown that some patients present functional, metabolic, and morphologic abnormalities away from the acute phase suggesting an incomplete recovery of the disease. In this revue we discuss about this topic through several tools used in those studies (echocardiography, exercise test, MRI, nuclear imaging, biology, as well).

Reducing stress and anxiety in patients with myocardial infarction with non-obstructive coronary arteries or Takotsubo syndrome: A non-randomized feasibility study

BACKGROUND AND AIM

In the aftermath of a myocardial infarction with non-obstructive coronary arteries (MINOCA) or Takotsubo syndrome (TS), patients commonly express high levels of stress and anxiety. Current treatment alternatives rarely address these issues. The planned E-health Treatment of Stress and Anxiety in Stockholm Myocardial Infarction With Non-obstructive Coronaries Study (e-SMINC) aims to evaluate the effects of an internet-based intervention, building on cognitive behavioral therapy (CBT) by comparison with treatment as usual using an RCT approach. This was a small-scale single arm study designed to test the feasibility of the RCT, addressing uncertainties regarding recruitment, data collection, and intervention delivery.

METHODS

Participant recruitment and screening took place before discharge from the coronary care unit at a large Swedish hospital. Eligible patients were invited to a nine-step psychologist guided, internet-based CBT intervention. The sample size was set in advance to 10 participants completing the intervention. The recruitment and flow of participants were documented and evaluated in relation to seven pre-defined progression criteria. Self-reports of anxiety (HADS-A), stress (PSS-14), cardiac anxiety (CAQ), posttraumatic stress (IES-6) and quality of life (Rand-36), collected at screening, pre-intervention and post-intervention, were analysed descriptively and by effect sizes (Cohen's d). Individual interviews targeting participant experiences were conducted.

RESULTS

Six out of seven progression criteria yielded no concerns. Out of 49 patients with a working diagnosis of MINOCA or TS, 31 were eligible for screening, 26 consented to participate, and 14 were eligible with regard to symptoms of stress and/or anxiety. Eleven completed the pre-assessment and were given access the intervention, and 9 completed the intervention. Only the number of patients screened prior to eligibility assessment was slightly lower than expected, indicating possible concerns. Self-reports of anxiety, stress, cardiac anxiety, posttraumatic stress, and quality of life all indicated symptom reduction from pre- to post-intervention, generally showing large effect sizes (d = 0.6-2.6). The general consensus among participants was that the programme was helpful and relevant, and that the personal contact with the psychologist was highly valued. Setting aside time to complete assignments was found critical.

CONCLUSION

Conducting a full scale RCT was found feasible. Inclusion of more study sites and minor amendments to the protocol and intervention were decided to improve feasibility further.

TRIAL REGISTRATION

Clinicaltrials.govNCT04178434.

Psychosocial and clinical characteristics of a patient with Takotsubo syndrome and her healthy monozygotic twin: a case report

Background

Takotsubo syndrome (TTS) is an acute heart failure syndrome characterized by transient left ventricular dysfunction, increased myocardial biomarkers, and electrocardiographic changes. Symptoms of TTS are similar to those of acute coronary syndromes, but there is often no significant coronary stenosis. Although emotional and physical stressors are often reported as having triggered TTS, the pathogenesis is largely unknown. To address this issue, we comprehensively characterized a monozygous pair of twin sisters, one of whom experienced TTS.

Case summary

The 60-year-old Caucasian monozygotic female twins with and without TTS were examined at the University Hospital Zurich in Switzerland. The twins completed questionnaires and clinical interviews assessing several sociopsychological factors. The twin sister with TTS exhibited higher levels of anxiety, vital exhaustion, social inhibition, and alexithymia, and lower levels of quality of and meaning in life. She was given the diagnoses of social phobia, adjustment disorder, specific anxiety disorder, obsessive-compulsive personality disorder, and an accentuated anxiety-avoidant personality disorder. Additionally, the twin with TTS experienced more-and also more severe-stressors involving life-threatening and dangerous situations over the life course.

Discussion

These monozygous female twins with and without TTS differed in several notable aspects of their psychological functioning, psychiatric status, personality, and lifetime stressor exposure. The results thus highlight several factors, besides genetic components, that may play an important role in the pathogenesis of TTS. Looking forward, larger studies using experimental and longitudinal designs are needed to elucidate the role that psychosocial factors play in TTS.

Takotsubo Syndrome in New Zealand: Current Knowledge and Future Challenges

Takotsubo syndrome (TS), also known as apical ballooning syndrome is a transient stress-related cardiomyopathy characterised by acute but reversible left ventricular dysfunction. The condition tends to occur in postmenopausal women after a stressful event. At presentation TS typically mimics acute myocardial infarction (MI) and the incidence of TS has been increasing worldwide. This is likely a consequence of an improved awareness of the existence of this syndrome and easier access to early echocardiography and coronary angiography. However, its aetiology remains poorly understood and it is probably still underdiagnosed. Similar to other countries. TS is being increasingly recognised in New Zealand. In this review, we discuss the demographics, clinical features and outcomes of patients with TS in New Zealand. Doing so informs us not only of the pattern of disease in New Zealand but it also provides insights into the condition itself. This article is protected by copyright. All rights reserved.

The Association of Mental Health Disorders with Takotsubo Syndrome (Broken Heart Syndrome) Among Older Women

Background: The prevalence of mental health disorders (MHD) and takotsubo syndrome (TS), also known as broken heart syndrome, is increasing and more common in older women. Mortality among persons with TS is comparable to that of persons with myocardial infarction. Although TS is poorly understood, it is thought to be precipitated by psychological stress. We examined the relationship between MHD and TS among elderly American women. Materials and Methods: Data consisted of 10.9 million hospitalizations among women aged ≥60 years recorded in the National Inpatient Sample from 2007 to 2015. International Classification of Diseases, Ninth Revision, codes were used to define TS, MHD, and other chronic conditions. Logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between MHD and TS. Results: The mean age of patients was 76 years, with 38% of them diagnosed with MHD. Over the 9-year period, the prevalence of TS hospitalizations increased by almost fourfold from 37.1/100,000 to 154.7/100,000, with a higher prevalence among patients with MHD. In multivariable adjusted models, MHD was associated with elevated odds of TS (OR = 1.25; 95% CI: 1.18-1.32), with the odds increasing with the frequency of MHD diagnosis. Among patients with one MHD, the odds of TS were significantly higher among those diagnosed with adjustment, anxiety, and mood disorders but lower among those with suicide ideations and personality disorders. Conclusions: The presence of MHD was associated with elevated odds of TS. Understanding underlying mechanisms linking MHD with TS will enhance MHD management.

Takotsubo Syndrome: A Review of Presentation, Diagnosis and Management

Takotsubo Syndrome (TTS) is a condition of transient left ventricular dysfunction that is typically triggered by emotional or physical stress. Since first described in Japan in 1990, it has increasingly been recognised in clinical practice, accounting for up to 2% of Acute Coronary Syndrome (ACS) presentations. In fact, the clinical presentation can be indistinguishable from a myocardial infarction. Although current evidence suggests a catecholamine induced myocardial stunning, the pathophysiological mechanisms remain unknown. Interestingly, it is more common in woman, particularly those who are post-menopausal. This review aims to summarise the current research and provide an overview of the diagnostic strategies and treatment options.

Impact of malnutrition on in-hospital outcomes in takotsubo cardiomyopathy

OBJECTIVE

This study assesses the effect of malnutrition on the in-hospital outcomes of patients with takotsubo cardiomyopathy (TCM).

METHODS

We performed a retrospective cohort analysis using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for a primary diagnosis of TCM from the National Inpatient Sample database (2016-2018). A concurrent diagnosis of malnutrition was then identified, and these patients were divided into the malnutrition group and non-malnutrition group. To adjust for underlying risk factors, a multivariable logistic regression model was employed followed by a propensity score matching analysis for the malnutrition and the non-malnutrition group. We then compared the in-hospital outcomes between these two groups.

RESULTS

Among 4733 patients with a primary diagnosis of TCM, 221 (4.7%) patients with TCM were found to be malnourished. After propensity score matching, patients with TCM with malnutrition were found to have a higher mortality rate (8.3% versus 2.0%, P < 0.001), a higher rate of complications including cardiogenic shock (16.1% versus 7.0%, P < 0.001), ventricular arrhythmia (8.8% versus 3.9%, P = 0.01), acute kidney injury (24.9% versus 10.6%, P < 0.001), and acute respiratory failure (32.7% versus 17.8%, P < 0.001). There was no statistically significant difference in the incidence of cardiac arrest between the two groups. Malnutrition of severe degree was associated with a sevenfold (odds ratio 6.8, 95% confidence interval, 3.2-13.4) increased risk of in-hospital mortality compared with those without malnutrition.

CONCLUSION

Patients with malnutrition who were admitted with TCM were associated with higher rates of in-hospital mortality and complications compared with those without malnutrition.

Simultaneous occurrence of a Takotsubo syndrome and paranoia delirium, related to Covid-19 pandemic: A case report

Some psychosomatic diseases, like Tako-tsubo cardiomyopathy, may occur because of exposure to a stressful event like COVID-19. The simultaneous development of psychosis and Tako-tsubo cardiomyopathy suggests a field of vulnerability. Specific measures need to be taken to help vulnerable people to manage these stressful events.

Prognostic factors of Takotsubo cardiomyopathy: a systematic review

Takotsubo cardiomyopathy (TCM), characterized by reversible ventricular dysfunction, has similar mortality to acute coronary syndrome. With the growing interest in the diagnosis of and interventions for TCM, many risk factors had been found to affect the prognosis of TCM patients, such as age, sex, and pre-existing diseases. Because of the incomplete understanding of the pathophysiologic mechanism in TCM, evidence-based medical therapy for this condition is lacking. Early intervention on risk factors may improve the outcomes of TCM. In this review, we sought to provide up-to-date evidence on risk factors and medical therapies that affect TCM outcome. We found that male sex, physical triggers, and certain comorbidities such as chronic kidney disease, malignant disease, higher body mass index, sepsis, chronic obstructive pulmonary disease, and anaemia were associated with poor TCM prognosis. In contrast, race, hyperlipidaemia, diabetes mellitus, and mood disorders were not clearly associated with TCM prognosis. We also reviewed the effect of medical therapies on TCM outcome, including angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, calcium channel blockers, and statins. The evidence that these medications confer a survival benefit on TCM patients is limited. Understanding these prognostic factors could help develop risk-stratification tools for TCM and establish effective prevention and interventions for this not-so-benign condition. Further multicentre clinical studies with large samples and meta-analyses of findings from previous studies are needed to address the inconsistent findings among the many potential risk factors for TCM.

Takotsubo Syndrome: Optimizing Care with a Multidisciplinary Approach

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.

Takotsubo Syndrome Associated with a New Onset Manic Episode: A case report

Takotsubo syndrome is a condition that mimics acute coronary syndrome. The exact pathogenesis of the condition is unclear but it tends to occur more frequently in elderly women and a large proportion of cases have acute, former, or chronic neurologic or psychiatric disorders. Here we describe a 55-year-old female patient, who was brought to the emergency department presenting with a new-onset manic episode characterized by grandiosity, distractibility, decreased need for sleep, and increased goal-directed behaviours. She experienced chest pain approximately two days later, and non-ST elevation myocardial infarction was observed. The emergent coronary angiogram showed patent coronary arteries, and a diagnosis of Takotsubo syndrome was made. We suggest clinical multidisciplinary vigilance for somatic complaints, especially cardiac ones, in people with psychiatric disorders in order to make timely therapeutic interventions.

Heart and brain interactions : Pathophysiology and management of cardio-psycho-neurological disorders

Cardiovascular diseases (CVD) and mental health disorders (MHD; e.g. depression, anxiety and cognitive dysfunction) are highly prevalent and are associated with significant morbidity and mortality and impaired quality of life. Currently, possible interactions between pathophysiological mechanisms in MHD and CVD are rarely considered during the diagnostic work-up, prognostic assessment and treatment planning in patients with CVD, and research addressing bidirectional disease mechanisms in a systematic fashion is scarce. Besides some overarching pathogenetic principles shared by CVD and MHD, there are specific syndromes in which pre-existing neurological or psychiatric illness predisposes and contributes to CVD development (as in Takotsubo syndrome), or in which the distorted interplay between innate immune and central nervous systems and/or pre-existing CVD leads to secondary MHD and brain damage (as in peripartum cardiomyopathy or atrial fibrillation). Clinical manifestations and phenotypes of cardio-psycho-neurological diseases depend on the individual somatic, psychosocial, and genetic risk profile as well as on personal resilience, and differ in many respects between men and women. In this article, we provide arguments on why, in such conditions, multidisciplinary collaborations should be established to allow for more comprehensive understanding of the pathophysiology as well as appropriate and targeted diagnosis and treatment. In addition, we summarize current knowledge on the complex interactions between the cardiovascular and central nervous systems in Takotsubo syndrome and peripartum cardiomyopathy, and on the neurological and psychiatric complications of atrial fibrillation.

Takotsubo cardiomyopathy caused by emotional stressors in the coronavirus disease 2019 (COVID-19) pandemic era

The COVID-19 pandemic has had far-reaching consequences beyond the disease itself, including economic, social, political, religious, and psychological implications. This novel coronavirus has been shown to have cardiovascular manifestations in the form of arrhythmias, conduction disturbances, myocarditis, stress cardiomyopathy, myocardial injury and myocardial ischemia or infarction from increased microvascular and/or macrovascular coagulopathy. However, in addition to these direct effects, we are now starting to recognize indirect cardiovascular effects of COVID-19 in the form of increased incidence of Takutsobo cardiomyopathy in patients without any evidence of coronavirus infection presumably due to the increased psychological stress of social isolation and societal turbulence. In this case series, we present two post-menopausal women, presenting with chest pain and acute coronary syndrome, who are finally diagnosed with stress cardiomyopathy, triggered by increased emotional stress-related to the pandemic. There is data from a retrospective cohort analysis showing a fourfold increase in the incidence of acute coronary syndrome resulting from stress cardiomyopathy during the pandemic period compared to similar times periods before the pandemic. Hence, health care providers need to be cognizant of the emotional ramifications of the ongoing pandemic in the form of increased risk of Takotsubo cardiomyopathy. Moreover, urgent measures need to be taken to help the at-risk population cope with the ongoing stressors to help decrease the incidence of this cardiomyopathy.

Identifying different phenotypes in takotsubo cardiomyopathy by latent class analysis

Aims

This study sought to determine whether clinical clusters exist in takotsubo cardiomyopathy. Takotsubo cardiomyopathy (TCM) is a heterogeneous disorder with a complex, poorly understood pathogenesis. To better understand the heterogeneity of TCM, we identified different clinical phenotypes in a large sample of TCM patients by using latent class analysis (LCA).

Methods and results

Using the National Inpatient Sample (NIS) database, we identified 3139 patients admitted to hospitals in 2016–2017 with a primary diagnosis of TCM. We performed LCA based on several patient demographics and comorbidities: age, sex, hypertension, hyperlipidaemia, diabetes mellitus, obesity, current smoking, asthma, chronic obstructive pulmonary disease (COPD), and anxiety and depressive disorders. We then repeated LCA separately with the NIS 2016 and 2017 data sets and performed a robust test to validate our results. We also compared in‐hospital outcomes among the different clusters identified by LCA. Four patient clusters were identified. C1 (n = 1228, 39.4%) had the highest prevalence of hyperlipidaemia (93.4%), hypertension (61.6%), and diabetes (34.3%). In C2 (n = 440, 14.0%), all patients had COPD, and many were smokers (45.8%). C3 (n = 376, 11.8%) largely comprised patients with anxiety disorders (98.4%) and depressive disorders (80.1%). C4 (n = 1097, 34.8%) comprised patients with isolated TCM and few comorbidities. Among all clusters, C1 had the lowest in‐hospital mortality (1.0%) and the shortest length of stay (3.2 ± 3.1 days), whereas C2 had the highest in‐hospital mortality (3.4%).

Conclusions

Using LCA, we identified four clinical phenotypes of TCM. These may reflect different pathophysiological processes in TCM. Our findings may help identify treatment targets and select patients for future clinical trials.

Takotsubo syndrome in bipolar affective disorder with alcohol withdrawal syndrome

A 40-year-old woman presented to the emergency department with epigastric pain and agitation. She recently separated from her husband and was consuming 30 units of alcohol daily for 5 days. She had a history of bipolar affective disorder, borderline personality disorder and alcohol dependence syndrome. Investigations revealed the following: elevated troponin I levels, ST elevation, early Q waves and prolonged QTc. Emergency angiogram confirmed Takotsubo's appearance. Medications with QTc prolongation propensity were held. A multidisciplinary apporach was required. She was discharged 10 days later when medically stabilised. It was later discovered that she died unexpectedly the following month. Takotsubo syndrome is a rare but unique cause of cardiac failure. This case highlights the need to consider the differential of Takotsubo syndrome in people presenting with possible acute ischaemic events, particularly in those with a history of combined emotional and physical stressors and a background history of mood disorder.

Role of Depression and Anxiety Disorders in Takotsubo Syndrome: The Psychiatric Side of Broken Heart

Takotsubo syndrome (TTS), also called broken heart syndrome, is an acute and transient cardiac wall motion abnormality of the left ventricle. The patient prototype is a post-menopausal woman with myocardial infarction-like symptoms (angina pectoris, breathlessness, palpitations, etc.) who has experienced sudden emotional or physical stress. Although prognosis is generally considered relatively benign, both complications and recurrence rates are not insignificant. Pathophysiological mechanisms underlying TTS are not entirely understood, but the sympathetic system over-activity has a leading role. Moreover, since emotional stress frequently triggers TTS and since precedent diagnosis of psychiatric disorders sometimes coexists, the psychological response to stress could be another potential therapeutic target. Indeed, this article aims to explore the association between underlying depression and anxiety disorders and TTS, as well as to find ideal therapeutic options useful to treat and prevent TTS. Thus in our review, we considered case reports, case-control studies, and review articles from PubMed. Papers dealing with Takotsubo syndrome and anxiety disorder or depression were selected. We included papers published since 2010 and whose abstract was in English. We concluded that anxiety disorders, but not depression, are associated with a higher occurrence of TTS. There is a link between anxiety, TTS, and inflammation leading to increased sympathetic activity. Nevertheless, patients with pre-admission psychiatric disorders have a higher risk of recurrent TTS. Importantly, the use of selective serotonin reuptake inhibitors (SSRIs) could be a potential therapeutic aid in preventing TTS's recurrence in selected patients.

Takotsubo syndrome

Takotsubo syndrome is an acute cardiomyopathy that mimics acute coronary syndrome and is characterized by acute heart failure with reversible ventricular motion abnormalities, in the absence of justifying coronary artery disease. This document offers an exhaustive review of various proposed hypotheses that attempt to explain the pathophysiology of this disease and provides an updated review of the different classifications that have emerged in recent years. In addition, we describe the main clinical characteristics of these patients, the diagnostic tests that must be performed and the most appropriate treatment.

Neuropsychiatry: Definitions, Concepts, and Patient Types

Neuropsychiatry is an integrative discipline defined by its history, its preferred patients, and its theoretic framework. Dealing with human behavior needs to consider the brain, but such consideration should avoid oversimplification: neurologic understanding is not essential, necessary, or desirable in all conditions encountered in clinical psychiatry. Neuropsychiatric theory is founded on discoveries in the areas of synaptic plasticity and cortical/limbic anatomy (bottom-up), but also evolutionary biology and anthropology (top-down). Going forward, we need to synthesize vital information, distinguish the essential from the trivial or tenuous, and remain open to dialogue with allied disciplines, our patients, and our students.

Modifiable lifestyle factors in women with Takotsubo syndrome: A case-control study

BACKGROUND

There is limited information on the relationship between modifiable lifestyle factors and Takotsubo syndrome (TS).

OBJECTIVES

To determine the association of physical activity, smoking, alcohol use, and caffeinated coffee consumption with TS.

METHODS

This case-control study enrolled women with newly diagnosed TS (n = 45), women post-myocardial infarction (MI; n = 32), and healthy women volunteers (HC; n = 30). Information on physical activity, smoking, alcohol use, and caffeinated coffee consumption was collected 1-month post-discharge for TS and MI, and 1-month post-enrollment for HC.

RESULTS

TS women reported a higher prevalence of lifetime smoking and cigarette packs/day, greater coffee consumption, and less physical activity than HC. Associations with cigarette and coffee use remained significant in adjusted models. Physical activity, smoking, and coffee consumption were similar in TS and MI women.

CONCLUSIONS

Use of psychostimulants (caffeine and cigarettes) may play a role in TS pathophysiology. These findings need to be confirmed in larger, fully powered studies.

Traumatic Events, Personality and Psychopathology in Takotsubo Syndrome: A Systematic Review

OBJECTIVE

Takotsubo syndrome (TTS) is a transient heart disease that has been historically related to the occurrence of psychological (emotional) factors ("broken heart" syndrome). We aimed to conduct a systematic review analyzing the role of psychological factors in TTS.

METHODS

All studies on TTS and psychological factors from January 1991 through April 2019 were scrutinized according to the Cochrane Collaboration and the PRISMA statements. Selected studies were additionally evaluated for the Risk of Bias according to the Newcastle-Ottawa Scale (NOS).

RESULTS

Fifteen case-control studies (by Mayo Clinic criteria) were finally selected. Most studies analyzed stressful life-events or trauma, although with conflicting findings, while a likely role of long-lasting psychological distress seemed to be a homogenous result. Among life-time psychopathology, only anxiety appeared to have a significant role. Some studies outlined a likely role of personality, but findings are conflicting.

CONCLUSION

Our findings do not lead to any definitive assumption on the specific role of psychological factors in TTS, also for scant strong methodology of the most part of the studies. More studies with stronger research methodology are needed to better characterize psychological elements in TTS.