Takotsubo cardiomyopathy: Review of broken heart syndrome

Takotsubo Cardiomyopathy-like Transient Systolic Dysfunction in Two Bald Eagles (Haliaeetus leucocephalus)

Two wild adult bald eagles (Haliaeetus leucocephalus) were presented to the University of Florida zoological medicine department on separate dates, both being unable to fly. One eagle had a fracture of the left humerus, and the second had no external injuries. Thoracic radiographs of both animals revealed cardiomegaly, and echocardiography revealed reduced systolic function. Both eagles were treated with oral pimobendan until recheck echocardiography documented normal systolic function. Several weeks after pimobendan was discontinued, the echocardiograms of both eagles showed normal systolic function and were considered normal. The transient nature of systolic dysfunction in these 2 eagles could be consistent with a stress-induced, Takotsubo cardiomyopathy-like phenotype although traumatic myocarditis or adverse anesthetic reactions must also be considered.

Association between the Tpeak-Tend interval on admission and coronary microvascular dysfunction in Takotsubo syndrome

AIMS

The Tpeak-Tend interval on electrocardiogram may be a predictor of worse outcomes in Takotsubo syndrome (TTS), but the mechanisms have not been fully determined. This study aimed to investigate the relationships between the corrected Tpeak-Tend (cTp-e) interval and coronary microvascular-dysfunction (CMD) assessed by the angiography-derived index of microvascular resistance (Angio-IMR) and the in-hospital prognosis in patients with TTS.

METHODS AND RESULTS

We retrospectively evaluated 111 consecutive patients admitted for TTS who underwent coronary angiography at Kindai University Hospital from October 2009 to July 2023. The Tpeak-Tend interval was defined as the time interval between the peak and the end of the T wave in electrocardiogram lead V5 on admission. Angio-IMR was assessed from aortic pressure, quantitative flow ratio (QFR), vessel length and hyperemic velocity using the formula described in validation studies. QFR, vessel length and hyperemic velocity was derived from coronary angiography and QAngio XA 3D software package. The degree of CMD was assessed by the maximum Angio-IMR value in each of the three coronary arteries. The primary endpoint was the relationship between the grade of a prolonged cTp-e interval on admission and Angio-IMR. The secondary endpoint was the relationship between the grade of a prolonged cTp-e interval on admission and in-hospital adverse cardiovascular events (composite of acute heart failure, cardiogenic shock, life-threatening arrhythmia, thrombotic events, stroke and all-cause death). The median age was 77.5 [71.0-83.0] years, and most patients were women (82.0%). The median cTp-e interval was 114.5 [91.2-147.0] ms. The patients were categorized according to the tertiles of the cTp-e interval (T1: 52.4-96.9 ms; T2: 100.1-129.1 ms; T3: 131.7-309.8 ms). There was a stepwise increment in the values of maximum Angio-IMR in each of the three coronary arteries in tertiles of the cTp-e interval (T1 vs. T2 vs. T3: 16.1 [14.7-19.3] vs. 21.8 [16.0-31.1] vs. 29.0 [27.2-31.9], P < 0.001). In-hospital adverse cardiovascular events occurred in 53 of 111 patients (47.7%). There was a stepwise increment in the incidence of in-hospital adverse cardiovascular events in tertiles of the cTp-e interval (T1 vs. T2 vs. T3: 27.1% vs. 54.1% vs. 62.2%, P = 0.007). The multivariable analysis showed that prolonged cTp-e interval (OR: 1.30; 95% CI: 1.12-1.56; P < 0.001) was independent predictors of in-hospital adverse cardiovascular events.

CONCLUSIONS

The Tpeak-Tend interval on admission reflected CMD and predicts in-hospital adverse cardiovascular events in patients with TTS.

Takotsubo Syndrome Following Catheter Ablation for Atrial Fibrillation: A Systematic Review and Metasummary of Case Reports/Series

Atrial fibrillation (AF) catheter ablation is safe and effective, though rare cases of takotsubo syndrome (TTS) have been observed without proven causation. This review synthesizes TTS following AF ablation case reports and series. Until October 2024, PubMed/Medline, SCOPUS, and Google Scholar were searched for AF ablation and TTS case reports and series. This study examines TTS incidence, clinical features, and prognosis after AF catheter ablation. Thirteen articles detailing 18 patients were included in the review. The study population had a mean age of 65 ± 9.18 years and 77.77% were female. Of the 18 patients, 6 patients (33.3%) underwent radiofrequency catheter ablation and 5 patients (27.7%) underwent cryoablation. All the patients developed TTS within 4 days of the procedure. Heart palpitations and breathlessness are predominant symptoms. Eight patients had T-wave inversion. Dyskinesia was the most prevalent echocardiography finding among the reported cases. Left ventricular ejection fraction was moderately reduced in 5 cases (35.7%) and severely reduced (left ventricular ejection fraction <30%) in 6 cases (42.8%). Of the 15 patients in whom a pattern of ballooning was reported, 13 patients had apical ballooning and 2 had atypical ballooning pattern. Of the 8 cases (44.44%) with complications, 1 had ventricular fibrillation and 2 patients had pulseless electrical activity. Left ventricular function is completely recovered among 17 patients whereas one patient died due to numerous cardiac electromechanical dissociation events. This systematic investigation highlights the need for TTS vigilance after AF ablation, especially in postmenopausal women having catheter ablation. More research is required to fully understand the prevalence, etiology, and risk factors of TTS after AF ablation.

The Impact of Surgery-Related Emotional Distress on Long-Term Outcome After Colorectal Surgery: An Observational Follow-Up

Background: Preoperative emotional distress has been linked to adverse health outcomes, diminished quality of life, increased symptom burden after surgery, and poorer postoperative outcomes. Therefore, this study aimed to assess the impact of perioperative emotional distress on the long-term outcomes of patients undergoing colorectal surgery. Methods: We conducted a follow-up study of a previously conducted observational study of colorectal surgery patients who underwent surgery at the University Medical Centre Freiburg, Germany, between April 2018 and February 2020. Initially, all the patients completed a multidimensional mood questionnaire (MDMQ) preoperatively and on postoperative days 3, 6, and 9. From June to November 2021, these patients were contacted again to capture the results of MDMQ at least one year after surgery and to assess the rate of late complications, quality of life, dietary changes, and overall health. Results: Of the original 80 patients, 51 took part in the follow-up study (55% female, on average 59 years old), on average 30 months after the operation. The average mood results of the surgical patients returned to those of the normal population. Most patients (80%) did not feel that their quality of life was affected by the surgery. Satisfaction with the surgical outcome averaged 8.5 out of 10, while current health was rated at 6.8 out of 10. Emotional distress levels varied over time, with mood and arousal improving significantly postoperatively. Late complications were reported by 28% of the patients, but there were no significant differences in the MDMQ scores, health status, or satisfaction between those with and without complications. Conclusions: The results indicate that there is no association between the emotional strain measured by the MDMQ and the occurrence of late postoperative complications.

Severe stress cardiomyopathy following spinal corrective surgery for scoliosis complicated with pectus excavatum: a case report

BACKGROUND

Stress cardiomyopathy (SCM) is an acute heart failure syndrome characterized by transient, usually reversible left ventricular systolic dysfunction with normal or enhanced basal compensatory wall motion abnormalities involving the left ventricular anterior septum and apex, resulting in a "ballooning" appearance. However, it has rarely been reported in patients undergoing spinal surgery.

CASE PRESENTATION

We report a case of severe stress cardiomyopathy in a scoliosis patient with pectus excavatum who underwent spinal corrective surgery. During the wake-up period, circulatory collapse occurred. After multidisciplinary consultation, the patient was diagnosed with stress cardiomyopathy. At last, she had a good prognosis after a series of treatments including ECMO.

CONCLUSION

Stress cardiomyopathy is a reversible but uncommon condition. It can cause death if it is not diagnosed in time. Consequently, this report should improve the awareness of orthopedists and anesthesiologists for timely identification and management. For patients with potential risk factors, timely preoperative intervention should be performed to reduce the occurrence of stress cardiomyopathy.

Intraoperative Takotsubo Syndrome

Takotsubo cardiomyopathy is a rare condition that presents a diagnostic challenge due to its close resemblance to acute myocardial ischemia and other cardiac disorders. The excessive production of catecholamines triggers abnormal and severe changes in the myocardium, typically resulting in significant dyskinesia of the left ventricle's apex, reduced ejection fraction, hypotension, and pulmonary edema. Recent reports suggest that potential risk factors may include postmenopausal syndrome and intense, unexpected stress, whether related to life events or medical conditions. Complications such as heart failure, thrombosis, and severe arrhythmias are infrequent and more likely to occur in patients with pre-existing cardiac conditions. We present the case of a 22-year-old woman who developed intraoperative Takotsubo cardiomyopathy during a transsphenoidal resection of a prolactin-secreting pituitary tumor under general anesthesia. Perioperative combination of cabergoline and oxymetazoline induced intraoperative hypertension, pulmonary edema, and Takotsubo stress cardiomyopathy. To our knowledge, this is the first reported case in the literature of intraoperative Takotsubo cardiomyopathy, potentially linked to the specific combination of intraoperative cabergoline and oxymetazoline.

Incidence of Takotsubo cardiomyopathy in patients with acute coronary syndrome: a single center retrospective analysis

BACKGROUND

Takotsubo cardiomyopathy (TTC) is an acute and usually reversible condition that often mimics the course of acute coronary syndrome (ACS), making it particularly challenging to differentiate, especially in the initial phases. In this study, we retrospectively analyzed the incidence, clinical course, examination results, and in-hospital mortality of TTC in patients with ACS hospitalized at our cardiology center from January 2018 to October 2023.

RESULTS

During the study period, a total of 3835 selective coronary angiograms were urgently performed at our facility, with a diagnosis of TTC established in 52 (1.35%) patients, the majority of whom were females-48 (93%), with an average age of 64.2 ± 10.2 years. Stress-induced mechanisms were identified in 36 (69%) patients. The most common symptom was chest pain (86.5%). Electrocardiographic changes primarily included ST-segment elevations (61.6%) and depressions (14%). The average left ventricular ejection fraction was 45.1 ± 8.3 (33-57%), typically with an echocardiographic pattern of apical ballooning dysfunction followed by midventricular dyskinesia. In-hospital mortality was zero.

CONCLUSIONS

TTC is a reversible condition with a low incidence of complications. Its occurrence in our patient cohort is lower compared to international registries. However, as demonstrated in this study, it is associated with significant in-hospital morbidity.

Takotsubo Cardiomyopathy: Patients Characteristics, Mortality, and Clinical Significance of Left Ventricular Outflow Tract Gradient, Retrospective Study

Background

Takotsubo cardiomyopathy (TC) is a reversible left ventricular systolic dysfunction with apical ballooning. Left ventricular outflow tract (LVOT) obstruction may develop in these cases due to hyperdynamic state of the left ventricle. Limited data are available on the prevalence of LVOT gradient in TC and its association with patient outcomes and mortality.

Methods

Data were collected retrospectively for patients diagnosed with TC in a single tertiary center, demographic information, blood analysis results, and imaging finding including ejection fraction, and LVOT gradient was obtained from medical records. Additionally, medical treatment and outcome during hospitalization were extracted. Follow-up was conducted through cardiology clinic or phone contact.

Result

A total of 59 patients diagnosed with TC were reviewed during hospitalization, and 40 patients were followed up after discharge by phone contact and cardiology clinic. Most patients were female (91.5%), and nonsignificant coronary artery disease was present in 16.9% of patients. Approximately two-third of the patients had a reduced ejection fraction on admission, and only two patients (5.4%) continued to have reduced ejection fraction on echocardiography follow-up within a period of 2-14 days. LVOT gradient was present in 17 patients (28.5%); patients with preserved ejection fraction had a higher probability of having an LVOT gradient. However, there was no association between LVOT gradient and shock or mortality. Four patients (6.7%) experienced 30-day mortality, while all-cause mortality was reported in eight patients (13.5%) over the follow-up period (mean (±SD) 20.8 months ± 16.2).

Conclusion

LVOT obstruction may occur in TC patients; it has no correlation with shock or mortality. However, determining whether there is a gradient is important for deciding on specific treatment approach.

Takotsubo Cardiomyopathy Associated With Influenza A and a Ground-Level Fall

Our case involves a 92-year-old female who presented to the emergency department due to a ground-level fall and difficulty breathing. She was found to have influenza A, elevated troponin, and decreased left ventricular ejection fraction. However, cardiac catheterization did not reveal any coronary artery stenosis, supporting a diagnosis of takotsubo cardiomyopathy (TC). The patient's ejection fraction was normal after nine months. This case highlights the importance of considering TC in elderly female patients who have reduced ejection fraction and elevated troponin in the setting of infection and a recent fall.

A Comprehensive Review on Alcohol Abuse Disorder Fatality, from Alcohol Binges to Alcoholic Cardiomyopathy

Frequent and excessive consumption of alcohol, be it episodic or sustained misuse, ranks among the top causes of mortality globally. This comprehensive analysis seeks to elucidate how alcohol misuse precipitates death, with a particular focus on associated cardiac anomalies. Notably, the phenomenon of "Holiday Heart Syndrome", linked to binge drinking, is recognized for inducing potentially fatal cardiac arrhythmias. Moreover, persistent alcohol consumption is implicated in the development of alcoholic cardiomyopathy, a condition that underlies heart failure and arrhythmic disturbances of the heart. Additionally, individuals undergoing withdrawal from alcohol frequently exhibit disruptions in normal heart rhythm, posing a risk of death. This review further delves into additional alcohol-related mortality factors, including the heightened likelihood of hypertension, cerebrovascular accidents (strokes), and the connection between excessive alcohol use and Takotsubo syndrome.

"I Love You to Death": Social Networks and the Widowhood Effect on Mortality

Research on "the widowhood effect" shows that mortality rates are greater among people who have recently lost a spouse. There are several medical and psychological explanations for this (e.g., "broken heart syndrome") and sociological explanations that focus on spouses' shared social-environmental exposures. We expand on sociological perspectives by arguing that couples' social connections to others play a role in this phenomenon. Using panel data on 1,169 older adults from the National Social Life, Health, and Aging Project, we find that mortality is associated with how well embedded one's spouse is in one's own social network. The widowhood effect is greater among those whose spouses were not well connected to one's other network members. We speculate that the loss of a less highly embedded spouse signals the loss of unique, valuable, nonredundant social resources from one's network. We discuss theoretical interpretations, alternative explanations, limitations, and directions for future research.

Atypical Stress Cardiomyopathy and the Need for Multidisciplinary Care

Reverse takotsubo cardiomyopathy is a rare variant of the classic stress-induced takotsubo cardiomyopathy. It is associated with transient left ventricular (LV) systolic dysfunction characterized by basal hypokinesis and apical hyperkinesis. We present a case of a 27-year-old woman who presented to an outside facility for a scheduled cesarean section and developed perioperative chest tightness, hypoxemia, and hypotension. Her electrocardiogram (ECG) showed sinus rhythm with marked ST segment depressions in leads V4-V6. High sensitivity troponin was elevated to 474 ng/L. Transthoracic echocardiography revealed an LV ejection fraction of 52% (Simpson's) with hypokinesis of the basal myocardial segments and hyperdynamic systolic function of the apical segments. Subsequent coronary angiography showed angiographically normal epicardial coronaries. Left ventriculography showed ballooning of the basal segments with apical hyperkinesis. She was subsequently diagnosed with reverse takotsubo cardiomyopathy and managed conservatively with beta-blockers. In this case, we highlight the need for collaboration between the cardiology and obstetric teams for tailored management strategies to ensure the well-being of both mother and baby.

Τakotsubo Syndrome After Surgical Removal of the Thyroid Gland and Major Bleeding

A 58-year-old male with a medical history of arterial hypertension, dyslipidemia, and psoriasis was admitted for a scheduled surgical removal of the thyroid gland. During the surgery, the patient suffered severe blood loss caused by vascular complications. After the operation, his electrocardiogram showed diffuse ST segment elevation along with high-sensitivity cardiac troponin T elevation and severe left ventricular systolic dysfunction. An emergency coronary angiography showed unobstructed coronary arteries. However, the left ventriculography demonstrated akinesia of the apical segments and hyperkinesia of the basal segments during systole. The patient was diagnosed with Takotsubo syndrome and he was successfully stabilized over the course of the next few days. Takotsubo cardiomyopathy is characterized by transient left ventricular systolic dysfunction and although the clinical and electrocardiographical presentation is similar to an acute coronary syndrome, the coronary arteries are unobstructed. Stressful events, both physical or psychological, could trigger an excessive catecholaminergic response which can cause the syndrome. Repetitive echocardiograms in our patient demonstrated complete recovery of the systolic function after a few days.

Approach to Imaging of Patients Presenting With Acute Coronary Syndrome With No Culprit Lesion Identified at Angiography

Chest pain is a common chief complaint among patients presenting to the emergency department. However, in the scenario where the clinical presentation is consistent with acute coronary syndrome and no culprit lesions are identified on angiography, clinicians and cardiac imagers should be informed of the differential diagnosis and appropriate imaging modalities used to investigate the potential causes. This review describes an imaging-based algorithm that highlights the diagnostic possibilities, their differentiating imaging features, and the important role of cardiovascular magnetic resonance imaging for narrowing the differential diagnosis.

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.

Pathophysiology of Myocardial Infarction With Nonobstructive Coronary Artery Disease: A Contemporary Systematic Review

Background

Myocardial infarction with nonobstructive coronary artery disease (MINOCA) is defined as acute myocardial infarction (AMI) with angiographically nonobstructive coronary artery disease. MINOCA represents 6% of all AMI cases and is associated with increased mortality and morbidity. However, the wide array of pathophysiological factors and causes associated with MINOCA presents a diagnostic conundrum. Therefore, we conducted a contemporary systematic review of the pathophysiology of MINOCA.

Methods

A comprehensive systematic review of MINOCA was carried out through the utilization of the PubMed database. All systematic reviews, meta-analyses, randomized controlled trials, and cohort studies available in English or French that reported on the pathophysiology of MINOCA published after January 1, 2013 were retained.

Results

Of the 600 identified records, 80 records were retained. Central to the concept of MINOCA is the definition of AMI, characterized by the presence of myocardial damage reflected by elevated cardiac biomarkers in the setting of acute myocardial ischemia. As a result, a structured approach should be adopted to thoroughly assess and address clinically overlooked obstructive coronary artery disease, and cardiac and extracardiac mechanisms of myocyte injury. Once these options have been ruled out, a diagnosis of MINOCA can be established, and the appropriate multimodal assessment can be conducted to determine its specific underlying cause (plaque disruption, epicardial coronary vasospasm, coronary microvascular dysfunction, and coronary embolism and/or spontaneous coronary dissection or supply-demand mismatch).

Conclusions

Integrating a suitable definition of AMI and understanding the pathophysiological mechanisms of MINOCA are crucial to ensure an effective multimodal diagnostic evaluation and the provision of adequate tailored therapies.

Mental stress, atheroma, myocardial ischaemia and injury: the link is inflammation

Increasing observational and experimental trial data have shown that mental stress can lead to an increase in adverse clinical cardiovascular events. Mental stress affects the heart by inducing ischaemia and precipitating myocardial infarction (MI) or direct myocardial injury. Mental stress leads to systemic inflammation. Inflammation is known to cause rapid atheromatous plaque progression, instability and thrombosis-the classic type 1 MI. Inflammation can also lead to type 2 MI or myocarditis and injury. The published data linking systemic inflammation, mental stress and cardiovascular disease will be reviewed to establish the linkage between mind and heart, thereby highlighting the importance of holistically managing the patient, not only addressing separate organ systems. Finally, recent trial evidence showing the value of anti-inflammatory drugs in cardiovascular and mental conditions will be briefly considered.

A Postoperative Complication of Takotsubo Syndrome in the Spinal Surgery: A Case Report

We present the case of a 32-year-old woman with a diagnosis of lumbar root syndrome and spondylolisthesis, which is why she underwent surgery. Anterior discectomy and intersomatic box placement plus posterior fixation were performed with percutaneous transpedicular screws in L5-S1. At 24 hours of the procedure, the patient presents sustained hypotension, adding sudden and intense chest pain with neck irradiation, dyspnea, and diaphoresis, as well as electrocardiographic abnormalities and elevation of cardiac enzymes suggestive of an acute coronary syndrome, subsequently evidence of basal hypokinesis in the echocardiogram. After providing hemodynamic support and analgesic management, the symptoms were resolved, and the electrocardiogram (ECG) and cardiac enzymes were normalized, allowing an adequate postoperative evolution.

The Critical Role of Lambda-Shaped QRS-ST-T Wave Fusion ST-Elevation in Diagnosing and Managing Takotsubo Cardiomyopathy: A Case Report and Review of Literature

Stress-induced cardiomyopathy, commonly known as Takotsubo cardiomyopathy (TCM), is a clinical syndrome characterized by acute and transient ventricular systolic dysfunction that often presents with chest pain and may resemble an acute coronary syndrome. This case report discusses a complex clinical scenario involving an adult female with severe depression who attempted suicide through drug overdose, subsequently developing serotonin syndrome. Her clinical presentation was further complicated by the emergence of a unique lambda-shaped triangular QRS-ST-T waveform fusion ST-elevation electrocardiographic (ECG) pattern closely mimicking an anterolateral occlusive myocardial infarction. The study delves into the clinical implications of this unique ECG pattern in TCM, providing valuable insights into diagnosing and treating such complex cases. This case underscores the importance of recognizing diverse manifestations of TCM and its potential for severe cardiovascular complications.

An ophthalmologist with myocardial bridging developed takotsubo cardiomyopathy while operating; A case report and literature review

Key Clinical Message

Healthcare workers are prone to very high level of physical as well as emotional stress that lead to devastating health-related consequences which include but not limited to cardiovascular events that may lead to death. Recognizing the risk of Takotsubo Cardiomyopathy among healthcare worker is the main aim of this report.

Abstract

Takotsubo Cardiomyopathy (TC) is a reversible left ventricular wall motion abnormality that could not be explained by coronary artery disease and is typically precipitated by either emotional or physical stress. There is no sufficient data regarding the incidence of TC among healthcare workers and people with myocardial bridging. Here we are describing a case of an ophthalmologist with myocardial bridging who developed TC while in the operation theater.

Takotsubo Cardiomyopathy Induced by Stress From Amyotrophic Lateral Sclerosis and a Mechanical Fall

Named after the Japanese octopus trap, Takotsubo cardiomyopathy is an acute myocardial condition characterized by a reversible ventricular dysfunction with ballooning of the left ventricle (LV) during systole. A catecholamine surge is likely the primary mechanism responsible for myocardial damage in this condition. The association between amyotrophic lateral sclerosis (ALS) and Takotsubo cardiomyopathy has not been well established. We present a unique case of Takotsubo cardiomyopathy diagnosed in a patient with ALS who presented after a fall with shortness of breath, generalized weakness, and hypotension. She was found to have troponinemia, elevated brain natriuretic peptide, and Osborn waves without ST-segment changes noted on electrocardiography (EKG). The diagnosis of Takotsubo cardiomyopathy was confirmed via transthoracic echocardiography (TTE), which revealed reduced left ventricular ejection fraction, apical ballooning of the LV, akinesis of the ventricular apex, and hyperkinesis of the base of the heart. Coronary angiography revealed no coronary artery disease. She was managed medically and was hemodynamically stable at the time of discharge.

Takotsubo cardiomyopathy induced by acute coronary syndrome: A case report

Takotsubo cardiomyopathy (TC) can be provoked by various triggers. It should be differentiated from acute coronary syndrome (ACS). Herein, we report a case of TC triggered by ACS. An 80-year-old woman was referred to the emergency room because of prolonged chest pain and ST-segment elevations. Echocardiography demonstrated left ventricular apical ballooning, findings suggestive of TC rather than ACS. Emergency coronary angiography revealed severe stenosis of the first diagonal branch of the left anterior descending coronary artery with distal flow delay. Recanalization of the diagonal branch was achieved by stent implantation and her chest pain was resolved. Cardiac magnetic resonance imaging showed increased signal intensities in the apex and the inner layer of the anterior wall on fat-suppressed, T2-weighted imaging. The present case highlights the importance of recognizing TC in relation to ACS not only as a differential diagnosis but also as a possibly concomitant condition unless clinical features fit one diagnosis.

Learning objective

Takotsubo cardiomyopathy can be provoked by various conditions and differentiated from acute coronary syndrome based on the presence or absence of coronary artery stenosis. Our case highlights the importance of acknowledging that takotsubo cardiomyopathy may be induced by acute coronary syndrome.

Advanced Cardiac Imaging and Women's Chest Pain: A Question of Gender

Awareness of gender differences in cardiovascular disease (CVD) has increased: both the different impact of traditional cardiovascular risk factors on women and the existence of sex-specific risk factors have been demonstrated. Therefore, it is essential to recognize typical aspects of ischemic heart disease (IHD) in women, who usually show a lower prevalence of obstructive coronary artery disease (CAD) as a cause of acute coronary syndrome (ACS). It is also important to know how to recognize pathologies that can cause acute chest pain with a higher incidence in women, such as spontaneous coronary artery dissection (SCAD) and myocardial infarction with non-obstructive coronary arteries (MINOCA). Coronary computed tomography angiography (CCTA) and cardiac magnetic resonance imaging (CMR) gained a pivotal role in the context of cardiac emergencies. Thus, the aim of our review is to investigate the most frequent scenarios in women with acute chest pain and how advanced cardiac imaging can help in the management and diagnosis of ACS.

Severe and Atypical Presentation of Takotsubo Cardiomyopathy in a Pediatric Patient after a Serious Crash Injury-Case Report and Literature Review

Takotsubo cardiomyopathy is an uncommon clinical entity in children, resulting in severe but sometimes reversible systolic dysfunction of the left ventricle. This condition is triggered by multiple emotional or physical stressors, while neurogenic stress cardiomyopathy after brain injuries has become increasingly recognized in children over the past few years. We report the case of an 11-year-old child with an atypical clinical presentation after a serious car crash accident. An initial computed tomography scan revealed an acute epidural hematoma, which was immediately treated by an emergency craniotomy. During the patient's following pediatric intensive care unit hospitalization, severe hemodynamic instability was observed, leading to gradually higher doses of vasopressors for circulatory support. On echocardiography, the patient had signs of severe cardiac contractility compromise, with characteristic pattern of regional wall motion abnormalities of the left ventricle, which, in combination with seriously elevated cardiac enzymes, electrocardiographic (ECG) abnormalities and continuous thermodilution hemodynamic monitoring (PICCO) findings, led to intensification of inotropic support and to the diagnosis of takotsubo cardiomyopathy. Despite supportive measures, the patient developed multiorgan failure and succumbed to their serious illness. For this atypical case, extracorporeal membrane oxygenation (ECMO) was addressed as an option for the seriously failing heart, but due to the extremely high risk of intracranial bleeding, it could not be used for this patient's treatment. In conclusion, Takotsubo cardiomyopathy should be suspected in pediatric cases of cardiac dysfunction after serious injuries or stress conditions.

Cardiac Imaging in Women with Ischemic Heart Disease

Cardiac diseases are the main cause of death for both sexes worldwide. Treatment varies widely according to the sex of a patient, as there are differences in physiopathology, epidemiology, clinical presentation and management. However, women have been largely excluded from research studies in this field. At present, differences are starting to be recognized and more attention is being paid to the identification of female-specific (or emergent) atherosclerotic risk factors. Diagnostic testing also merits attention because cardiac imaging offers important information to help diagnosis and guide cardiac disease management. In this sense, multimodal imaging should be used with the most cost-effective approach, integrating this information into the clinical sphere according to the pretest probability of the disease. In this review, we address sex-specific features of ischemic heart disease that should be considered in the clinical assessment of women, as well as the value of different imaging techniques (including technical and clinical aspects) for management of women with ischemic heart disease, and identify future areas of action concerning ischemic heart disease in women.

Reverse Takotsubo Cardiomyopathy During Immediate Post-partum: A Case Report

Takotsubo cardiomyopathy or stress-induced cardiomyopathy is a particular entity with a transient left ventricular dysfunction without significant coronary artery obstruction, preceded by a stressful circumstance. Clinical presentation may mimic myocardial infarction, acute heart failure among the most common conditions. If suspected, the integration of clinical aspects, imaging results, and laboratory tests allows its diagnosis and proper management. Once described as a post-menopausal women's disease, is now recognized as a more frequent condition of young women, especially after stressful conditions such as post-surgical status and peripartum period, rendering as a disease with a certain predisposition to female patients, with a not always benign evolution. This case remarks an atypical presentation experiencing a first nigh fatal evolution but a later satisfactory recuperation.

Takotsubo cardiomyopathy following envenomation: An updated review

BACKGROUND

Takotsubo cardiomyopathy (TTC) can be diagnosed in patients presenting with clinical features of acute coronary syndrome (ACS) by using Mayo clinic criteria. Multiple precipitators have been attributed to causing TTC. Rarely it has been reported to occur following an acute envenomation.

AIM

This review describes the various patterns, mechanisms, and outcomes of envenomation induced TTC.

METHODS

In this review, we included all studies on “TTC” and “envenomation “published in the various databases before June 2022. To be included in the review articles had to have a distinct diagnosis of TTC and an envenomation

RESULTS

A total of 20 patients with envenomation induced TTC were identified. Most episodes of envenomation induced TTC were reported following a bee sting, scorpion sting, and snake envenomation. Fear and anxiety related to the sting, direct catecholamine toxicity and administration of exogenous beta-adrenergic agents have been commonly postulated to precipitate TTC in these patients. 95% of these patients presented with a clinical picture of ACS. Most of these patients also fulfill at least 3 out of 4 criteria of Mayo clinic criteria for TTC. Echocardiographic evidence of Apical TTC was noted in 72% of patients. 94% of these patients had clinical improvement following optimal management and 35% of these patients were treated with guideline directed medications for heart failure.

CONCLUSION

Envenomation following multiple insect stings and reptile bites can precipitate TTC. Most reported envenomation related TTC has been due to bee stings and scorpion bites. Common mechanisms causing TTC were fear, anxiety, and stress of envenomation. Most of these patients present with clinical presentation of ACS, ST elevation, and elevated troponin. The most common type of TTC in these patients is Apical, which improved following medical management.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Takotsubo cardiomyopathy. Literature review: concept, epidemiology, pathogenesis. Part I

Up-to-date data on the problem of takotsubo cardiomyopathy, including key issues of epidemiology, clinical presentation, diagnostic criteria, and general pathophysiological mechanisms of the disease is presented in review.

Surgery as an Emotional Strain: An Observational Study in Patients Undergoing Elective Colorectal Surgery

Recent research suggests an impact of psychological distress on postoperative outcomes in orthopedic and neurosurgery. It is widely unknown whether patients' mood might affect the postoperative outcome and complication rate in colorectal surgery. Over a period of 22 months, a monocentric, observational study among patients undergoing elective colorectal surgery without the creation of an ostomy was conducted. Patients were asked to fill in a standardized multi-dimensional mood questionnaire (MDMQ) preoperatively as well as on the third, sixth, and ninth postoperative days to assess mood, wakefulness, and arousal. The results of 80 patients (51% male, mean age 59 years) were analyzed. Almost half of the patients (58%) developed postoperative complications according to the Clavien-Dindo classification (Grade I 14%, Grade II 30%, Grade III 9%, Grade IV 3%). Patients' mood increased continually from the preoperative day to the ninth postoperative day. Patients' wakefulness decreased initially (pre- to third postoperative day) and increased again in the further course. Patients' arousal decreased pre- to postoperatively. Neither preoperative mood, nor arousal or wakefulness of patients showed a clear association with the development of postoperative complications. In conclusion, preoperative psychological distress measured by MDMQ did not affect the postoperative complication rate of patients undergoing elective colorectal surgery.

The association of Takotsubo cardiomyopathy and aneurysmal subarachnoid hemorrhage: A U.S. nationwide analysis

OBJECTIVE

Takotsubo cardiomyopathy (TC) is a stress-induced cardiomyopathy that can be precipitated by aneurysmal subarachnoid hemorrhage (aSAH). Several studies have shown patients who develop TC following aSAH have an increased risk of disability and mortality. The goal of this study is to examine the incidence of TC in aSAH, identify its risk factors, and analyze its impact on patient outcomes.

METHODS

Data for patients with aSAH between the years of 2009 and 2018 were extracted from the Nationwide Inpatient Sample (NIS) and stratified based on the diagnosis of TC. Univariate analysis was used to assess the incidence of TC and covariates including patient demographics, aneurysmal treatment, in-hospital mortality rate, length of stay and costs. Multivariate logistic regression models analyzed the relationship between TC and these variables RESULTS: 80,915 aSAH patient-discharges were included in this study, 673 (0.83%) of which, developed TC. Females (OR 3.49, CI [2.82-4.33], P < 0.001), white ethnicity (69% vs 63%, P = 0.003) and patients with certain comorbidities including smoking (OR 1.64, CI [1.38-1.95], P < 0.0001) and seizures (OR 1.32, CI [1.07, 1.64], P = 0.01) were most likely to develop TC. Patients who developed TC had significantly increased mortality (OR 1.36, CI [1.13-1.65], P = 0.001), hospital stays (mean days of 19.4 vs 11.5, P < 0.0001), and costs ($104,111 vs $48,734, P < 0.0001). Hypertension (OR 0.63, CI [0.54-0.74], P < 0.0001) and hyperlipidemia (OR 0.63, CI [0.51-0.77], P < 0.0001) were found to be protective against TC. Patients with TC after acute SAH were more likely to undergo endovascular coiling (OR 1.68, CI [1.327-2.127], P < 0.001) rather than surgical clipping (OR 0.66, CI [0.52-0.83], P < 0.0001).

CONCLUSIONS

Female sex, white ethnicity, smoking and seizures represented significant predictors of developing TC after aSAH, while hypercholesterolemia and hypertension were protective.

Characteristics of Takotsubo cardiomyopathy in patients with COVID-19: Systematic scoping review

BACKGROUND

COVID-19 has recently been associated with the development of Takotsubo cardiomyopathy (TCM). This scoping review aims to summarize the existing evidence regarding TCM in COVID-19 and offer future direction for study.

METHODS

Following the PRISMA Extension for Scoping Reviews, MEDLINE and EMBASE were searched for all peer-reviewed articles with relevant keywords including "Takotsubo", "Stress-induced cardiomyopathy" and "COVID-19" from their inception to September 25, 2021.

RESULTS

A total of 40 articles with 52 cases were included. Patients with TCM and COVID-19 showed only slight female predominance (59.6%), median age of 68.5 years, and were mostly of the apical subtype (88.6%). All-cause mortality was 36.5%. The median LVEF was 30%. Compared to those without TCM, those with TCM in COVID-19 had more critical illness, higher mortality, lower LVEF, and higher cardiac and inflammatory biomarkers. Notably, the diagnostic criteria of TCM were considerably different between case reports and observational studies.

CONCLUSION

This scoping review identifies that TCM in COVID-19 may have distinct features that distinguish this condition from TCM without COVID-19. Future studies are warranted to help describe risk factors, determine the utility of inflammatory biomarkers and serum catecholamine levels, and establish disease-specific diagnostic criteria.

Investigating changes in β-adrenergic gene expression (ADRB1 and ADRB2) in Takotsubo (stress) cardiomyopathy syndrome; a pilot study

Background

Takotsubo Cardiomyopathy (TC) is a rare disorder that is mostly caused by stress and is often misdiagnosed. We aimed to analyze Takotsubo Syndrome at the molecular level by using the Oxford Nanopore Minion Device and its protocol.

Methods and results

Ten patients who were previously diagnosed with Takotsubo Syndrome (increased after decrease in ejection fraction and without critical stenosis in coronary arteries) and 10 healthy individuals in the control group were included in our project. The mean age was 53 ± 12.2 for the patient group and 52.4 ± 9.9 for the control group, and the left ventricular ejection fraction was 50.3 ± 11.5 for the patient group and 64.2 ± 2.8 for the control group (p < 0.05). Peripheral blood of patients and healthy individuals was taken and their DNA was obtained. By making long reads throughout the genome, the most studied regions responsible for β-adrenergic signaling pathways; The gene expression level of cardiac β-1 ADRB1 (rs1801253-ENST00000369295.4), G > C, (Gly389Arg) and cardiac β-2 ADRB2 (rs1800888-ENSG00000169252), C > T, (Thr165Ile) adrenoceptors was investigated. As a result; no structural variation was detected leading to Takotsubo Cardiomyopathy. The results obtained from the bioinformatics analysis were also checked from the VarSome Tools and similar results were found.

Conclusions

Many publications in TC susceptibility have that may lead to adrenergic pathway dysregulation, most studied adrenergic receptor genes in the similar literatures too. We searched for genetic variants in b1AR and b2AR genes in our study and however we could not find any variants in this study, we think larger numbers of cohort studies are needed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11033-021-06816-w.

Review of multi-modality imaging update and diagnostic work up of Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC) is an acute but reversible non-ischemic heart failure syndrome. It is characterized by a transient form of ventricular dysfunction typically manifesting as basal hyperkinesis with hypokinesia and ballooning of left ventricle mid-cavity and apex. Imaging helps in both diagnosis and follow up. Echocardiogram is the first-line modality to assess the typical contractile dysfunction in suspected patients with catheter angiography showing normal coronary arteries. Cardiac MRI is currently the modality of choice for the non-invasive initial assessment of TC and for follow up imaging. The current review focusses on historical background of TC, its pathophysiology, diagnostic work up and differential diagnosis and provides multimodality imaging work up of TC including role of echocardiogram, invasive catheterization, nuclear imaging, cardiac computed tomography and cardiac MRI including basic and advanced MRI sequences.

Acute ischemic stroke after enjoying Top of Europe

Sudden onset of disturbed consciousness, neurocognitive deficits, and weakness of the proximal limbs are typical findings of a watershed stroke. Occurrence after an intense emotional experience and electrocardiogram changes are hints toward the rare cause of stroke of a takotsubo cardiomyopathy, even more if the stroke pattern is embolic.

Energy drink-induced cardiomyopathy

We report a case of severe biventricular heart failure potentially related to excessive energy drink consumption in a 21-year-old man. The patient presented with a 4-month history of shortness of breath on exertion, orthopnoea and weight loss. Transthoracic echocardiography demonstrated severely impaired biventricular systolic function and bilateral ventricular thrombi, subsequently confirmed on cardiac magnetic resonance imaging, which found in addition no oedema, inflammation or focal fibrosis. Blood tests, renal ultrasound and subsequent abdominal MRI demonstrated severe renal failure caused by a chronic obstructive uropathy, long-standing and previously undiagnosed. There was no significant past medical, family or social history other than excessive intake of an energy drink. This case report adds to the growing concern in the literature about the potential cardiotoxic effects of energy drinks, which should be considered when assessing young patients presenting with a non-ischaemic dilated cardiomyopathy.

Understanding the heart-brain axis response in COVID-19 patients: A suggestive perspective for therapeutic development

In-depth characterization of heart-brain communication in critically ill patients with severe acute respiratory failure is attracting significant interest in the COronaVIrus Disease 19 (COVID-19) pandemic era during intensive care unit (ICU) stay and after ICU or hospital discharge. Emerging research has provided new insights into pathogenic role of the deregulation of the heart-brain axis (HBA), a bidirectional flow of information, in leading to severe multiorgan disease syndrome (MODS) in patients with confirmed infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Noteworthy, HBA dysfunction may worsen the outcome of the COVID-19 patients. In this review, we discuss the critical role HBA plays in both promoting and limiting MODS in COVID-19. We also highlight the role of HBA as new target for novel therapeutic strategies in COVID-19 in order to open new translational frontiers of care. This is a translational perspective from the Italian Society of Cardiovascular Researches.

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

RATIONALE

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

PATIENT CONCERNS

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

DIAGNOSIS

A fracture in a thoracic vertebra; TTS.

INTERVENTIONS

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

OUTCOMES

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

LESSONS

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

Acute onset heart failure due to reverse type Takotsubo cardiomyopathy caused by a single dose of 4-Fluoroamphetamine in a healthy young individual

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4-Fluoroamphetamine (4-FA) is a popular new psychoactive stimulant that is used for recreational purposes.

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A single dose of 4-FA can lead to reverse type Takotsubo cardiomyopathy with cardiogenic shock.

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4-FA use can cause a very sudden onset of severe symptoms.

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Due to mild and late onset of effect, 4-FA users have the tendency to take an extra dose.

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Phosphodiesterase-3-inhibitors are effective for amphetamine type stimulant induced Takotsubo cardiomyopathy.

Introduction

4-fluoroamphetamine (4-FA) is a novel psychoactive stimulant with a global presence on the drug market. Despite the popularity of 4-FA, data on severe adverse effects are scarce. We present a case of laboratory confirmed 4-FA mono intoxication causing acute heart failure due to a reverse type Takotsubo cardiomyopathy.

Case

A 20-year-old male with no previous medical history and no reported previous drug use, presented to the emergency department (ED) with complaints of headache, nausea and vomiting, approximately 4.5 h after the ingestion of a single 4-FA pill. After 30 min his condition deteriorated with severe hypertension, tachycardia and respiratory failure. Echocardiography showed a reverse type Takotsubo cardiomyopathy. The patient was successfully treated with mechanical ventilation, a phosphodiesterase-3-inhibitor (PDE3-inhibitor) and diuretics. Three months after hospital admission, the patient was free of complaints and his left ventricular function fully recovered.

Conclusion

Recreational use of 4-FA may result in acute onset life-threatening cardiorespiratory toxicity, preceded by severe hypertension, even in drug-naïve patients without any medical history. Emergency physicians and cardiologists should be cautious not to underestimate life-threatening 4-FA complications.

Chinese Society of Anesthesiology Expert Consensus on Anesthetic Management of Cardiac Surgical Patients With Suspected or Confirmed Coronavirus Disease 2019

The outbreak of a new coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) in China in December 2019 has brought serious challenges to disease prevention and public health. Patients with severe coronavirus disease 2019 (COVID-19) who undergo cardiovascular surgery necessitate extremely high demands from anesthesia personnel, and face high risks of mortality and morbidity. Based on the current understanding of COVID-19 and the clinical characteristics of cardiovascular surgical patients, the authors provide anesthesia management guidelines for cardiovascular surgery along with the prevention and control of COVID-19.