Pathophysiology of takotsubo syndrome: temporal phases of cardiovascular responses to extreme stress

Diverse distribution patterns of segmental longitudinal strain are associated with different clinical features and outcomes in dilated cardiomyopathy

BACKGROUND

Dilated cardiomyopathy (DCM) presents with diverse clinical courses, hardly predictable solely by the left ventricular (LV) ejection fraction (EF). Longitudinal strain (LS) offers distinct information from LVEF and exhibits various distribution patterns. This study aimed to evaluate the clinical significance of LS distribution patterns in DCM.

METHODS

We studied 139 patients with DCM (LVEF ≤ 35%) who were admitted for heart failure (HF). LS distribution was assessed using a bull's eye map and the relative apical LS index (RapLSI), calculated by dividing apical LS by the sum of basal and mid-LS values. We evaluated the associations of LS distribution with cardiac events (cardiac death, LV assist device implantation, or HF hospitalization) and LV reverse remodeling (LVRR), as indicated by subsequent LVEF changes.

RESULTS

Twenty six (19%) and 29 (21%) patients exhibited a pattern of relatively apical impaired or preserved LS (defined by RapLSI < 0.25 or > 0.75, signifying a 50% decrease or increase in apical LS compared to other segments), and the remaining patients exhibited a scattered/homogeneously impaired LS pattern. The proportion of new-onset heart failure and LVEF differed between the three groups. During the median 595-day follow-up, patients with relatively-impaired apical LS had a higher rate of cardiac events (both log-rank p < 0.05) and a lower incidence of LVRR (both p < 0.01) compared to patients with other patterns. RapLSI was significantly associated with cardiac event rates after adjusting for age, sex, and new-onset HF or global LS.

CONCLUSION

DCM patients with reduced EF and distinct distribution patterns of impaired LS experienced different outcomes.

Takotsubo syndrome after a minimally invasive tooth extraction in a patient without dental phobia: A case report

Takotsubo syndrome (TTS) is a rare, stress-induced acute cardiac disorder. Its precipitating factors include emotionally or physically stressful events and exogenous and endogenous adrenaline. In this report, we describe a case of atypical TTS in a 73-year-old woman who reported no dental fear and required acute cardiac care in an outpatient setting. She underwent routine extraction of an upper left premolar under local anesthesia. She reported heart palpitations after the injection, and the procedure was completed in 15 min. After presenting symptoms of sweating, pale skin, vomiting, low blood pressure, and ST-segment elevation, cardiologists ordered echocardiography, coronary angiography, and ventriculography. Upon receiving a TTS diagnosis, the patient was hospitalized and administered an intra-aortic balloon pump and beta-blocker. Her symptoms resolved, and she was discharged with no sequelae. We found no precipitating factors in the progression of TTS in this case, which suggests that TTS can develop in the absence of precipitating factors. All general dentists and oral surgeons should recognize the possible risk of TTS, even during minimally invasive dental procedures, such as routine extractions in patients without dental phobia.

Heartbroken Child: A Rare Case Report of Neurogenic Pulmonary Edema and Takotsubo Cardiomyopathy following Recurrent Medulloblastoma Excision with Possible Aetio-Patho-Bio-Physiological Mechanisms

INTRODUCTION

Takotsubo (Japanese fishing pot for trapping octopus) cardiomyopathy is a rare phenomenon of acute coronary syndrome presenting usually with the presence of transient apical ballooning of the left ventricle in the absence of obstructive coronary artery disease. It is mainly seen in women of older age secondary to emotional, physical, or psychological stress. In age less than 18 years, it is mainly seen in adolescents suffering from psychiatric disorders and substance abuse. In children, it is rarely described.

CASE PRESENTATION

We present here a peculiar case of a 12-year-old child with neurogenic pulmonary oedema and takotsubo cardiomyopathy syndrome after surgery for recurrent medulloblastoma. Also, management challenges are discussed.

DISCUSSION/CONCLUSION

Takotsubo cardiomyopathy is not just a classical or inverted type but indeed a spectrum. It can be seen in any case, be it a child or adult secondary to handling or injury to the ponto-medullary junction, rostral pons, or dorsolateral medulla. The density and distribution of beta-adrenergic receptors may be different in children and adults which needs further research. Prognosis is usually excellent across all ages.

Pathophysiology of Takotsubo Syndrome - a joint scientific statement from the Heart Failure Association Takotsubo Syndrome Study Group and Myocardial Function Working Group of the European Society of Cardiology - Part 1: Overview and the central role for catecholamines and sympathetic nervous system

This is the first part of a scientific statement from the Heart Failure Association of the European Society of Cardiology focused upon the pathophysiology of Takotsubo syndrome and is complimentary to the previous HFA Position Statement on Takotsubo syndrome which focused upon clinical management. In part 1 we provide an overview of the pathophysiology of Takotsubo syndrome and fundamental questions to consider. We then review and discuss the central role of catecholamines and the sympathetic nervous system in the pathophysiology, and the direct effects of high surges in catecholamines upon myocardial biology including β-adrenergic receptor signaling, G protein coupled receptor kinases, cardiomyocyte calcium physiology, myofilament physiology, cardiomyocyte gene expression, myocardial electrophysiology and arrhythmogenicity, myocardial inflammation, metabolism and energetics. The integrated effects upon ventricular haemodynamics are discussed and integrated into the pathophysiological model. This article is protected by copyright. All rights reserved.

Anesthetic implications of perioperative Takotsubo syndrome: a retrospective cohort study

PURPOSE

Takotsubo syndrome is a reversible cardiomyopathy triggered by emotional or physical stressors. Although surgeries could be physical triggers, this has been scantily investigated. We aimed to describe the baseline characteristics, surgical/anesthesia-related triggering events, clinical presentation, and in-hospital outcomes of a cohort of patients diagnosed with perioperative Takotsubo syndrome.

METHODS

In this retrospective study, we included all consecutive adult patients who were admitted to Hospital Italiano de Buenos Aires between 1 June 2008 and 30 November 2017 and diagnosed with Takotsubo syndrome according to the revised criteria of the European Society of Cardiology during hospitalization.

RESULTS

We diagnosed 21 patients with perioperative Takotsubo syndrome out of 305,906 patients undergoing procedures with anesthesia care. The median (interquartile range [IQR]) patient age was 75 (55-82) yr, and 16 (76%) were women. The median (IQR) left ventricular ejection fraction was 35 (35-42)% at diagnosis and 55 (46-55)% at discharge. Fifteen patients (71%) required inotropic/vasopressor support; however, this is a controversial treatment considering the physiopathology of the syndrome. Severe complications such as unexplained syncope/cardiac arrest, cardiogenic shock, and ventricular thrombus formation occurred in seven (33%) patients, and two (10%) patients died. These results were compared with 31 patients who experienced non-perioperative Takotsubo syndrome during the same period of time.

CONCLUSION

Perioperative Takotsubo syndrome is a reversible cardiomyopathy. Nevertheless, it seems to be associated with severe complications, the need for aggressive treatment, and non-negligible mortality.

Takotsubo cardiomyopathy in elderly female trauma patients: a case series

BACKGROUND

Takotsubo cardiomyopathy is a syndrome characterized by acute left ventricular wall motion abnormalities leading to left ventricular systolic dysfunction. It remains an important differential diagnosis for acute coronary syndrome.

CASE PRESENTATIONS

Here we describe three cases of Takotsubo cardiomyopathy occurring in three Caucasian female trauma patients (aged 79, 81, and 82 years old) and the impact on their clinical course.

CONCLUSIONS

For patients requiring surgical management, delays in the diagnosis of Takotsubo cardiomyopathy may lead to postponement of urgent operative management. This delay in surgery likely impacts on length of hospital stay, leading to an increasing morbidity and mortality.

A rare manifestation of Takotsubo Cardiomyopathy associated with non-tuberculous mycobacterium

Background

Takotsubo Cardiomyopathy or broken heart syndrome is a rare cause of non-ischemic cardiomyopathy that produce left ventricular dysfunction with characteristic left ventricular apical ballooning. It rarely caused by infection. We present an atypical manifestation of non-tuberculous mycobacterial (NTM) infection with myocardial involvement and its diagnostic challenge.

Case illustration

A 57-year-old female presented with prolonged fever, fatigue and weight loss for one and half months. General examination was unremarkable with elevated C-Reactive Protein and normal troponin. Electrocardiogram (ECG) showed diffuse T wave inversion with prolonged QTc. Echocardiography showed hypokinetic apical with normal ejection fraction. Angiography showed patent coronary arteries. Ventriculography showed apical ballooning. Workup with ethambutol scan revealed active mycobacterial infection in both lung and mesentery. Sputum polymerase chain reaction (PCR) was positive for non-tuberculous mycobacterium. Follow up ECG and echocardiography showed improvement in QTc interval and left ventricular wall motion abnormalities.

Results

Takotsubo Cardiomyopathy may manifest as asymptomatic ventricular dysfunction following non-tuberculous mycobacterial infection. A thorough investigation will help identify the systemic disease with cardiac involvement which potentially could be fatal.

Conclusion

Takotsubo cardiomyopathy may be triggered by infection. Identification of causal is crucial as a management strategy to restore cardiac function.

Simultaneous assessment of calcium handling and contractility dynamics in isolated ventricular myocytes of a rat model of post-acute isoproterenol-induced cardiomyopathy

Stress-induced cardiomyopathy (SIC) results from a profound catecholaminergic surge during strong emotional or physical stress. SIC is characterized by acute left ventricular apex hypokinesia, in the absence of coronary arteries occlusion, and can lead to arrhythmias and acute heart failure. Although, most SIC patients recover, the process could be slow, and recurrence or death may occur. Despite that the SIC common denominator is a large catecholamine discharge, the pathophysiological mechanism is incompletely understood. It is thought that catecholamines have direct cytotoxicity on apical ventricular myocytes (VM), which have the highest β-adrenergic receptors density, and whose overstimulation might cause acute Ca²⁺ overload and oxidative stress, causing death in some VM and stunning others. Rodents receiving acute isoproterenol (ISO) overdose (OV) mimic SIC development, however, they have not been used to simultaneously assess Ca²⁺ handling and contractility status in isolated VM, which might explain ventricular hypokinesia. Therefore, treating rats with a single ISO-OV (67 mg/kg body weight), we sought out to characterize, with confocal imaging, Ca²⁺ and shortening dynamics in Fluo-4-loaded VM, during the early (1-5 days) and late post-acute phases (15 days). We found that ISO-OV VM showed contractile dysfunction; blunted shortening with slower force development and relaxation. These correlated with Ca²⁺ mishandling; blunted Ca²⁺ transient, with slower time to peak and SR Ca²⁺ recovery. SR Ca²⁺ content was low, nevertheless, diastolic Ca²⁺ sparks were more frequent, and their duration increased. Contractility and Ca²⁺ dysfunction aggravated or remained altered over time, explaining slow recovery. We conclude that diminished VM contractility is the main determinant of ISO-OV hypokinesia and is mostly related to Ca²⁺ mishandling.

Takotsubo Syndrome during Haemodialysis

Takotsubo syndrome (TS) is typically characterized by transient (reversible) systolic dysfunction of the apical and mid segments of the left ventricle (LV), usually without obstruction of coronary arteries, in postmenopausal women after a stressful event. Usually, patients may experience symptoms such as chest pain, shortness of breath, palpitations, and rarely syncope or cardiogenic shock. There are many theories about pathophysiology of TS. Among these, most acceptable is the catecholamine theory. The prognosis is usually good with recovery of symptoms and imaging findings at most within a few weeks. However, complications may occur. We present the 11^th published case of a patient on hemodialysis, who presented with TS and discuss why this situation may occur in patients on hemodialysis. Contrary to our patient, half of previously published cases presented with atypical symptoms. Therefore, it is important to be alert in order to timely diagnose, support the patient, and treat if any complications appear.

Copy number variants implicate cardiac function and development pathways in earthquake-induced stress cardiomyopathy

The pathophysiology of stress cardiomyopathy (SCM), also known as takotsubo syndrome, is poorly understood. SCM usually occurs sporadically, often in association with a stressful event, but clusters of cases are reported after major natural disasters. There is some evidence that this is a familial condition. We have examined three possible models for an underlying genetic predisposition to SCM. Our primary study cohort consists of 28 women who suffered SCM as a result of two devastating earthquakes that struck the city of Christchurch, New Zealand, in 2010 and 2011. To seek possible underlying genetic factors we carried out exome analysis, genotyping array analysis, and array comparative genomic hybridization on these subjects. The most striking finding was the observation of a markedly elevated rate of rare, heterogeneous copy number variants (CNV) of uncertain clinical significance (in 12/28 subjects). Several of these CNVs impacted on genes of cardiac relevance including RBFOX1, GPC5, KCNRG, CHODL, and GPBP1L1. There is no physical overlap between the CNVs, and the genes they impact do not appear to be functionally related. The recognition that SCM predisposition may be associated with a high rate of rare CNVs offers a novel perspective on this enigmatic condition.

Hydrogen sulfide attenuates cardiac injury in takotsubo cardiomyopathy by alleviating oxidative stress

Takotsubo cardiomyopathy (TCM) is characterized by transient left ventricular apical ballooning with the absence of coronary occlusion, which is an acute cardiac syndrome with substantial morbidity and mortality. It was reported that reduced endogenous hydrogen sulfide (H₂S) levels may be related to various heart diseases. The present study investigated the mechanism by which H₂S administration modulates and protects cardiac function in TCM rats. In order to establish a TCM model, Sprague Dawley (SD) rats were injected with a single dose of β-adrenergic agonist isoprenaline (ISO). We found that ISO induced cardiac dysfunction, which was characterized by a significant decrease in left ventricular systolic pressure (LVSP), maximum contraction velocity (+dp/dtmax), maximum relaxation velocity (-dp/dtmax) and increased left ventricular end-diastolic pressure (LVEDP). Accordingly, we found that plasma and heart tissue H₂S levels in TCM rats decreased significantly, and cardiac cystathionine γ-lyase (CSE) and 3-mercaptopyruvate sulfurtransferase (3-MST) expression were lower. Moreover, cardiac dysfunction in TCM was associated with oxidative stress response and reactive oxygen species (ROS) formation. NADPH Oxidase 4 (NOX₄) and p67 protein expressions significantly increased in TCM cardiac tissues. In addition, Sodium hydrosulfide (NaHS) ameliorated ISO-induced cardiac dysfunction and reversed ISO-induced oxidative stress. This study revealed that H₂S exerted cardioprotective effects by reducing NADPH oxidase, which reduced ROS formation and prevented oxidative stress. Our study provided novel evidence that H₂S is protective in myocardial dysfunction in TCM rats and could be a therapeutic target for alleviating β-adrenergic system overstimulation-induced cardiovascular dysfunction.

Comprehensive Histological and Immunochemical Forensic Studies in Deaths Occurring in Custody

In-custody deaths have several causes, and these include homicide, suicide, natural death from chronic diseases, and unexplained death possibly related to acute stress, asphyxia, excited delirium, and drug intoxication. In some instances, these deaths are attributed to undefined accidents and natural causes even though there is no obvious natural cause apparent after investigation. Understanding these deaths requires a comprehensive investigation, including documentation of circumstances surrounding the death, review of past medical history, drug and toxicology screens, and a forensic autopsy. These autopsies may not always clearly explain the death and reveal only nonspecific terminal events, such as pulmonary edema or cerebral edema. There are useful histologic and biochemical signatures which identify asphyxia, stress cardiomyopathy, and excited delirium. Identifying these causes of death requires semiquantitative morphologic and biochemical studies. We have reviewed recent Bureau of Justice Statistics on in-custody death, case series, and morphological and biochemical studies relevant to asphyxia, stress cardiomyopathy, and excited delirium and have summarized this information. We suggest that regional centers should manage the investigation of these deaths to provide more comprehensive studies and to enhance the expertise of forensic pathologists who would routinely manage potentially complex and difficult cases.

Challenges of Chronic Cardiac Problems in Survivors of Takotsubo Syndrome

A hallmark feature of the Takotsubo syndrome (TTS) is the reversible nature of the observed cardiac dysfunction. This is underlined in diagnostic criteria. However, it would appear this reversibility is a subtle process, and that myocardial catecholamine toxicity can cause lasting permanent abnormalities of myocardial physiology. A growing body of evidence suggests persisting abnormalities may predispose post-TTS patients to cardiac and noncardiac morbidity and mortality. The cardiology community needs to understand more clearly how TTS evolves, how to identify high-risk patients with incomplete resolution, and perform studies to assess which treatment(s) are effective to improve cardiac recovery and clinical outcomes.

Clinical and Echocardiographic Characteristics of Acute Cardiac Dysfunction Associated With Acute Brain Hemorrhage - Difference From Takotsubo Cardiomyopathy

BACKGROUND

Cardiac dysfunction (CD) associated with brain hemorrhage is similar to that with takotsubo cardiomyopathy but still not well understood. We aimed to investigate the clinical and echocardiographic findings of acute CD (ACD) related to brain hemorrhage.

METHODS AND RESULTS

Between 2013 and 2014, consecutive patients diagnosed with spontaneous and traumatic brain hemorrhage were prospectively enrolled. Electrocardiography, cardiac enzymes, and echocardiography were performed. Left ventricular (LV) systolic dysfunction on echocardiography was defined as ACD related to brain hemorrhage when all the following conditions were satisfied: abnormal ECG and cardiac troponin level, LV wall motion abnormality or decreased LV systolic function on echocardiography, and no previous history of cardiac disease. Otherwise, LV dysfunction was considered to be other CD unrelated to brain hemorrhage. In a total of 208 patients, 15 (7.2%) showed ACD. Of them, 8 patients were men and 8 showed apex-sparing LV hypokinesia and 9 died in hospital. Other cardiac abnormalities observed in the study patients were NT-proBNP elevation (n=123), QT interval prolongation (n=95), LV hypertrophy (n=89), and troponin I elevation (n=47). There were 36 in-hospital deaths (17.3%). Glasgow coma score and ACD were independently associated with in-hospital death.

CONCLUSIONS

ACD was observed in patients with various brain hemorrhages. Unlike takotsubo cardiomyopathy, high proportions of male sex, apex-sparing LV dysfunction, and in-hospital death were observed for ACD associated with brain hemorrhage. (Circ J 2016; 80: 2026-2032).

Rare Variants in Cardiomyopathy Genes Associated With Stress-Induced Cardiomyopathy

BACKGROUND

Stress-induced cardiomyopathy (SIC) is a poorly understood condition associated with periods of emotional and physical stress. The clinical approaches for management of SIC are supportive and reactive to patient symptoms.

OBJECTIVE

To utilize next-generation exome sequencing to define genetic variation associated with, and potentially responsible for, this disease.

METHODS

We performed exome sequencing of 7 white female patients with SIC. Filtering of the identified variants was performed to limit our investigation to those sequences that passed quality control criteria, were rare or novel, were determined algorithmically to have high impact on the associated protein, and were within regions of high species conservation. All variants were verified by using Sanger sequencing.

RESULTS

Exome-sequencing analysis revealed that each patient carried predicted deleterious variants affecting known cardiomyopathy genes. In each case, the identified variant was either not previously found in public human genome data or was previously annotated in a database of clinical variants associated with cardiac dysfunction.

CONCLUSION

Patients with SIC harbor deleterious mutations in established cardiomyopathy genes at a level higher than healthy controls. We hypothesize that patients at highest risk for SIC likely live in a compensated state of cardiac dysfunction that manifests clinically only after the myocardium is stressed. In short, we propose that SIC is another example of an occult cardiomyopathy with a distinct physiological trigger and suggest that alternative clinical approaches to these patients may be warranted.

ABBREVIATIONS

CADD, Combined Annotation Dependent DepletionFPKM, fragments per kilobase pair of exon per million fragments mappedNHLBI GO ESP, National Heart, Lung, and Blood Institute Grand Opportunity Exome Sequencing ProjectPCR, polymerase chain reactionSIC, stress-induced cardiomyopathy.

Arrhythmias in takotsubo cardiomyopathy

Acute emotional or physical stress can trigger a catecholamine-mediated myocardial stunning known as takotstubo cardiomyopathy (TCM). Although TCM is generally reversible, it can be associated with significant morbidity, including secondarily to cardiac arrhythmia. Lethal arrhythmias such as heart block, ventricular tachycardia, and ventricular fibrillation have been described. Repolarization abnormalities associated with TCM can lead to characteristic T-wave abnormalities and QT prolongation that place patients at increased risk for ventricular arrhythmia, including torsades de pointes. This article focuses on the arrhythmic complications associated with TCM and explores the underlying etiology of these arrhythmias.

Epidemiology and pathophysiology of Takotsubo syndrome

Takotsubo syndrome is an acute cardiac syndrome first described in 1990 and characterized by transient left ventricular dysfunction affecting more than one coronary artery territory, often in a circumferential apical, mid-ventricular, or basal distribution. Several pathophysiological explanations have been proposed for this syndrome and its intriguing appearance, and awareness is growing that these explanations might not be mutually exclusive. The reversible apical myocardial dysfunction observed might result from more than one pathophysiological phenomenon. The pathophysiology of Takotsubo syndrome is complex and integrates neuroendocrine physiology, potentially involving the cognitive centres of the brain, and including the hypothalamic-pituitary-adrenal axis. Cardiovascular responses are caused by the sudden sympathetic activation and surge in concentrations of circulating catecholamines. The multiple morphological changes seen in the myocardium match those seen after catecholamine-induced cardiotoxicity. The acute prognosis and recurrence rate are now known to be worse than initially thought, and much still needs to be learned about the epidemiology and the underlying pathophysiology of this fascinating condition in order to improve diagnostic and treatment pathways.