Update of Takotsubo cardiomyopathy: Present experience and outlook for the future

Takotsubo cardiomyopathy (TTS) has become a recognised clinical entity since the Japanese scientist Sato first described it in 1990. Despite an increasing number of confirmed cases, especially during the COVID-19 pandemic, its pathophysiology remains incompletely understood, and decision-making differs in the diagnosis and treatment. In addition, it is not evident whether a significant increase in TTS is due to better understanding among practitioners and widespread access to coronary angiography, or if it is a reflection of an actual increase in incidence. We analysed a series of international research studies from 1990 to 2021. Beyond epidemiology and clinical presentation, we evaluated and summarised fundamental knowledge about various predisposing factors, with particular attention to the iatrogenic impact of certain drugs, namely antidepressants, chemotherapy, and antiarrhythmics. Furthermore, we highlighted the main pathophysiological theories to date. In addition, based on published studies and clinical cases, we investigated the role of numerous diagnostic approaches in the differential diagnosis of TTS and identified predictors of TTS complications, such as cardiogenic shock, ventricular fibrillation, and left ventricular thrombi. Accordingly, we sought to propose a diagnostic algorithm and further treatment management of TTS under the presence of possible complications to help practitioners make more informed decisions, as the initial presentation continues to pose a challenge due to its close similarity to acute coronary syndrome with ST-elevation. In conclusion, this article examines Takotsubo cardiomyopathy from different perspectives and, along with future systematic reviews and meta-analyses, can be of particular interest to practising cardiologists and researchers in developing clinical guidelines.

Takotsubo Syndrome After Surgical and Nonsurgical Oral and Maxillofacial Events: Review of Published Cases

PURPOSE

Takotsubo syndrome (TS) is an acute and potentially serious cardiac disorder that is often attributed to an exuberant catecholaminergic response to a severely physical or emotional event. As there is a paucity of information in the dental literature on TS, this article will provide an overview of this uncommon syndrome, including clinical presentation, demographic characteristics, etiopathogenesis, diagnosis, management, and recovery, particularly emphasizing its occurrence with oral and maxillofacial procedures.

PATIENTS AND METHODS

A PubMed search with the keyword "takotsubo" for publications from 1991 through May 2018 yielded 3,778 articles. Case reports and case series of TS associated with surgical and nonsurgical procedures in the oral and maxillofacial region were reviewed. Other cases were identified using a defined search strategy.

RESULTS

The literature search identified 28 documented episodes of TS that occurred with head and neck surgical procedures, mostly sinus, carotid, nasal, and cancer reconstruction surgical procedures, and notably, 3 cases occurred concurrently with dental extractions. In all of the featured patients, some degree of cardiovascular impairment developed and phenotypic overlap with acute occlusive coronary disease was shown. Most patients recovered within 2 weeks, and recovery in the remainder extended up to 3 months.

CONCLUSIONS

On rare occasions, TS has been reported in association with oral and maxillofacial procedures. As stress appears to be a precipitating factor in the development of TS, perioperative efforts should be instituted to reduce an adrenergic cascade.

Differences between Takotsubo cardiomyopathy and reverse Takotsubo cardiomyopathy associated with subarachnoid hemorrhage

BACKGROUND

Both Takotsubo cardiomyopathy (TTC) and reverse TTC (r-TTC) are characterized by reversible regional wall motion abnormalities of the heart unrelated to coronary artery pathology. It remains unclear whether and/or how r-TTC differs from TTC. Subarachnoid hemorrhage (SAH) is occasionally causative of TTC/r-TTC, and this study was conducted to detect possible differences between TTC and r-TTC associated with SAH.

METHODS

A single-center retrospective study was conducted on 328 consecutive SAH patients. They routinely underwent transthoracic echocardiography (TTE), ECG, and measurements of plasma catecholamines and other cardiac biomarkers within 24 h of admission. Demographic, echocardiographic, electrocardiographic and neurochemical profiles were compared between patients with TTC and r-TTC. The diagnosis of TTC/r-TTC was based on the revised Mayo Clinic Criteria.

RESULTS

Data of 21 SAH-induced TTC and 10 SAH-induced r-TTC patients admitted between January 2009 and December 2014 were analyzed. The patients with r-TTC were significantly younger than those with TTC (51.8 ± 10.9 vs. 63.5 ± 14.4 years, p = 0.04). The former exhibited significantly higher plasma epinephrine levels than the latter (809 ± 710 vs. 380 ± 391 pg/mL, p = 0.04). Plasma norepinephrine levels did not differ significantly (2421 ± 1374 vs. 1724 ± 1591 pg/mL, p = 0.25). No significant differences were observed in other demographic/physiologic variables, echocardiographic parameters, frequency of ECG abnormalities, and 90-day mortality. Moreover, none of the patients who underwent a follow-up TTE exhibited morphologic change from one type to the other.

CONCLUSIONS

The pathomechanisms in TTC and r-TTC may not be identical: however, distinguishing the two conditions may not have great importance from the standpoint of clinical management and prognostication.

Takotsubo cardiomyopathy: a novel beta-adrenergic blocker withdrawal syndrome

The authors describe two cases of takotsubo cardiomyopathy developing after an abrupt withdrawal of carvedilol and bisoprolol. Takotsubo or stress cardiomyopathy is characterized by acute and reversible cardiac dysfunction without coronary artery disease. It is triggered by acute emotional or physical stress, drugs or drug withdrawal. The immediate discontinuation of the long acting vasodilator beta-blocker, carvedilol has not yet been described to cause takotsubo cardiomyopathy. The authors recommend cautious withdrawal of beta-blockers. Orv. Hetil., 2013, 154, 267–271.