Takotsubo Cardiomyopathy: A Brief Review

Adrenaline Auto-Injectors for Preventing Fatal Anaphylaxis

Anaphylaxis affects up to 5% of people during their lifetime. Although anaphylaxis usually resolves without long-term physical consequences, it can result in anxiety and quality of life impairment. Rarely and unpredictably, community anaphylaxis can cause rapid physiological decompensation and death. Adrenaline (epinephrine) is the cornerstone of anaphylaxis treatment, and provision of adrenaline autoinjectors (AAI) has become a standard of care for people at risk of anaphylaxis in the community. In this article, we explore the effectiveness of AAIs for preventing fatal outcomes in anaphylaxis, using information drawn from animal and human in vivo studies and epidemiology. We find that data support the effectiveness of intravenous adrenaline infusions for reversing physiological features of anaphylaxis, typically at doses from 0.05 to 0.5 μg/kg/min for 1-2 h, or ~ 10 μg/kg total dose. Intramuscular injection of doses approximating 10 μg/kg in humans can result in similar peak plasma adrenaline levels to intravenous infusions, at 100-500 pg/mL. However, these levels are typically short-lived following intramuscular adrenaline, and pharmacokinetic and pharmacodynamic outcomes can be unpredictable. Epidemiological data do not support an association between increasing AAI prescriptions and reduced fatal anaphylaxis, although carriage and activation rates remain low. Taken together, these data suggest that current AAIs have little impact on rates of fatal anaphylaxis, perhaps due to a lack of sustained and sufficient plasma adrenaline concentration. Effects of AAI prescription on quality of life may be variable. There is a need to consider alternatives, which can safely deliver a sustained adrenaline infusion via an appropriate route.

Contemporary characteristics, outcomes and novel risk score for Takotsubo cardiomyopathy: a national inpatient sample analysis

BACKGROUND

Takotsubo cardiomyopathy (TC) is an established differential diagnosis of myocardial infarction with non-obstructive coronaries with significant interest but limited data on prognostication. We reviewed the characteristics and in-hospital outcomes and developed a novel risk score for TC.

METHODS

Using the National Inpatient Sample data from 2016 to 2020, we identified adult patients (≥18 years) with acute coronary syndrome (ACS) and TC. We divided the cohort into ACS with and without TC and retrieved baseline data. Multivariable regression analysis was conducted to identify factors associated with TC diagnosis and adverse outcomes, leading to the development of a risk-scoring system.

RESULTS

Among 7 219 004 adult ACS admissions, 78 214 (1.0%) were diagnosed with TC, with a mean age of 68.2 years, 64 526 (82.5%) being female and 5475 (7.0%, compared with 8.4% for other ACS) in-hospital mortality events. Factors significantly associated with TC were female sex (OR 6.78 (95% CI 6.47 to 7.09), p<0.001) and chronic heart failure (OR 1.60 (95% CI 1.54 to 1.66), p<0.001). A novel risk score was developed, including the following parameters: male sex, age >70 years, non-white race, hypertension, hyperlipidemia, history of coronary artery bypass grafting, history of percutaneous coronary intervention, cardiac arrhythmias, renal failure, cardiogenic shock and vasopressor use. The area under curves for in-hospital mortality was 0.716 in the derivation and 0.725 in the validation cohorts.

CONCLUSIONS

TC remains a high-risk diagnosis in a minority of ACS cases, with mortality rates similar to other ACS causes. Our novel risk score offers a valuable tool for risk stratification in patients with TC, but external validation is needed to confirm its utility.

Intraoperative Reverse Takotsubo Cardiomyopathy in Liver Transplantation: An Anesthesiologist's Nightmare

BACKGROUND

Reverse Takotsubo cardiomyopathy (TTC) is a rare variant of stress cardiomyopathy, characterized by basal akinesia with apical sparing. To our knowledge, this case is the first reported in the literature of intraoperative reverse TTC (rTTC) in liver transplantation.

CASE

After a thorough workup, a 19-year-old man, diagnosed with extrahepatic biliary atresia, was taken up for living-related donor liver transplantation. The patient developed intraoperative rTTC. This case report describes the challenges and successful management of this cardiomyopathy intraoperatively and postoperatively.

CONCLUSION

Intraoperative rTTC is challenging and requires aggressive and immediate hemodynamic and pharmacological management, along with supportive treatment and management of complications. This case report describes the challenges and successful management of this cardiomyopathy intraoperatively and postoperatively. To our knowledge, this case is the first reported in the literature of intraoperative rTTC in liver transplantation.

Intraoperative Takotsubo Cardiomyopathy: A Case Report

Takotsubo cardiomyopathy (TTC) is a rare condition associated with transient akinesia of apical segments and hyperkinesia of basal segments of the heart. Although several mechanisms have been proposed to cause direct and indirect myocardial damage owing to catecholamine excess, the underlying pathophysiology remains unknown. An 18-year-old female was referred to our otorhinolaryngology outpatient clinic for a septorhinoplasty. Apart from the fear of surgery, the patient had no other health issues. After the administration of local anesthesia (lidocaine and epinephrine mix), tachycardia storms occurred and soon ended with cardiac collapse. Further evaluation revealed TTC. TTC should be considered, especially in cases of treatment-resistant hemodynamic problems after cardiac resuscitation, and nurses can play a crucial role during the preanesthetic period in helping the patient cope with the stress factors related to the upcoming surgery.

Beyond the appearances: exploring complexities in anaphylaxis differential diagnosis

PURPOSE OF REVIEW

Anaphylaxis is a severe, and potentially life-threatening hypersensitivity reaction whose diagnosis is based on clinical signs and symptoms and their prompt recognition. The presence of mimics and unusual presentations necessitate a careful evaluation and expertise in the field, due to potential diagnostic errors and hence a delay in the treatment.The aim of this review is to analyze and make an overview of the potential differential diagnosis of anaphylaxis, focusing on the clinical challenges of recognizing these conditions effectively among similar others.

RECENT FINDINGS

The presence of mimics and unusual presentations of anaphylaxis necessitate a careful evaluation, emphasizing the importance of a comprehensive diagnostic approach.Tryptase is well known marker of mast cells activation, and a useful tool assisting the diagnosis of anaphylaxis, helping to differentiate it from atypical mimickers.

SUMMARY

The differential diagnosis of anaphylaxis comprises a very wide setting, and a systematic approach assessing different categories of cardiovascular, skin, respiratory airway, neuropsychiatric, and hematologic systems, can facilitate recognition of the correct diagnosis of this complex and life-threatening condition.

Acute myocardial infarction or Takotsubo syndrome in a patient with stunned myocardium due to myocardial bridging? A case report of diagnostic dilemma clarified after serial workup

BACKGROUND

Myocardial bridging is a cardiac anomaly where a segment of epicardial coronary arteries runs through the myocardium and can rarely cause MI. Takotsubo syndrome is a stress-induced cardiomyopathy that can mimic MI. Catecholamine surge during stress can contribute to Takotsubo syndrome, but whether this surge can trigger an inconspicuous myocardial bridging to manifest symptomatically remains unclear, and alternately, whether a myocardial bridge might cause worsening of Takotsubo syndrome is also a matter that needs further research.

CASE PRESENTATION

We report the case of a patient who initially presented with features of acute exacerbation of bronchiectasis and subsequently developed symptoms and ECG features suggestive of acute myocardial infarction. Echocardiography revealed features of takotsubo syndrome, and complete myocardial bridging was revealed via coronary angiography. The patient was managed conservatively with pharmacological treatment, and after a few days, echocardiographic features were reversed. As such, the diagnosis shifted toward Takotsubo syndrome with myocardial stunning due to co-existent myocardial bridging.

CONCLUSION

We report a rare case of a patient with acute bronchiectasis exacerbation with features suggestive of acute myocardial infarction who had findings of Takotsubo syndrome and complete myocardial bridging. In the beginning, it was difficult to determine whether the symptoms arose due to acute MI resulting from myocardial bridging or were solely due to takotsubo syndrome because of stress from bronchiectasis. Although myocardial bridging is often overlooked as an etiology for acute MI, this case highlights the importance of expanding the differential diagnosis to myocardial bridging in the work-up for the cause of acute MI and how Takotsubo syndrome can mimic acute MI and pose a diagnostic challenge.

Investigating the effect of cancer medication in the development of Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TCM) is a cardiac condition that is usually characterized by sudden heart failure (HF) or chest pain that resembles acute coronary syndrome (ACS). It is identified by severe systolic dysfunction of the left ventricle (LV) and can be caused by physical, medical, or emotional stress. The pathophysiological mechanisms leading to TCM have not yet been clearly determined. TCM is a complex condition to diagnose and may go undetected during cancer treatment due to the wide variety of cardiotoxic effects associated with antineoplastic therapies. Consequently, timely identification and effective treatment are critical to enhancing the prognosis. Nevertheless, TCM is a more prevalent condition in oncology than was previously believed; therefore, clinicians who treat cancer patients should consider it in their differential diagnosis. The purpose of this manuscript is to provide physicians with a summary of the available evidence regarding the ramifications of the association between TCM and cancer to aid in improving patient management.

Spectrum of Non-Obstructive Coronary Artery Disease and Its Relationship with Atrial Fibrillation

This article aims to analyze the relationship between non-obstructive coronary artery disease (NOCAD) and atrial fibrillation (AF), exploring the underlying pathophysiological mechanisms and implications for clinical management. NOCAD and AF are prevalent cardiovascular conditions that often coexist, yet their interrelation is not well understood. NOCAD can lead to ischemic necrosis of cardiomyocytes and their replacement with fibrous tissue, sustaining focal ectopic activity in atrial myocardium. Atrial fibrillation, on the other hand, the most common sustained cardiac arrhythmia, is able to accelerate atherosclerosis and increase oxygen consumption in the myocardium, creating a mismatch between supply and demand, and thus promoting the development or worsening of coronary ischemia. Therefore, NOCAD and AF seem to be a complex interplay with one begets another.

An uncommon combination: a case report of herpes simplex virus encephalitis induced takotsubo cardiomyopathy

Background

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy or broken-heart syndrome, is a non-ischemic cardiomyopathy that presents as a transient regional systolic dysfunction of the left ventricle with minimal increase in troponins. The pathogenesis of takotsubo cardiomyopathy is not well understood. Some possible theories include increased catecholamines causing sympathetic overdrive, microvascular dysfunction, coronary spasm, or inflammation. The association of herpes simplex virus (HSV) encephalitis with takotsubo cardiomyopathy has rarely been reported with only two cases being described in literature.

Case Description

We present a patient that came in with altered mental status who was found to have herpes simplex virus 1 (HSV-1) encephalitis. During his hospital stay, the patient had developed shortness of breath on hospital day 3. The patient's troponin was found to be mildly elevated and echocardiogram revealed takotsubo cardiomyopathy with left ventricle ejection fraction (LVEF) of 20% and severe hypokinesis of all left ventricle segments except the basal segments. His echocardiogram nine months prior revealed a LVEF 60-65%. He was treated with intravenous (IV) acyclovir and repeat echocardiogram three weeks following hospitalization revealed resolution of his takotsubo cardiomyopathy.

Conclusions

Physicians should keep HSV encephalitis induced takotsubo cardiomyopathy in their differential diagnosis when patients present with HSV encephalitis along with shortness of breath and pulmonary vascular congestion on imaging.

Takotsubo syndrome as an outcome of the use of checkpoint inhibitor therapy in patients with COVID-19

Takotsubo Syndrome (TS) is a heart disease caused by extreme exposure of the body to physical or psychological stress. In the context of COVID-19, the virus can be a significant source of stress, with particular attention being paid to the cytokine storm as a cause of damage to the body. New research shows that the production of specific cytokines is linked to the activation of immune checkpoint proteins such as PD-1, PD-L1, and CTLA-4 on T cells. Although initially beneficial in combating infections, it can suppress defense and aid in disease progression. Therefore, checkpoint inhibitor therapy has been highlighted beyond oncological therapies, given its effectiveness in strengthening the immune system. However, this treatment can lead to excessive immune responses, inflammation, and stress on the heart, which can cause Takotsubo Syndrome in patients. Several studies investigate the direct link between this therapy and cardiac injuries in these patients, which can trigger TS. From this perspective, we must delve deeper into this treatment and consider its effects on the prognosis against SARS-CoV-2 infection.

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.

Cardioversion-Induced Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy or "broken heart syndrome," is a rare and reversible condition characterized by transient left ventricular dysfunction. It is typically triggered by acute emotional or physical stressors. Here, we present a unique case of TCM occurring in a 77-year-old woman following cardioversion for persistent and symptomatic atrial fibrillation. The patient underwent uncomplicated cardioversion with recent imaging showing intact global systolic function. She presented four days post-procedure for chest pain, shortness of breath, and peripheral edema. A repeat echocardiogram showed a marked decrease in cardiac function evidenced by an ejection fraction of 20-25%. The patient was readmitted and managed with IV diuretics. Symptoms resolved within three days and the patient showed improved cardiac function on imaging prior to discharge.

Cardiac Anomaly: Reverse Takotsubo Following Gallbladder Surgery

Takotsubo cardiomyopathy is an acute but often reversible left ventricular dysfunction commonly triggered by emotional stress. There are multiple variants within the general condition; however, reverse Takotsubo cardiomyopathy is a rare variant of stress-induced cardiomyopathy affecting the basilar segment of the left ventricle. This commonly manifests in younger women with clinical presentations similar to acute coronary syndrome. Cases of postoperative reverse Takotsubo cardiomyopathy are limited in the current literature. Hence, we present an 81-year-old female with shortness of breath and chest pain with exertion following a recent laparoscopic cholecystectomy. Based on her symptoms during the presentation, troponin and beta-natriuretic peptide were obtained. Results demonstrated an elevation in both markers, raising concerns for possible acute coronary syndrome (ACS). The patient subsequently underwent a transthoracic echocardiogram (TTE), which demonstrated findings consistent with reverse Takotsubo cardiomyopathy (rTTC). Therefore, we present a unique case of an 81-year-old female presenting with rTTC following laparoscopic cholecystectomy.

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.

A Case of Stress-Induced Cardiomyopathy After Ketamine Infusion

We report the case of a 64-year-old female with a history of hypothyroidism and isolated parotid sarcoidosis who presented with acute-onset chest pain and dyspnea. Echocardiogram demonstrated transiently reduced ejection fraction with apical hypokinesis, without evidence of obstructive coronary lesions on angiography, compatible with stress-induced cardiomyopathy. She received a ketamine infusion as a mental health treatment shortly before the development of symptoms, suggesting that this medication may have precipitated her cardiomyopathy. In recent years, ketamine has become a popular option for treating mental health disorders, including major depressive disorder and substance use disorders. It should be used with caution in patients with known cardiovascular disease, and its cardiac effects warrant further study.

Opioid Intoxication to Withdrawal: A Case of Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TTC) is characterized by a transient reduction in left ventricular systolic function with apical akinesis. TTC is usually associated with stress and emotional responses; however, opioid withdrawal has been identified as a rare cause of precipitation of TTC. We describe the case of an elderly female with chronic opioid dependence, who presented with symptoms of toxicity and developed TTC upon opioid withdrawal. Her symptoms improved with clonidine. In the time of an ongoing opioid crisis and an attempt to reduce opioid use among patients, this case reinforces the importance of anticipating TTC as a possibly life-threatening complication of sudden discontinuation of opioids in patients who have developed dependence on it.

Fat embolism syndrome: A severe case diagnosed early using dual-energy CT and saved with VA-ECMO and inhaled nitric oxide

Diagnosing FES is difficult and time-consuming, and identify FES as an etiology of right ventricular volume overload for early diagnosis. Because FES is a reversible condition, even severe cases can bse treated if the patient survives the acute phase.

A Case of Reverse Takotsubo Cardiomyopathy After Administering a Local Anesthetic Containing Epinephrine

Takotsubo cardiomyopathy (TCM) is a rare syndrome characterized by acute and transient distinctive wall motion abnormalities accompanied by other defined objective findings. There are many variants of TCM, including the reverse (or basal) subtype. While the pathogenesis is not fully understood, both endogenous and exogenous catecholamines have been implicated. This case report describes a 30-year-old active-duty military female who developed reverse TCM immediately following local anesthetic with epinephrine administration in preparation for an elective septorhinoplasty. She developed electrocardiogram (ECG) changes, temporary hemodynamic instability, and cardiac troponin elevation. Transthoracic echocardiogram (TTE) demonstrated significantly reduced systolic and diastolic function, with akinesis of the basal segments and normal wall motion of the apical segments, consistent with a reverse Takotsubo pattern. Coronary computed tomography (CT) angiography showed normal coronary arteries. Repeat TTE was performed two days after the initial event and showed near-complete resolution of the wall motion abnormalities. Fourteen days later, TTE showed normalization of cardiac function. While there is a favorable prognosis for most patients with this diagnosis, there does remain the potential for significant adverse outcomes, risk of recurrence, and a non-negligible mortality rate. It is widely known that physical and emotional triggers can precipitate TCM through the release of catecholamines. This case, in addition to numerous other case reports, provides further documentation and support that exogenous epinephrine administration is also associated with the development of TCM. Clinicians should consider the diagnosis of Takotsubo cardiomyopathy if hemodynamic or ECG changes arise following epinephrine administration.

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.

Diagnostic challenges between takotsubo cardiomyopathy and acute myocardial infarction-where is the emergency?: a literature review

BACKGROUND

Takotsubo cardiomyopathy (TC) is an emergency cardiovascular disease, with clinical and paraclinical manifestations similar to acute myocardial infarction (AMI), but it is characterized by reversible systolic dysfunction of the left ventricle (LV) in the absence (most of the time) of obstructive coronary artery disease (CAD).

MANAGEMENT OF PATIENTS WITH TC

TC seems to be more frequent in post-menopausal women and it is triggered by emotional or physical stress. The diagnosis of TC is based on the Mayo Clinic criteria. Initially, patients with TC should be treated as those with AMI and carefully monitored in intensive care unit. Urgent clinical and paraclinical distinction between TC and AMI is mandatory in all patients, because of the different therapeutical management between the two diseases. Chest pain and dyspnea are the most common symptoms in TC. Paraclinical diagnosis is based on cardiac biomarkers, electrocardiogram (ST-segment elevation/T wave inversion in precordial leads without reciprocal ST-segment depression in inferior leads and absence of Q waves), echocardiography (LV systolic dysfunction, regional wall motion abnormalities extended in more than one coronary territory), cardiac magnetic resonance and in most of the cases the positive diagnosis is established by performing CA to exclude obstructive CAD. The prognosis of patients with TC is considered benign in most cases, with a complete LV function recovery, but severe complications may occur, such as cardiogenic shock, LV free wall rupture, life-threatening arrhythmia, and cardiac arrest. Postoperative TC may develop after any type of surgical intervention due to acute stress and it should be differentiated from postoperative AMI. The management of patients with TC is medical and it is based on supportive care and the treatment of heart failure, while patients with AMI require myocardial revascularization.

CONCLUSIONS

TC leads to transient LV dysfunction that mimics AMI from which it should be differentiated for a good therapeutic approach. Patients with TC should be carefully monitored during hospitalization because they have a high recovery potential if optimally treated.

Current Pharmacology and Modulation of the Purinergic System in Takotsubo Syndrome Triggered by Cytokine Storm

Studies show that with the COVID-19 pandemic, the world's population went through multiple stress and anxiety factors, generating serious psychological problems, in addition, the virus also caused damage and physical stress to those contaminated. In this way, the intense emotional experiences and stressful effects on the body caused by SARS-CoV-2 are capable of triggering the excessive release of catecholamines in the body. Thus, the framework of Takotsubo Syndrome is characterized by myocardial dysfunction as a response of cardiac receptors to the spillage of such hormones in an unregulated way in the human body. The purinergic system plays a central role in this process, as it actively participates in actions responsible for the syndromic cascade, such as the stress generated by the cytokine storm triggered by the virus and the stimulation of deregulated catecholamine release. Therefore, further pharmacological studies on the role of purines in this pathology should be developed in order to avoid the evolution of the syndrome and to modulate its P1 and P2 receptors aiming at developing means of reversing or treating the Takotsubo Syndrome.

Unveiling the Multifaceted Problems Associated with Dysrhythmia

Dysrhythmia is a term referring to the occurrence of spontaneous and repetitive changes in potentials with parameters deviating from those considered normal. The term refers to heart anomalies but has a broader meaning. Dysrhythmias may concern the heart, neurological system, digestive system, and sensory organs. Ion currents conducted through ion channels are a universal phenomenon. The occurrence of channel abnormalities will therefore result in disorders with clinical manifestations depending on the affected tissue, but phenomena from other tissues and organs may also manifest themselves. A similar problem concerns the implementation of pharmacotherapy, the mechanism of which is related to the impact on various ion currents. Treatment in this case may cause unfavorable effects on other tissues and organs. Drugs acting through the modulation of ion currents are characterized by relatively low tissue specificity. To assess a therapy's efficacy and safety, the risk of occurrences in other tissues with similar mechanisms of action must be considered. In the present review, the focus is shifted prominently onto a comparison of abnormal electrical activity within different tissues and organs. This review includes an overview of the types of dysrhythmias and the basic techniques of clinical examination of electrophysiological disorders. It also presents a concise overview of the available pharmacotherapy in particular diseases. In addition, the authors review the relevant ion channels and their research technique based on patch clumping.

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.

Accurate Classification of Non-ischemic Cardiomyopathy

PURPOSE OF REVIEW

This article aims to review the accurate classification of non-ischemic cardiomyopathy, including the methods, basis, subtype characteristics, and prognosis, especially the similarities and differences between different classifications.

RECENT FINDINGS

Non-ischemic cardiomyopathy refers to a myocardial disease that excludes coronary artery disease or ischemic injury and has a variety of etiologies and high incidence. Recent studies suggest that traditional classification methods based on primary/mixed/acquired or genetic/non-genetic cannot meet the precise needs of contemporary clinical management. This article systematically describes the history of classifications of cardiomyopathy and presents etiological and genetic differences between cardiomyopathies. The accurate classification is described from the perspective of morphology, function, and genomics in hypertrophic cardiomyopathy, dilated cardiomyopathy, restrictive cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, left ventricular noncompaction, and partially acquired cardiomyopathy. The different clinical characteristics and treatment needs of these cardiomyopathies are elaborated. Some single-gene mutant cardiomyopathies have unique phenotypes, and some cardiomyopathies have mixed phenotypes. These special classifications require personalized precision treatment, which is worthy of independent research. This article describes recent advances in the accurate classification of non-ischemic cardiomyopathy from clinical phenotypes and causative genes, discusses the advantages and usage scenarios of each classification, compares the differences in prognosis and patient management needs of different subtypes, and summarizes common methods and new exploration directions for accurate classification.

Takotsubo cardiomyopathy prevalence and associated factors in patients presenting with a clinical picture of acute myocardial infarction in Palestine

BACKGROUND

Takotsubo cardiomyopathy (TC) is a transient cardiac syndrome that manifests with symptoms resembling acute myocardial infarction (MI). It is characterized by temporary wall-motion abnormalities predominantly affecting the apical and mid-portions of the left ventricle, despite the absence of significant obstructive coronary disease. TC poses diagnostic challenges due to its resemblance to ST-segment elevation myocardial infarction. Our study aimed to determine the prevalence of TC and identify the factors associated with its occurrence in patients presenting with acute MI in Palestine.

RESULTS

A retrospective analysis was conducted on a cohort of patients diagnosed with TC at Al-Makassed hospital. Women accounted for 90.7% of TC cases (95% CI 88.2-93.2%). The mean age of affected individuals ranged from 62 to 76 years. The most common presenting symptoms were chest pain (83.4%, 95% CI 80.0-86.7%) and dyspnea (20.4%, 95% CI 16.3-24.5%), often following an emotionally or physically stressful event. Electrocardiography (ECG) on admission indicated ST-segment elevations in 71.1% of cases (95% CI 67.2-75.1%), accompanied by mild elevations of Troponins in 85.0% of cases (95% CI 80.8-89.1%). Despite the initial severity, left ventricular ejection fraction (LVEF) improved from 20-49.9 to 59-76% within a mean time of 7-37 days. The in-hospital mortality rate was 1.7% (95% CI 0.5-2.8%), with complete recovery observed in 95.9% of cases (95% CI 93.8-98.1%) and rare recurrence. The underlying etiology is believed to involve exaggerated sympathetic stimulation.

CONCLUSIONS

TC should be considered as a significant differential diagnosis in acute coronary syndrome (ACS) cases, particularly among postmenopausal women with a preceding stressful event. Our study provides insights into the prevalence and characteristics of TC in the Palestinian population. While stress has been recognized as a potential trigger for TC, further research is needed to explore if there are specific associations between occupation and other unique stressors in the Palestinian context and the prevalence of TC. The study's results can raise awareness among healthcare professionals in Palestine about the prevalence and characteristics of TC in their patient population.

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.

When a Tooth Pulls the Heart Strings: Takotsubo Cardiomyopathy Post-dental Extraction

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, is a temporary left ventricular dysfunction caused by a catecholamine surge under severe stress. It's characterized by chest pain, non-specific ECG changes, and left ventricular apical ballooning observed during catheterization. We present a case of a 59-year-old postmenopausal female with a past medical history of asthma who arrived at the ED complaining of chest pain following dental extraction. The patient's abnormal ECG findings and elevated cardiac enzymes required cardiac catheterization, which revealed normal coronary vasculature but demonstrated left ventricular apical ballooning. Transthoracic echocardiogram (TTE) showed septal left ventricular hypertrophy, decreased ejection fraction (EF), and akinetic segments consistent with takotsubo cardiomyopathy. Secondary takotsubo cardiomyopathy induced by stress in the setting of dental procedures like a tooth extraction for a periapical dental abscess is rarely described in the literature. Our case serves as a reminder of the potential for stress-induced cardiomyopathy in postmenopausal women, especially those with undiagnosed underlying anxiety disorders, even following minimally invasive procedures.

Takotsubo cardiomyopathy associated with Herpes simplex encephalitis: A case report and literature review

Takotsubo cardiomyopathy (TCM) is a stress-induced cardiomyopathy characterized by transient left ventricular dysfunction. It can be triggered by various central nervous system pathologies including status epilepticus (SE) and N-methyl-d-aspartate receptor (NMDAr) encephalitis. Herpex simplex encephalitis (HSE) is a life-threatening, sporadic, encephalitis associated with focal or global cerebral dysfunction caused by herpes simplex viruses type 1(HSV-1), or less commonly, type 2(HSV-2). While approximately 20% of patients with HSE develop NMDAr antibodies, not all manifest with encephalitis clinically. We present here a 77-year-old woman admitted with HSV-1 encephalitis who presented with acute encephalopathy and seizure-like activity. Continuous EEG monitoring (cEEG) showed periodic lateralized epileptiform discharges (PLEDs) involving the left parietotemporal region but no evidence of electrographic seizures. Her early hospital course was complicated by TCM which subsequently resolved on repeat TTE. She demonstrated initial neurological improvement. However, five weeks later her mental status declined. Again, no seizures were appreciated on cEEG. Unfortunately, repeat studies including lumbar puncture and magnetic resonance imaging (MRI) of the brain were consistent with NMDAr encephalitis. She was treated with immunosuppression and immunomodulation therapies. To our knowledge we report the first case of TCM secondary to HSE without comorbid status epilepticus. However, further studies are needed to better understand the correlation between, and underlying pathophysiology of HSE and TCM, as well as any potential association with this presentation and subsequent development of NMDAr encephalitis.

Severe COVID-19 Myocarditis in a Young Unvaccinated Patient

Coronavirus disease 2019 (COVID-19) myocarditis is a rare but serious complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and has been associated with high-case fatality. For a very long time, since the beginning of the pandemic, there were no definitive guidelines to diagnose and manage this condition, probably secondary to the gaps in understanding the exact pathophysiology of the disease. We present the case of a young, unvaccinated female, with no comorbidities, who had an aggressively progressive COVID-19 myocarditis that was fatal. The patient presented with exertional dyspnea of two days duration and was found to be tachycardic with a heart rate ranging between 130-150 beats per minute. A nasopharyngeal swab for SARS CoV-2 was positive and a bedside echocardiogram showed a low ejection fraction of 20%. Within hours of presenting, she experienced a rapid decompensation requiring intubation. Due to fulminant myocarditis with cardiogenic shock, the patient was planned for cardiac catheterization, Impella placement, and extracorporeal membrane oxygenation (ECMO) support. The cardiac catheterization revealed non-obstructive coronary arteries and the hemodynamics suggested biventricular failure. However, around the time of the cardiac catheterization procedure, she had two events of cardiac arrest with pulseless electrical activity and unfortunately could not be revived after the second arrest despite all resuscitative efforts.

Epidemiology, Pathophysiology, Diagnosis, and Principles of Management of Takotsubo Cardiomyopathy: A Review

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, is a reversible syndrome commonly found among patients presenting for acute coronary syndromes, especially women. With the COVID-19 pandemic, the incidence of takotsubo cardiomyopathy was dramatically increased. However, this clinical cardiac entity remains underdiagnosed, largely due to the interplay with acute coronary syndrome. The pathophysiology of takotsubo cardiomyopathy is miscellaneous, including coronary vasospasm, microcirculatory dysfunction, catecholamine surge, and sympathetic overdrive. Diagnosing takotsubo cardiomyopathy requires a high index of clinical suspicion and multimodality tests. To date, there are no guidelines for the management of takotsubo cardiomyopathy. Thus, available data are derived from case series, retrospective analyses, and experts' opinions. Heart failure medicines were investigated in takotsubo cardiomyopathy patients. Evidence supports the benefits of angiotensin-converting enzyme inhibitors and angiotensin receptors blockers use on mortality and recurrence rates, while results from use of beta-blockers are controversial. In complicated cases, inotropes are preferred over vasopressors, except in the presence of left ventricular outflow tract obstruction, in which medical therapy is limited to fluids administration and beta-blockers. Use of oral vitamin K antagonist can benefit patients at high thrombo-embolic risk for up to 3 months. Mechanical supports are reserved for refractory hemodynamically unstable cases. This review aims to provide an update on the epidemiology, diagnosis, and outcomes of takotsubo cardiomyopathy, and an extended discussion on the management of complicated and non-complicated cases.

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.

An Incidental Finding of Takotsubo Cardiomyopathy in a Trauma Case

Takotsubo cardiomyopathy (TC) is a transient condition characterized by left ventricular wall motion abnormalities, ventricular systolic dysfunction, and apical ballooning. When initially presented, the pathology is often erroneously attributed to acute coronary syndrome (ACS) or acute-onset heart failure due to similar symptoms and electrocardiogram (ECG) findings. However, upon further review of imaging, coronary arteries are often void of disease. The highest prevalence of Takotsubo cardiomyopathy is noted in elderly, postmenopausal women who recently experienced an emotionally or physically triggering event. Although the true underlying pathophysiology of Takotsubo cardiomyopathy remains poorly elucidated, a few leading concepts suggest that stress-induced sympathetic responses may lead to catecholamine-induced cardiotoxicity. Other ideologies implicate poor coronary perfusion, neurogenic myocardial stunning, and coronary artery vasospasms. As features of TC are transient, it has an excellent prognosis, and patients see improvement in ventricular function and symptoms within weeks after the initiation of therapy. In this paper, we discuss a case of TC noted incidentally on imaging in a middle-aged female presenting with encephalopathy after a motor vehicle accident.

ATAK Complex (Adrenaline, Takotsubo, Anaphylaxis, and Kounis Hypersensitivity-Associated Coronary Syndrome) after COVID-19 Vaccination and Review of the Literature

Anaphylactic events triggered by mRNA COVID-19 vaccines are neither serious nor frequent. Kounis syndrome is described as the concomitant occurrence of acute coronary events and hypersensitivity reactions induced by vasospastic mediators after an allergic event. Kounis syndrome caused by vaccines is very rare. Up to now, only a few cases of allergic myocardial infarction after mRNA COVID-19 vaccine administration have been reported. Takotsubo cardiomyopathy is a syndrome characterized by transient wall movement abnormalities of the left ventricular apex, mid-ventricle, or other myocardial distribution, usually triggered by intense emotional or physical stress. Takotsubo cardiomyopathy after COVID-19 vaccine administration has been reported, usually with a delayed onset. A new entity characterized by the association of adrenaline administration, Takotsubo cardiomyopathy, anaphylaxis, and Kounis hypersensitivity was recently described: the ATAK complex. Here, we report a case of Takotsubo cardiomyopathy that occurred together with an anaphylactic reaction to an mRNA COVID-19 vaccine that required the use of adrenaline. The timing of the allergic reaction and the referenced clinical symptoms could not exclude the idea that Kounis syndrome occurred. Therefore, we can assume the patient presented the ATAK complex. We believe that highlighting on this ATAK complex will aid the application of proper diagnostic, preventive and therapeutic measures.

Takotsubo Cardiomyopathy and COVID-19: A Case Report and Literature Review

BACKGROUND

Takotsubo cardiomyopathy is characterized by transient regional ventricular abnormalities in the absence of coronary artery disease and is reported as a complication of COVID-19.

CASE PRESENTATION

It can have a diverse clinical presentation, occasionally resembling an acute coronary syndrome, and progress to acute heart failure and cardiogenic shock, adversely affecting patients' prognosis. A high index of suspicion and a thorough diagnostic approach supported by ancillary studies like echocardiography and coronary angiography is key for an accurate diagnosis and correct medical treatment. Herein, we report a patient with severe COVID-19 who developed Takotsubo cardiomyopathy.

CONCLUSION

We also present a detailed literature review regarding the relationship between COVID-19 and Takotsubo cardiomyopathy.

Takotsubo syndrome and COVID‐19: A systematic review

Background and Aims

Takotsubo syndrome (TTS), also known as stress cardiomyopathy, is characterized by acute and transient left ventricular dysfunction and has increased during the COVID-19 pandemic. Herein, we aim to review studies on TTS that were associated with COVID-19 infection, vaccine, and other COVID-19-related etiologies including psychosocial stressors.

Methods

We systematically searched PubMed, EMBASE, and Scopus up to May 12, 2022. We included case reports, case series, and original articles that reported at least one TTS case associated with COVID-19, or TTS cases after receiving COVID-19 vaccines, or TTS cases secondary to psychological stress due to the COVID-19 pandemic. The quality assessment was conducted using the Joanna Briggs Institute checklist.

Results

Sixty-seven articles including 102 cases were included. Hypertension was the most frequently accompanying comorbidity (N = 67 [65.6%]) and the mean left ventricular ejection fraction was 36.5%. Among COVID-19 patients, the in-hospital mortality rate was 33.3%. On the other hand, only one COVID-19-negative individual expired (2.3%). The most common presenting clinical symptom was dyspnea in 42 (73.6%) patients. the mean time interval from the first symptom to admission was 7.2 days. The most common chest imaging finding was ground-glass opacity which was reported in 14 (31.1%) participants. The most common abnormalities were T-wave inversion in 35 (43.2%) and ST-segment elevation in 30 (37%). Brain natriuretic peptide and troponin were elevated in 94.7% and 95.9% of participants, respectively.

Conclusion

The TTS in patients with COVID-19 is almost rare, whereas it could lead to a great mortality and morbidity. An individual with COVID-19, especially an elderly woman, presented with dyspnea in addition to a rise in brain natriuretic peptide and troponin should be evaluated for TTS.

Pediatric Takotsubo cardiomyopathy resulting from clonidine overdose

Takotsubo cardiomyopathy is a syndrome characterized by localized apical dysfunction of the left ventricle. It is rarely seen in pediatric patients, but can carry significant morbidity and mortality. While most commonly associated with psychosocial stressors or physical exertion, a growing number of cases are being attributed to medications. We describe a case of a six-month-old male diagnosed with Takotsubo cardiomyopathy in the setting of an accidental clonidine overdose. The patient presented with altered mental status and hypertension. In the course of his broad workup, cardiac dysfunction was indicated by bedside ultrasound in the Emergency Department. The classic apical dyskinesis was seen on a follow-up, cardiology-based echocardiogram. The patient responded to high-dose naloxone and only briefly required an epinephrine infusion. His symptoms resolved in a few days and serial echocardiograms showed a return to normal LV function. Rates of pediatric clonidine overdoses are increasing in the setting of changing prescribing practices. Our case illustrates some key features of the clinical presentation, as well as demonstrates a rare sequelae to this common toxic exposure. To our knowledge, this is the first reported pediatric case of Takotsubo cardiomyopathy secondary to a clonidine overdose.

GPER limits adverse changes to Ca2+ signalling and arrhythmogenic activity in ovariectomised guinea pig cardiomyocytes

Background: The increased risk of post-menopausal women developing abnormalities of heart function emphasises the requirement to understand the effect of declining oestrogen levels on cardiac electrophysiology and structure, and investigate possible therapeutic targets, namely the G protein-coupled oestrogen receptor 1 (GPER). Methods: Female guinea pigs underwent sham or ovariectomy (OVx) surgeries. Cardiomyocytes were isolated 150-days post-operatively. Membrane structure was assessed using di-8-ANEPPs staining and scanning ion conductance microscopy. Imunnohistochemistry (IHC) determined the localisation of oestrogen receptors. The effect of GPER activation on excitation-contraction coupling mechanisms were assessed using electrophysiological and fluorescence techniques. Downstream signalling proteins were investigated by western blot. Results: IHC staining confirmed the presence of nuclear oestrogen receptors and GPER, the latter prominently localised to the peri-nuclear region and having a clear striated pattern elsewhere in the cells. Following OVx, GPER expression increased and its activation reduced Ca²⁺ transient amplitude (by 40%) and sarcomere shortening (by 32%). In these cells, GPER activation reduced abnormal spontaneous Ca²⁺ activity, shortened action potential duration and limited drug-induced early after-depolarisation formation. Conclusion: In an animal species with comparable steroidogenesis and cardiac physiology to humans, we show the expression and localisation of all three oestrogen receptors in cardiac myocytes. We found that following oestrogen withdrawal, GPER expression increased and its activation limited arrhythmogenic behaviours in this low oestrogen state, indicating a potential cardioprotective role of this receptor in post-menopausal women.

Perioperative changes in cardiac biomarkers in juvenile cats during neutering

Perioperative myocardial injury (PMI) is commonly caused by myocardial ischemia that develops during or after non-cardiac surgery. It occurs in 17.9% of human patients after non-cardiac surgery due to elevated high-sensitive perioperation cardiac troponin. However, PMI has not been demonstrated in cats. To investigate its occurrence, this study aimed to analyze the perioperative changes in cardiac biomarkers and clinical data, including measurement of vital signs, echocardiography, blood pressure, electrocardiogram, X-ray, and anesthetic profile, in 30 juvenile cats under neutering surgery. All cats had increased high-sensitive cardiac troponin I (hs-cTnI) postsurgery compared with presurgery. In particular, 48% of cats (14/29) showed elevated hs-cTnI over a reference range after surgery. In all groups, hs-cTnI and systolic arterial blood pressure (SAP) were significantly higher at 0 h and 18 h postoperation than at preoperation. A significant positive correlation was found between hs-cTnI and SAP at 18 h postoperation. Atrial natriuretic peptides, heart rate, and left ventricular wall thickness were markedly higher at 0 h postoperation than at preoperation; however, respiratory rate and body temperature were significantly lower at 0 h postoperation than at preoperation. Anesthetic time and hs-cTnI were significantly higher at 18 h postoperation in females than in males. Significant positive correlations were observed between hs-cTnI and anesthetic time at 18 h postoperation in females. These results indicate that postoperative hs-cTnI level can greatly increase in juvenile cats and hs-cTnI measurement at perioperation is potentially beneficial for early detection and evaluation of the presence of PMI.

Takostubo syndrome combined with ventricular septal perforation: a case report

Background

The precise clinical features and etiologic basis of Takotsubo syndrome remain unclear, although an association with emotional or stressful triggers has been recognized. Ventricular septal perforation is a very rare life-threatening complication.

Case presentation

A 77-year-old female patient presented to the hospital with unrelieved chest tightness and shortness of breath. Three months ago, the patient's electrocardiogram revealed ischemic T wave inversion of the anterior wall, along with an increase in myocardial injury markers. There was no evidence of a ventricular septal defect on echocardiography. The patient was admitted to the respiratory department to treat lung lesions. The electrocardiogram demonstrated dynamic changes following admission, and the myocardial markers returned to normal, but the echocardiography revealed a ventricular septal defect. The initial diagnosis was ventricular septal perforation because of myocardial infarction with acute anterior ST-segment elevation. Coronary angiography revealed no abnormalities, but left ventricular angiography revealed an enlarged apex and VSD, with a right ventricular shunt bundle. Later, cardiac MRI revealed an apical ventricular septal defect. Further inquiry of the patient's medical history revealed that her husband died unexpectedly three months ago, and her daughter was seriously injured in a car accident, causing the patient severe emotional distress. Takotsubo syndrome was then determined in conjunction with the patient's medical history, symptoms, signs, and pertinent examinations. Without using a catheter or a surgical procedure, we managed the patient's medical condition. Two weeks later, the patient was discharged with symptoms improved.

Conclusions

Takotsubo syndrome is comparable to an acute myocardial infarction on clinical and electrocardiographic examination in the absence of significant coronary disease. Although ventricular septal perforation is most commonly associated with acute myocardial infarction, it can also happen following Takotsubo syndrome. Takotsubo syndrome complicated by ventricular septal perforation is easily misdiagnosed. The early recognition and management of this condition can avoid or reduce morbidity and mortality.

A Case Report and 31-Case Study: Does Takotsubo Cardiomyopathy in Myasthenia Gravis Patients Have a High Mortality Rate?

Myasthenia gravis is an autoimmune disorder in which antibodies are formed against post-synaptic nicotinic acetylcholine receptors that lead to impeded muscle contraction and commonly affects the oculomotor muscles. Takotsubo cardiomyopathy (TTC) is a dilated cardiomyopathy that can mimic a myocardial infarction and causes reversible systolic dysfunction. This is a case of a 66-year-old Caucasian male with a known history of ocular myasthenia gravis that presented to the emergency room with worsening dyspnea secondary to a myasthenic crisis. One day, following admission, his shortness of breath failed to improve and was found to meet the diagnostic criteria for takotsubo cardiomyopathy. A brief review of 31 previous cases summarizes the current case reports, patterns, and mortality associated with the myasthenic crisis associated with TTC.

Alcohol Withdrawal Syndrome as a Precipitating Factor of Takotsubo Cardiomyopathy on a Background of Wernicke’s Encephalopathy

Takotsubo cardiomyopathy (TC) is a rare entity defined by a temporary, reversible left ventricular systolic abnormality similar to myocardial infarction in the absence of coronary artery disease. Alcohol withdrawal syndrome (AWS) can result from a marked decrease or sudden cessation of alcohol consumption and seems to be related to excess catecholamines that induce a cardiomyotoxic effect. Wernicke's encephalopathy (WE), mostly associated with alcoholism, is caused by a deficiency in vitamin B1 (thiamine) and is severe if not supplemented in a timely manner. We present a complex case of a patient with the simultaneous presentation of two rare conditions, takotsubo cardiomyopathy, and Wernicke's encephalopathy, precipitated by an alcohol withdrawal syndrome.

TakoTsubo Syndrome: A Well-Known Disease but Not Everything Is Clear Yet

TakoTsubo Syndrome (TTS) is a stress-induced cardiac disease characterized by temporary and segmental left ventricle dysfunction, typically involving the apex. Post-menopause women are more frequently affected. ECG and clinical features at presentation may be similar to those observed in acute coronary syndrome (ACS). However underlying pathomechanisms are completely different and, for what concerns TTS, extremely debated and not yet completely understood. Some hypotheses have been proposed during years, mostly regarding catecholamine-induced cardiotoxicity and microvascular dysfunction, usually following a trigger event which may be either "emotional" (primary TTS) or "physical" (secondary TTS). Additional modulators like neuroendocrine disorders (particularly hypothalamic-pituitary-adrenal axis dysfunction and estrogen drop in menopause) may play a crucial role in TTS onset. Despite being originally considered more benign than ACS, several studies have enlightened that TTS and STEMI are burdened by the same in-hospital mortality and complications. However, TTS and ACS complications somehow differ for what concerns incidence, the underlying mechanisms, and both long- and short-term outcomes. Full recovery in TTS requires weeks to months and cases of recurrences have been described, but no single clinical feature seems to predict subsequent episodes so far. By now, apart from inhibitors of the Renin-Angiotensin-Aldosterone System (RAASi), no drug has proved to be effective either in the acute or chronic phase in reducing mortality, improving outcome, or preventing recurrences.