Takotsubo Cardiomyopathy-Acute Cardiac Dysfunction Associated With Neurological and Psychiatric Disorders

Subarachnoid hemorrhage with Takotsubo syndrome as the prominent manifestation: A case and literature review

Background

Takotsubo syndrome, which is often induced by physical or psychological stress, is typically a cardiac syndrome with transient left ventricular dysfunction in the absence of obstructive coronary artery disease. Subarachnoid hemorrhage with typical symptoms and signs is frequently reported, whereas the incidence of subarachnoid hemorrhage with Takotsubo syndrome as the prominent manifestation without a typical headache is rarely reported.

Case description

We present a rare case of a 63-year-old male patient with cough and fever as the first manifestations, accompanied by mild dizziness, headache, and mental discomfort; however, the patient was eventually diagnosed with atypical subarachnoid hemorrhage with Takotsubo syndrome. The patient underwent general anesthesia downwards stent-assisted spring coil embolization and was discharged from the hospital after postoperative treatment consisting of anti-cerebrovascular spasm, anti-platelet aggregation, and cerebrospinal fluid replacement.

Conclusion

This case demonstrates the association between Takotsubo syndrome and subarachnoid hemorrhage. When patients present with unexplained pulmonary edema with mild neurologic symptoms, clinicians should be alerted to subarachnoid hemorrhage and Takotsubo syndrome.

Dobutamine-Induced Takotsubo Cardiomyopathy With Severe Left Ventricular Dysfunction

Takotsubo cardiomyopathy (TCM) is characterized by severe left ventricular dysfunction. It presents as an acute coronary syndrome; however, the difference lies in the lack of coronary artery obstruction during a coronary angiogram. The left ventricular dysfunction extends beyond the area supplied with concordant coronary arteries. We describe a case of a 41-year-old female evaluated for acute coronary syndrome, later diagnosed with a unique reverse subtype of TCM.

Takotsubo syndrome and its linkage to neuroendocrinological disorders: a case report

Takotsubo syndrome (TTS) is an increasingly diagnosed entity, however the underlying pathophysiological mechanisms and their clinical implications are incompletely understood. An 82-year-old female, diagnosed with pituitary apoplexy, presented with ECG abnormalities and hsTnI levels consistent with an acute coronary syndrome and therefore underwent urgent coronary angiography that showed no significant stenosis and apical ballooning at left ventricle angiogram and therefore a TTS diagnosis was made. Moreover, during catheterization a 20 s Torsade de Pointes was registered. TTS is an entity that can be triggered by numerous conditions. This case of TTS was linked to many neuroendocrinological disorders.

Takotsubo syndrome: A current review of presentation, diagnosis, and management

Takotsubo syndrome is a syndrome of acute heart failure due to left ventricular systolic dysfunction that is associated with increased cardiovascular morbidity and mortality. It occurs in both sexes and at all ages, but predominates in post-menopausal women for reasons that are unclear. In a patient who presents with cardiac symptoms, electrocardiographic changes, and/or biomarker elevation indicating myocardial stress (i.e. troponin elevation), this condition should be considered in the differential diagnosis. Cardiac imaging is critical for a timely diagnosis of this condition and has management implications. This syndrome can occur with or without underlying coronary artery disease, and while there are various characteristic myocardial patterns described on imaging, the most common one is left ventricular dysfunction due to apical stunning with basal hyperkinesis. In the acute phase, Takotsubo syndrome can lead to life-threatening sequelae, including cardiogenic shock, pulmonary edema, thromboembolism, and arrhythmias. Multiple pathophysiologic mechanisms are implicated, including an acute increase in left ventricular afterload in the setting of sympathetic activation with a catecholamine storm, multi-vessel coronary vasospasm, coronary endothelial microvascular dysfunction, and inflammation. In this review, we discuss the current knowledge surrounding presentation, diagnosis, and treatment of this under-diagnosed condition.

Pathophysiology of stress cardiomyopathy: A comprehensive literature review

Introduction

Takotsubo cardiomyopathy is a transient type of acute heart failure with distinct wall motion abnormalities and unclear pathophysiology. This review focuses on the proposed pathophysiological mechanisms that could be involved in the occurrence takotsubo cardiomyopathy.

Main body

Acute stress and subsequent excessive activation of the sympathetic nervous system are major factors in the pathophysiology of takotsubo cardiomyopathy. The high levels of catecholamine work in a triggering manner, generate reactive oxygen species, release inflammatory cytokines, and induce endothelial injury. The incidence of Takotsubo cardiomyopathy has increased following COVID-19 infection and vaccination, which suggests that neurohormonal and psychological factors (i.e., fear and anxiety of infection or vaccination) may have an additional role in the pathophysiology. In addition, inflammatory state, cytokine storm, augmented sympathetic activity, and endothelial dysfunction during the acute phase of COVID-19 infection may participate in Takotsubo cardiomyopathy. Chronic stress is also linked to this complex mechanism by accelerating cripple of endocrinal hypothalamic-pituitary-adrenal axis activity, which influences the cortisol effect on releasing catecholamine, which is directly related to the pathogenesis of takotsubo cardiomyopathy.

Conclusion

The excessive activation of the sympathetic nervous system and subsequent high levels of catecholamines could initiate the process. The catecholamines, in turn, generate reactive oxygen species and release inflammatory cytokines (i.e., IL-1, IL-2, IL-6, IL-7, IL-8, CXCL1, TNF-α, and IFN-γ), which causes endothelial injury.

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The excessive activation of the sympathetic nervous system is the major drive for Stress Cardiomyopathy.

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Catecholamines are responsible for the subsequent endothelial injury.

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IL-1, IL-2, IL-6, IL-7, IL-8, CXCL1, TNF-α, and IFN-γ are the major cytokines involved in Stress Cardiomyopathy.

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.

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

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

Risk factors for delirium among SARS-CoV-2 positive veterans

There have been increasing reports of atypical neuropsychological symptoms among patients hospitalized with Coronavirus Disease 2019 (COVID-19). Although numerous pathophysiological mechanisms have been proposed to account for the association between COVID-19 and delirium, few studies have examined factors associated with its development and none have done so in the context of a veteran sample. The current study exploratorily examined demographic and medical variables that might be associated with delirium among a cohort of SARS-CoV-2 positive veterans. Demographic and medical data were extracted from the computerized patient records of 162 veterans who were admitted to a large southeastern Veterans Affairs hospital for COVID-19 complications between March 1, 2020 and April 20, 2020. At the zero-order level, age, a history of cardiovascular illness, length of stay, intensive care unit admission, initiation of new dialysis, and the development of new thromboembolic or cardiac findings were associated with delirium. However, when simultaneously examining the impact of these predictor variables in a logistic regression, only length of stay and new cardiac findings increased the odds of delirium. Findings highlight the importance of continued investigation into factors that may account for neuropsychiatric dysfunction among COVID-19 patients.

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

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

The Brain-Heart Link: A Case Report of a Critically Located Multiple Sclerosis Lesion in the Brainstem Leading to Recurrent Takotsubo Syndrome

Various central nervous system (CNS) diseases, including neurovascular and neuroinflammatory diseases, can lead to stress cardiomyopathy, also known as Takotsubo syndrome (TTS). We present a case of a 69-year-old woman with cardiovascular comorbidities, suffering from repeated episodes of TTS and respiratory failure due to a critical lesion in the brainstem, leading to a diagnosis of multiple sclerosis (MS). Despite aggressive treatment, intractable and recurrent symptoms in our patient occurred. Repeated bouts of autonomic dysfunction and respiratory failure ultimately led to installment of palliative care and the patient passing away. TTS should raise suspicion for underlying neurological diseases. Thorough questioning of previous neurological symptoms and extensive neurological workup is warranted. MS should be considered as a trigger of TTS also in elderly patients with cardiovascular risk factors.

Association of marital status with takotsubo syndrome (broken heart syndrome) among adults in the United States

BACKGROUND

The pathophysiology of takotsubo syndrome (TTS) is not well understood, however, it is often precipitated by psychological or physical stress. Marital status is related to emotional stress, but its associations with TTS are limited.

AIM

To explored the potential association between marital status and TTS.

METHODS

We conducted a case-control study using data on patients aged ≥ 40 years with marital status data in the National Hospital Discharge Survey (2006-2010). The International Classification of Diseases Ninth Revision codes were used to identify cases with TTS and other comorbid conditions. Each case was matched to 5 controls by age, sex, year of TTS diagnosis and bed size of hospital. Two sets of controls were selected: Acute myocardial infarction (AMI) controls and non-cardiovascular disease (CVD) controls. Conditional logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for the association of marital status with TTS.

RESULTS

The 59 patients with TTS who had information on marital status were matched to 295 controls with AMI and 295 non-CVD controls, resulting in a sample of 649 patients. The average age of cases was 69.7 ± 11 years with 90% being women and 88% reporting White race. In multivariable-adjusted models, compared to singles, patients who were married had lower odds of TTS (OR = 0.86, 95%CI: 0.79–0.93) while those who were widowed (OR = 1.14, 95%CI: 1.05–1.23) or divorced/separated (OR = 1.32, 95%CI: 1.21–1.45) had elevated odds for TTS when compared to non-CVD controls. Similar results were observed when cases were compared to controls with AMI.

CONCLUSION

In this study, being married was associated with lower odds for TTS while being divorced/separated or widowed was related to elevated odds for TTS. These novel findings that underscore the potential importance of social factors like marital status in the development of TTS need confirmation in larger studies.

The brain-heart interaction in epilepsy: implications for diagnosis, therapy, and SUDEP prevention

The influence of the central nervous system and autonomic system on cardiac activity is being intensively studied, as it contributes to the high rate of cardiologic comorbidities observed in people with epilepsy. Indeed, neuroanatomic connections between the brain and the heart provide links that allow cardiac arrhythmias to occur in response to brain activation, have been shown to produce arrhythmia both experimentally and clinically. Moreover, seizures may induce a variety of transient cardiac effects, which include changes in heart rate, heart rate variability, arrhythmias, asystole, and other ECG abnormalities, and can trigger the development of Takotsubo syndrome. People with epilepsy are at a higher risk of death than the general population, and sudden unexpected death in epilepsy (SUDEP) is the most important direct epilepsy-related cause of death. Although the cause of SUDEP is still unknown, cardiac abnormalities during and between seizures could play a significant role in its pathogenesis, as highlighted by studies on animal models of SUDEP and registration of SUDEP events. Recently, genetic mutations in genes co-expressed in the heart and brain, which may result in epilepsy and cardiac comorbidity/increased risk for SUDEP, have been described. Recognition and a better understanding of brain-heart interactions, together with new advances in sequencing techniques, may provide new insights into future novel therapies and help in the prevention of cardiac dysfunction and sudden death in epileptic individuals.

Left Ventricular Free Wall Rupture in Broken-Heart Syndrome: A Fatal Complication

Takotsubo cardiomyopathy is usually a transient condition and is treated conservatively. It is rarely associated with ventricular free wall rupture, a fatal complication of the disease described in this report. Cardiothoracic surgery performed emergent ventricular wall repair; however, treatment was unsuccessful, and the patient expired.

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

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

[Case Report] Stress induced (Takotsubo) cardiomyopathy triggered by the COVID-19 pandemic

Stress induced (Takotsubo) cardiomyopathy (TC) represents an acute heart failure syndrome triggered by physical or emotional stressors. COVID-19 pandemic has caused an unprecedented health crisis resulting in fear, distress and anxiety, with emerging cardiovascular implications. COVID-19 related stress can act as potential trigger for TC. We present a case of an elderly female who developed TC due to stress surrounding COVID-19.