Traumatic Events, Personality and Psychopathology in Takotsubo Syndrome: A Systematic Review

The heart-mind relationship in women cardiovascular primary prevention: the role of depression, anxiety, distress and Type-D personality in the 10-years cardiovascular risk evaluation

Introduction

Cardiovascular diseases are the leading cause of death among women. Prevention programmes underscore the need to address women-specific risk factors. Additionally, mental well-being is a significant aspect to consider when grappling with cardiovascular disease in women, particularly depression, anxiety, distress, and personality traits. This study aimed to create "at-risk" psychological profiles for women without prior cardiovascular disease history and to evaluate the association between anxiety, depression, distress, and Type-D personality traits with increased cardiovascular risk over 10 years.

Methods

219 women voluntarily participated in the "Monzino Women's Heart Centre" project for primary prevention and early diagnosis of cardiovascular diseases. Psychological profiles were developed utilising cluster analysis.

Results

The primary finding indicating that belonging to the "at-risk" psychological cluster was associated with a surge in the 10-year cardiovascular risk prediction score, despite the number of comorbid risk factors (Psychological "at-risk" cluster: β = .0674; p = .006; Risk factors: β = .0199; p = .242).

Conclusions

This finding suggests that psychological well-being of women should be assessed from the very beginning of cardiovascular prevention programmes.

Heart rate variability alterations in takotsubo syndrome and related association with psychological factors: a systematic review and meta-analysis

Psychological factors may have a precipitant role in takotsubo syndrome (TS). Aberrant Heart Rate Variability (HRV) has been reported in TS, suggesting inflexibility of the autonomous nervous system. Nevertheless, results on HRV alterations and their link with psychological factors in TS are conflicting. This work aimed to systematically explore whether TS may be associated with HRV alterations and their association with specific psychological profiles in TS patients. A literature search was conducted across databases (Pubmed, Scopus, PsycInfo, Web of Science) and empirical studies including TS patients which were evaluated in one or more HRV indices were retrieved. HRV and psychological outcomes were extracted. 10 empirical studies with 194 TS patients were included. Results showed significant alteration of HRV in TS patients, with indices compared to controls, and a progressive increase over time. Nevertheless, retrieved data presented mixed results, as also shown by a large heterogeneity in the meta-analytic findings. 2 studies found significant relationships between HRV alterations and trait-rather than state-psychological outcomes (i.e., coping strategies and emotional arousal), pointing to the need to explore the role of psychological vulnerabilities, rather than single traumatic stressors, in the association between HRV and TS.

Perceived Anxiety, Coping, and Autonomic Function in Takotsubo Syndrome Long after the Acute Event

BACKGROUND

Anxiety and depressive disorders represent predisposing factors for the autonomic dysfunctions that characterize the acute phase of Takotsubo syndrome (TS). However, there is insufficient data on this relationship after the acute event. The present study aimed at evaluating the psychological and autonomic status of patients with a history of TS.

METHODS

Ten TS patients whose acute event occurred at least 1 year prior to the evaluation and nine healthy age- and sex-matched subjects were evaluated. The cardiovascular assessment included a clinical examination, beat-to-beat heart rate monitoring to assess heart rate variability, and a psychological examination using the 16 Personality Factors-C Form (16PF), the Acceptance and Action Questionnaire-II, the Coping Orientations to Problems Experienced (COPE), the Beck Depression Inventory-II, and the State-Trait Anxiety Inventory (STAI).

RESULTS

TS patients scored significantly higher on the STAI (i.e., Anxiety Trait), 16PF (i.e., Tension), and COPE (i.e., Transcendental Orientation). TS patients also showed lower heart rate variability. Moreover, a significant inverse correlation was found between sympathetic tone (LF/HF ratio) and coping orientation.

CONCLUSIONS

Long after the acute event, TS patients are characterized by elevated anxiety, high tension, and a specific religious coping strategy.

Psychosocial and clinical characteristics of a patient with Takotsubo syndrome and her healthy monozygotic twin: a case report

Background

Takotsubo syndrome (TTS) is an acute heart failure syndrome characterized by transient left ventricular dysfunction, increased myocardial biomarkers, and electrocardiographic changes. Symptoms of TTS are similar to those of acute coronary syndromes, but there is often no significant coronary stenosis. Although emotional and physical stressors are often reported as having triggered TTS, the pathogenesis is largely unknown. To address this issue, we comprehensively characterized a monozygous pair of twin sisters, one of whom experienced TTS.

Case summary

The 60-year-old Caucasian monozygotic female twins with and without TTS were examined at the University Hospital Zurich in Switzerland. The twins completed questionnaires and clinical interviews assessing several sociopsychological factors. The twin sister with TTS exhibited higher levels of anxiety, vital exhaustion, social inhibition, and alexithymia, and lower levels of quality of and meaning in life. She was given the diagnoses of social phobia, adjustment disorder, specific anxiety disorder, obsessive-compulsive personality disorder, and an accentuated anxiety-avoidant personality disorder. Additionally, the twin with TTS experienced more-and also more severe-stressors involving life-threatening and dangerous situations over the life course.

Discussion

These monozygous female twins with and without TTS differed in several notable aspects of their psychological functioning, psychiatric status, personality, and lifetime stressor exposure. The results thus highlight several factors, besides genetic components, that may play an important role in the pathogenesis of TTS. Looking forward, larger studies using experimental and longitudinal designs are needed to elucidate the role that psychosocial factors play in TTS.

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.

Psychological Characteristics of Patients with Takotsubo Syndrome and Patients with Acute Coronary Syndrome: An Explorative Study toward a Better Personalized Care

During an acute cardiac event, Takotsubo Syndrome (TTS) and Acute Coronary Syndrome (ACS) apparently share very similar clinical characteristics. Since only a few inconsistent studies have evaluated the psychological features that characterize these different patients, the aim of the present explorative research was to investigate if post-recovery TTS and ACS patients present different psychological profiles. We also investigated whether the occurrence of acute psychological stressful episodes that had occurred prior to the cardiac event could be found in either syndrome. Twenty TTS and twenty ACS female patients were recruited. All patients completed self-report questionnaires about anxiety and depressive symptoms, perceived stress, type-D personality and post-traumatic symptoms. Results showed that only three subscales of health anxiety (i.e., Fear of Death/Diseases, Interference and Reassurance) significantly differed between the two groups, while no differences were found in the other psychological measurements. Moreover, personality traits seem to not be associated with the impact of the cardiac traumatic event. Finally, only TTS patients reported the presence of a significant emotional trigger preceding the acute cardiac event. In conclusion, post-recovery TTS patients differ from ACS patients in their level of concern about their health and in their need of reassurance and information only, probably as a result of the different clinical characteristics of the two illnesses.

Smidt Heart Institute Takotsubo Registry - Study design and baseline characteristics

Background

Takotsubo syndrome (TTS) is an acute form of transient systolic heart failure that occurs predominantly among women and in association with emotional or physical stressors. The Smidt Heart Institute Takotsubo Registry aims to establish a database through an online patient-advocate registry for deep phenotyping of this syndrome.

Methods

The Takotsubo Registry is a retrospective and prospective observational registry of individuals with a prior history of TTS. Participants are sourced through physician referrals, medical records review, peer- and self-referrals using social media. Research Electronic Data Capture (REDCap) and Mitra® microsamplers are used to collect questionnaire data and blood samples to facilitate completely remote study enrollment and participation for most participants.

Results

From January 2019 to May 2021, 125 participants (99% female, mean age: 61.5 ± 9.9 years) enrolled in the registry across 25 US states and 3 international countries, with reported first TTS event a median of 2 years prior to enrollment. Psychosocial characteristics determined by standardized questionnaires at baseline include relatively high anxiety trait (44%), moderate to severe depression severity (19%), moderate to high severity of posttraumatic stress disorder symptoms (58%) and a history of childhood trauma/abuse (50%).

Conclusions

The Smidt Heart Institute Takotsubo Registry will contribute to advancing the management of TTS by deep phenotyping to understand its pathophysiology, and identify treatment targets in a participant base for future clinical trials.

Psychological Traumas and Cardiovascular Disease: A Case-Control Study

Adverse childhood experiences could be important determinants of adult disease. The present study analyzed the association between early traumatic experiences and the onset of cardiovascular disease (CVDs). It was hypothesized that patients with CVD would report a higher number of traumatic experiences during childhood and that this association would be stronger in women. The Traumatic Experiences Checklist (TEC) was fulfilled by 75 patients with a first-time diagnosis of CVD and 84 healthy controls randomly selected from the general population. The two groups were not balanced for age and sex. Multivariate analyses of covariance (MANCOVAs) and analyses of covariance (ANCOVAs), with group (clinical vs. control) and gender (male vs. female) as between-subjects factors, and age of participants as covariate, were performed on the number and the impact of the traumatic experiences (emotional neglect, emotional abuse, physical abuse, sexual harassment, and sexual abuse) for the three age group in which the trauma was experienced (from 0 to 10, from 11 to 18, from 19 years onwards). The main results showed that participants with CVDs have experienced a higher number of early traumatic experiences compared to the control group, such as emotional neglect (p = 0.023), emotional abuse (0.008 ≤ p ≤ 0.033), and physical abuse (0.001 < p ≤ 0.038). The results also revealed that women with CVDs have experienced more traumatic events compared to the women of the control group (0.001 < p ≤ 0.020). These results seem to highlight an association between traumatic experiences in childhood and CVD in adulthood, particularly in women. Such findings could have relevant implications for clinical practice, suggesting the importance of adopting an integrated approach in the care of the patient with cardiovascular diseases paying attention also to the clinical psychological risk factors.

Persistent long-term platelet activation and endothelial perturbation in women with Takotsubo syndrome

BACKGROUND

Takotsubo (TTS) syndrome is an acute cardiac condition characterized by transient and reversible left ventricle dysfunction that mainly affects postmenopausal women. Catecholamine burst is the most accredited mechanism underpinning TTS onset and leading to endothelial dysfunction and platelet activation. Even if the use of low dose acetylsalycilic acid (ASA) in this clinical setting is based on both clinical presentation and unfavorable long-term prognosis, its efficacy has been recently challenged.

AIM

This study was designed to assess endothelial function, residual thromboxane formation and platelet aggregation in TTS women on low-dose ASA treatment at long-term follow-up.

METHODS

Twenty-eight females with previously diagnosis of TTS syndrome were enrolled. Data were compared to those obtained from 23 coronary artery disease (CAD) women with a history of acute myocardial infarction, and 26 control subjects with no TTS or clinically evident CAD. Psychological and clinical profile were assessed in all study groups at the enrollment. Main metabolites involved in L-arginine/nitric oxide pathway, urinary prostacyclin, serum and urine thromboxane metabolites were measured by LCMS/MS methods. Thrombomodulin levels were quantified using an ELISA kit, and platelet aggregation, carried out on platelet rich-plasma, was induced by ADP or by epinephrine (EPI), norepinephrine (NORE) and TRAP-6, alone or in association with ADP and evaluated by Born's method.

RESULTS

In TTS women an endothelial derangement, characterized by reduced citrulline production and increased thrombomodulin concentration, with no perturbation in prostacyclin levels, was evidenced. In addition, despite ASA treatment, TTS displayed a higher residual thromboxane formation, in parallel with an enhanced platelet response to compared to CAD.

CONCLUSIONS

Our study highlighted the presence of endothelial perturbation in TTS patients even at long-term from the index event. The residual thromboxane production and platelet aggregation still leave open the question about the use of low dose ASA in this clinical setting.

Takotsubo syndrome in COVID-19 era: Is psychological distress the key?

Covid-19 pandemic, starting from Wuhan, China spread all over the world and Italy was one of the most affected countries, especially in Lombardy, where, on February 20, the first confirmed case was detected. Italian Government ordered a national lockdown on the 9 th March 2020, forcing the population to severe restrictive isolation measures. The burden on mental health of the medical emergency related to COVID19 is progressively been revealed. Takotsubo syndrome (TTS), is estimated to represent 1-3% of patients admitted with suspected STEMI, mostly affecting elderly women with emotional stress and/or acute illness preceding the presentation. Comparing patients hospitalised from February to May 2020 with those of the corresponding period in 2019 we observed a significantly increased number of TTS diagnosis in 2020 (11 patients vs 3 in 2019), especially during the first period of lockdown. The only two males were patients with COVID-19 and were the only two who died in hospital. At psychological examination all patients enrolled report to have lived a particularly stressful experience at IES-R in the last year, without presenting the symptoms of a post-traumatic stress disorder. Most patients were positive to the allostatic overload. Only one patient showed a clinical cut-off for HADS and no one for the Fear COVID-19 scale. We finally concluded that subjects with pre-pandemic psychological distress may have experienced additional psychological overload, opening the door to TTS by a series of physiological alterations as the secretion of cortisol and catecholamines, making the subject more vulnerable to the onset of TTS.