Usefulness of MRI in takotsubo cardiomyopathy: a review of the literature

An Extensive Review on Imaging Diagnosis Methods in Takotsubo Syndrome

Takotsubo Syndrome (TS) is an acute, reversible cardiac dysfunction, with complex, not entirely understood pathophysiology and heterogeneous clinical picture. Imaging methods each have a crucial role in the diagnosis, in-hospital management, short term and long term follow up. Coronary angiography needs to be performed, especially in the setting of a suspected acute coronary syndrome, in order to rule out coronary artery disease. Echocardiography plays a central role both in the acute and the chronic phase. It is the first imaging investigation performed in patients with TS, valuable to diagnose systolic dysfunction, the wall motion pattern and early complications. Cardiac magnetic resonance tissue characterization provides an essential role in the differential diagnosis of TS with other non-ischemic causes of systolic dysfunction. This review focuses on the imaging methods and the important part they play in the complex management of the disease.

A novel and simple cardiac magnetic resonance score (PE2RT) predicts outcome in takotsubo syndrome

OBJECTIVES

To find simple imaging-based features on cardiac magnetic resonance (CMR) that are associated with major adverse cardiovascular events (MACE) in takotsubo syndrome (TTS).

METHODS

Patients with TTS referred for CMR between 2007 and 2021 were retrospectively evaluated. Besides standard CMR analysis, commonly known complications of TTS based on expert knowledge were assessed and summarised via a newly developed PE2RT score (one point each for pleural effusion, pericardial effusion, right ventricular involvement, and ventricular thrombus). Clinical follow-up data was reviewed up to three years after discharge. The relationship between PE2RT features and the occurrence of MACE (cardiovascular death or new hospitalisation due to acute myocardial injury, arrhythmia, or chronic heart failure) was examined using Cox regression analysis and Kaplan-Meier estimator.

RESULTS

Seventy-nine patients (mean age, 68 ± 14 years; 72 women) with TTS were included. CMR was performed in a median of 4 days (IQR, 2-6) after symptom onset. Over a median follow-up of 13.3 months (IQR, 0.4-36.0), MACE occurred in 14/79 (18%) patients: re-hospitalisation due to acute symptoms (9/79, 11%) or chronic heart failure symptoms (4/79, 5%), and cardiac death (1/79, 1%). Patients with MACE had a higher PE2RT score (median [IQR], 2 [2-3] vs 1 [0-1]; p < 0.001). PE2RT score was associated with MACE on Cox regression analysis (hazard ratio per PE2RT feature, 2.44; 95%CI: 1.62-3.68; p < 0.001). Two or more PE2RT complications were strongly associated with the occurrence of MACE (log-rank p < 0.001).

CONCLUSIONS

The introduced PE2RT complication score might enable an easy-to-assess outcome evaluation of TTS patients by CMR.

KEY POINTS

• Complications like pericardial effusion, pleural effusion, right ventricular involvement, and ventricular thrombus (summarised as PE2RT features) are relatively common in takotsubo syndrome. • The proposed PE2RT score (one point per complication) was associated with the occurrence of major adverse cardiac events on follow-up. • Complications easily detected by cardiac magnetic resonance imaging can help clinicians derive long-term prognostic information on patients with takotsubo syndrome.

The Stressed Heart: A Case Report of Takotsubo Cardiomyopathy in a Patient With Known Coronary Artery Disease

Takotsubo cardiomyopathy and acute coronary syndrome are often clinically indistinguishable, making their differentiation challenging for physicians. We present a case of a 65-year-old female who presented with acute chest pain, shortness of breath, and a recent psychosocial stressor. This is a unique case in which our patient, with known history of coronary artery disease and recent percutaneous intervention, favored a misleading initial diagnosis of non-ST elevation myocardial infarction.

Takotsubo cardiomyopathy in a female presenting with status asthmaticus: a case report and review of literature

Background

Takotsubo cardiomyopathy (TCM) is a non-ischemic syndrome characterized by transient acute left ventricular dysfunction as evident on transthoracic echocardiography. It can often mimic myocardial ischemia and is characterized by the absence of angiographic evidence of obstructive coronary artery disease. Reports of Takotsubo syndrome in elderly with asthma exacerbations have been noted.

Case presentation

We describe a case of TCM in a 68-year-old female who presented with acute shortness of breath secondary to status asthmaticus. Her electrocardiogram showed ST segment elevations in multiple coronary artery distributions and mildly elevated troponin levels. Coronary angiography showed no significant stenosis of the coronary arteries with left ventriculography that showed systolic apical ballooning with a 10% ejection fraction, consistent with TCM.

Conclusions

Takotsubo syndrome should be considered in the differential diagnosis of patients presenting with status asthmaticus and elevated troponin levels on admission. Patients should be asked about the use of beta agonist prior to admission. A thorough literature review including a summary of 11 previously published case reports of TCM with acute asthma exacerbations has been presented.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43044-022-00310-9.

Serotonin Syndrome Induced Tako-Tsubo Syndrome

Tako-tsubo syndrome is characterized by temporary systolic dysfunction of the left ventricle in the absence of coronary artery disease. Serotonin syndrome is a life-threatening condition associated with increased serotonergic activity in the central nervous system (CNS). We report a case of Tako-tsubo syndrome following seizures secondary to serotonin syndrome.

Takotsubo Cardiomyopathy: Role of Cardiac MRI

We present a case of Takotsubo Cardiomyopathy (TC) which is a non ischemic cardiomyopathy. It is stress related and also known as broken heart syndrome. The patient presented to our emergency department with symptoms of chest pain and breathlessness. The patient was diagnosed as acute coronary syndrome and various tests including ECG, Screening ECHO, Coronary CT and Cardiac Magnetic Resonance (CMR) were done before arriving at the diagnosis of TC. Currently CMR is the modality of choice as it detects the wall motion abnormalities (WMA), presence of wall edema and late gadolinium enhancement (LGE) characteristics can be well appreciated. No intervention was done and the case was managed medically.

Myocardial Viability Imaging using Manganese-Enhanced MRI in the First Hours after Myocardial Infarction

Early measurements of tissue viability after myocardial infarction (MI) are essential for accurate diagnosis and treatment planning but are challenging to obtain. Here, manganese, a calcium analogue and clinically approved magnetic resonance imaging (MRI) contrast agent, is used as an imaging biomarker of myocardial viability in the first hours after experimental MI. Safe Mn2+ dosing is confirmed by measuring in vitro beating rates, calcium transients, and action potentials in cardiomyocytes, and in vivo heart rates and cardiac contractility in mice. Quantitative T1 mapping-manganese-enhanced MRI (MEMRI) reveals elevated and increasing Mn2+ uptake in viable myocardium remote from the infarct, suggesting MEMRI offers a quantitative biomarker of cardiac inotropy. MEMRI evaluation of infarct size at 1 h, 1 and 14 days after MI quantifies myocardial viability earlier than the current gold-standard technique, late-gadolinium-enhanced MRI. These data, coupled with the re-emergence of clinical Mn2+ -based contrast agents open the possibility of using MEMRI for direct evaluation of myocardial viability early after ischemic onset in patients.

Takotsubo syndrome: the broken-heart syndrome

Takotsubo syndrome - also known as broken-heart syndrome, Takotsubo cardiomyopathy, and stress-induced cardiomyopathy - is a recently discovered acute cardiac disease first described in Japan in 1991. This review aims to update understanding on the epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment of Takotsubo syndrome, highlighting aspects of interest to cardiologists and general practitioners.

Takotsubo Cardiomyopathy: A Brief Review

Takotsubo cardiomyopathy is a reversible cardiomyopathy with a unique morphological feature of the left ventricle characterized by an apical ballooning appearance known for approximately known 25 years. Catecholamine drive plays an essential role in the pathogenesis and pathophysiology of Takotsubo cardiomyopathy; hence, it is also called stress cardiomyopathy. Physical stress could also have an impact and leads to a greater variety of characteristics in Takotsubo cardiomyopathy.

Supportive and symptomatic medication remains the mainstay therapy with priority to improving the function of the left ventricle for several days and full recovery in 3-4 weeks. Due to its similarity with myocardial infarction, Takotsubo cardiomyopathy requires careful diagnosis and management for the best possible outcome.

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

Takotsubo cardiomyopathy (TTC) is an acute and reversible cardiac wall motion abnormality of the left myocardium. Although many studies focused on etiology, diagnostic and treatment of TTC, precise clinical guidelines on TTC are not available. Research revealed emotional and physical triggering factors of TTC and emphasized the association of TTC with psychiatric and particularly acute neurological disorders. Similar clinical presentation of acute coronary syndrome (ACS) and TTC patients, makes an anamnestic screening for TTC risk factors necessary. In psychiatric anamnesis affective disorders and chronic anxiety disorders are presumably for TTC. Subarachnoid hemorrhages and status epilepticus are typical acute neurological associated with a higher risk for TTC. Moreover, magnetic resonance imaging (MRI) studies reveled brain alterations of the limbic system and reduced connectivity of central autonomic nervous system structures. Diagnosis of TTC is made by elevation of cardiac enzymes, electrocardiogram (ECG) and visualization of myocardial wall motion. Major differential diagnoses like acute coronary syndrome and myocarditis are hereby in synopsis with anamnesis with respect of possible emotional and physical triggering factors of TTC ruled out. In most cases the TTC typical wall motion abnormalities resolve in weeks and therapy is only necessary in hemodynamic instable patients and if rare complications, like cardiac wall ruptures occur. Recently, the two-parted International expert consensus document on Takotsubo syndrome was published, providing a detailed characterization of TTC and allows clinicians to understand this cardiac dysfunction with a multidisciplinary view.

Recurrent Takotsubo cardiomyopathy in a postmenopausal Indian lady: Is there a pattern?

Takotsubo cardiomyopathy (TTC) is a syndrome of acute left ventricular dysfunction with a clinical presentation often mimicking acute coronary syndrome. Without a high index of suspicion, this clinical entity often goes unrecognized. Although initially categorized as a benign completely reversible condition, it is no longer considered to be so. Recurrence of this condition, though rare, has been reported in a non-Indian population. We present a case of recurrent TTC in a postmenopausal Indian lady who had a similar clinical presentation both at the index event and at recurrence.

Takotsubo syndrome

Takotsubo syndrome is a reversible acute heart failure frequently precipitated by an emotional or physical stress. The clinical presentation resembles acute coronary syndrome. Pathogenesis is complex and may involve brain-heart axis and neuro-hormonal stunning of the myocardium. Coronary angiography reveals normal epicardial arteries with no obstruction or spasm. NT-ProBNP maybe remarkably elevated. Regional wall motion akinesia (RWMA) of left ventricle extends beyond the territory of one coronary artery. Reduced left ventricle ejection fraction (LVEF) and RWMA recover in 6-12 weeks. Prognosis is generally good. Recent meta-analysis shows in-hospital mortality of 1-4.5% and recurrence rate of 5-10% during five year follow-up.

Stress cardiomyopathy of the critically ill: Spectrum of secondary, global, probable and subclinical forms

Stress cardiomyopathy (SC) typically presents as potential acute coronary syndrome (ACS) in previously healthy people. While there may be physical or mental stressors, the initial symptom is usually chest pain. This form conforms to the published Mayo diagnostic criteria, is well reported and as the presentation is initially cardiac, is considered primary SC. Increasingly we see SC develop several days into the hospitalization secondary to medical or surgical critical illness. This condition is more complex, presents atypically, is not easy to recognize and carries a much worse prognosis. Label of Secondary SC is appropriate as it manifests in sicker hospitalized patients with numerous comorbidities. We review the limited but provocative literature pertinent to SC in the critically ill and describe important clues to identify global, subclinical and probable forms of SC. We illustrate the several unique clinical features, demographic differences and propose a diagnostic algorithm to optimize cardiac care in the critically ill.

Impact of cardiac magnetic resonance imaging in non-ischemic cardiomyopathies

Non-ischemic cardiomyopathies include a wide spectrum of disease states afflicting the heart, whether a primary process or secondary to a systemic condition. Cardiac magnetic resonance imaging (CMR) has established itself as an important imaging modality in the evaluation of non-ischemic cardiomyopathies. CMR is useful in the diagnosis of cardiomyopathy, quantification of ventricular function, establishing etiology, determining prognosis and risk stratification. Technical advances and extensive research over the last decade have resulted in the accumulation of a tremendous amount of data with regards to the utility of CMR in these cardiomyopathies. In this article, we review CMR findings of various non-ischemic cardiomyopathies and focus on current literature investigating the clinical impact of CMR on risk stratification, treatment, and prognosis.

Myocardial infarction, symptomatic third degree atrioventricular block and pulmonary embolism caused by thalidomide: a case report

Background

Thalidomide has been reported to cause numerous thromboembolic events. Deep vein thrombosis and pulmonary embolism are more common. It can also cause bradycardia and even total atrioventricular block. Rarely, it causes coronary artery spasm and even myocardial infarction. But almost simultaneous onset of myocardial infarction, third degree atrioventricular block and pulmonary embolism in one patient has not been reported so far.

Case presentation

A 53-year old man presented because of chest pain, nausea and then syncope for several minutes. Previous medical history included neurodermitis for which thalidomide was given and hypercholesterolemia with simvastatin taking. The patient didn’t exhibit any other established risk factors for coronary artery disease. Electrocardiography showed sinus rhythm with third degree atrioventricular block and complete right bundle branch block, and precordial leads ST segment elevation. The diagnosis of acute coronary syndrome was suspected, but further coronary angiography demonstrated no flow-limiting lesions in coronary arteries, and temporary pacemaker was implanted. After admission, low SpO₂ and elevated D-dimer level was mentioned. Further computed tomography pulmonary angiography revealed pulmonary embolism. Thalidomide was thought to be the cause of hypercoagulability and coronary spasm, so it was ceased immediately. Therapeutic low molecule weight heparin was initiated and then switched to warfarin with appropriate INR, and nifedipine was described for coronary spasm. The patient’s symptoms completely relived and SpO₂ recovered, and atrioventricular block had disappeared during hospitalization with pacemaker removed.

Conclusion

This is the very first case in which myocardial infarction, third degree atrioventricular block and pulmonary embolism almost simultaneously developed. We should be ware that anti-thrombotic prophylaxis, which needs further investigation for optimal drug and dosage, may be beneficial in thalidomide therapy. And it is also important to monitor patients taking thalidomide for signs and symptoms of bradycardia or higher degree atrioventricular block.

Takotsubo cardiomyopathy: A potentially serious trap (Data from the International Takotsubo Cardiomyopathy Registry)

Takotsubo cardiomyopathy (TTC) is an acute cardiac condition characterized by transient left ventricular dysfunction with wall motion abnormalities, most commonly in the form of apical ballooning. Despite being considered as a generally benign condition, many studies have emphasized potentially sinister outcomes associated with TTC. In this article, we review the most recent results of the International Takotsubo Registry, which investigated the clinical features, prognostic predictors, and outcomes of 1750 patients.

The evolution of capture myopathy in hooved mammals: a model for human stress cardiomyopathy?

Background and objectives: Capture myopathy (CM) syndromes in wildlife may be a model for human stress cardiomyopathy, including Takotsubo cardiomyopathy. Emotional stress or grief may trigger heart attack-like symptoms, and occasionally, sudden death in some humans. Similarly, wildlife exposed to predatory stresses, chase, or capture occasionally results in sudden death. To better understand the nature of vulnerability to stress-induced sudden death, we studied cases of CM in hooved mammals—ungulates—and hypothesized that CM would be associated with a syndrome of longevity-related traits.

Methodology: We reconstructed the evolution of CM in ungulates then determined how a set of life history traits explained variation in the likelihood that CM was reported.

Results: CM is broadly reported, but not in all genera, and phylogenetic analyses suggest that it is an evolutionarily labile trait. We found that the following traits were significantly associated with reports of CM: greater brain mass, faster maximum running speed, greater minimum group size and greater maximum longevity.

Conclusions and implications: CM may be an unavoidable consequence of adaptations to reduce predation risk that include increased running speed, sociality and having larger brains. Moreover, longer-lived species seem to be more likely to be susceptible to CM. Exploring variable susceptibility to CM highlights the evolutionary origins of the disorder, potential basic mechanisms that underlie vulnerability to the phenomenon, and the potential for reduction of risk through modification of life history trajectory.

Cardiac MR enables diagnosis in 90% of patients with acute chest pain, elevated biomarkers and unobstructed coronary arteries

OBJECTIVE

To assess the diagnostic value of cardiac MRI (CMR) in patients with acute chest pain, elevated cardiac enzymes and a negative coronary angiogram.

METHODS

This study included a total of 125 patients treated in the chest pain unit during a 39-month period. Each included patient underwent MRI within a median of 3 days after cardiac catheterization. The MRI protocol comprised cine, oedema-sensitive and late gadolinium-enhancement imaging. The standard of reference was a consensus diagnosis based on clinical follow-up and the synopsis of all clinical, laboratory and imaging data.

RESULTS

MRI revealed a multitude of diagnoses, including ischaemic cardiomyopathy (CM), dilated CM, myocarditis, Takotsubo CM, hypertensive heart disease, hypertrophic CM, cardiac amyloidosis and non-compaction CM. MRI-based diagnoses were the same as the final reference diagnoses in 113/125 patients (90%), with the two diagnoses differing in only 12/125 patients. In two patients, no final diagnosis could be established.

CONCLUSION

CMR performed early after the onset of symptoms revealed a broad spectrum of diseases. CMR delivered a correct final diagnosis in 90% of patients with acute chest pain, elevated cardiac enzymes and a negative coronary angiogram.

ADVANCES IN KNOWLEDGE

Diagnosing patients with acute coronary syndrome but unobstructed coronary arteries remains a challenge for cardiologists. CMR performed early after catheterization reveals a broad spectrum of diseases with only a simple and quick examination protocol, and there is a high concordance between MRI-based diagnoses and final reference diagnoses.

Ischemic heart disease in women: a focus on risk factors

Heart disease remains a major contributor to morbidity and mortality in women in the United States and worldwide. This review highlights known and emerging risk factors for ischemic heart disease (IHD) in women. Traditional Framingham risk factors such as hypertension, hyperlipidemia, diabetes, smoking, as well as lifestyle habits such as unhealthy diet and sedentary lifestyle are all modifiable. Health care providers should be aware of emerging cardiac risk factors in women such as adverse pregnancy outcomes, systemic autoimmune disorders, obstructive sleep apnea, and radiation-induced heart disease; psychosocial factors such as mental stress, depression, anxiety, low socioeconomic status, and work and marital stress play an important role in IHD in women. Appropriate recognition and management of an array of risk factors is imperative given the growing burden of IHD and need to deliver cost-effective, quality care for women.