Transient left ventricular apical ballooning after cocaine use: is catecholamine cardiotoxicity the pathologic link?

Takotsubo Syndrome: Differences between Peripartum Period and General Population

Takotsubo syndrome (TTS) was first described in postmenopausal women with transient regional wall motion abnormalities. The trigger is usually an emotional or physical stress. The catecholamine hypothesis seems to be the most prevailing. The main difference between TTS and acute coronary syndromes is that there is no obstructive coronary disease to explain the regional abnormalities. In this form, the left ventricle resembles the fishing jar which is used to trap octopus in Japan. However, to date more atypical forms are recognized. Also, the syndrome is not limited to older women. Nowadays, TTS is presented even in pregnancy and postpartum females. Our experience revealed cases of patients during these periods and some of them suffered from reverse Takotsubo. Additionally, the initial diagnosis in some patients was other than TTS. Due to these findings, we suggest that this type of TTS is not very rare but underestimated. For this reason, further studies are needed to support and explain this condition.

Cardiac Arrest (CA) as the Initial Presentation of Cocaine-Induced Takotsubo Cardiomyopathy (TCM): A Case Report and Review of Literature

Cocaine is used as an illicit substance responsible for the most common cause of drug-related death. It is a stimulant that acts on the sympathetic nervous system and cardiovascular system leading to exaggerated, prolonged sympathetic activity due to the accumulation of neurotransmitters. Cardiovascular side effects of cocaine are coronary artery spasms, myocarditis, arrhythmias, and congestive heart failure. Takotsubo cardiomyopathy (TCM) is characterized by transient hypokinesis, akinesis, or dyskinesis of the left ventricle (LV) wall with or without apical involvement in the absence of obstructive coronary artery disease. Cocaine-induced TCM is an extremely rare condition emphasizing the need of its prompt diagnosis by the physicians. We present a case report of a 54-year-old male, brought to the emergency department (ED) after an out-of-hospital cardiac arrest (CA), found to have TCM in the setting of cocaine use. Clinicians need to understand the association between cocaine use and the development of TCM as cardiomyopathy of this type can result in complete remission after discontinuing the offending agent.

Synthetic Cathinone-Induced Myocarditis and Psychosis: A Case Report

Psychoactive substances are a diverse group of chemical substances that are ever-evolving structurally. Novel psychoactive substances are being reported in and are becoming increasingly popular in East and Southeast Asia, with synthetic cathinones becoming the drugs of choice. The use of synthetic cathinones has increased significantly over the years. However, the easy accessibility of these substances and their potentially damaging health effects have raised many concerns. Herein, we present the case of a patient who ingested mixed synthetic cathinones and eventually developed acute myocarditis and subsequent psychotic symptoms. The delayed presentation of psychosis coupled with initial cardiovascular symptoms was a unique phenomenon, making differential diagnosis challenging. The association between the use of synthetic cathinones and psychosis and myocarditis should be explored in view of the lack of relevant clinical data and potentially dire outcomes.

A Case Series of Concomitant Cardiac Electrical Disease among Takotsubo Syndrome Patients and Literature Review

The pathophysiology of Takotsubo Syndrome (TTS) is not completely understood and the trigger of sudden cardiac death (SCD) in TTS is not clear either. We therefore sought to find an association between TTS and primary electrical diseases. A total of 148 TTS patients were analyzed between 2003 and 2017 in a bi-centric manner. Additionally, a literature review was performed. The patients were included in an ongoing retrospective cohort database. The coexistence of TTS and primary electrical diseases was confirmed in five cases as the following: catecholaminergic polymorphic ventricular tachycardia (CPVT, 18-year-old female) (n = 1), LQTS 1 (72-year-old female and 65-year-old female) (n = 2), LQTS 2 (17-year-old female) (n = 1), and LQTS in the absence of mutations (22-year-old female). Four patients suffered from malignant tachyarrhythmia and recurrent syncope after TTS. Except for the CPVT patient and one LQTS 1 patient, all other cases underwent subcutaneous ICD implantation. An event recorder of the CPVT patient after starting beta-blocker did not detect arrhythmias. The diagnosis of primary electrical disease was in 80% of cases unmasked on a TTS event. This diagnosis triggered a family clinical and genetic screening confirming the diagnosis of primary electrical disease. A subsequent literature review identified five cases as the following: a congenital atrioventricular block (n = 1), a Jervell and Lange-Nielsen Syndrome (n = 1), and a family LQTS in the absence of a mutation (n = 2), LQTS 2 (n = 1). A primary electrical disease should be suspected in young and old TTS patients with a family history of sudden cardiac death. In suspected cases, e.g., ongoing QT interval prolongation, despite recovery of left ventricular ejection fraction a family screening is recommended.

Acute onset heart failure due to reverse type Takotsubo cardiomyopathy caused by a single dose of 4-Fluoroamphetamine in a healthy young individual

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4-Fluoroamphetamine (4-FA) is a popular new psychoactive stimulant that is used for recreational purposes.

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A single dose of 4-FA can lead to reverse type Takotsubo cardiomyopathy with cardiogenic shock.

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4-FA use can cause a very sudden onset of severe symptoms.

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Due to mild and late onset of effect, 4-FA users have the tendency to take an extra dose.

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Phosphodiesterase-3-inhibitors are effective for amphetamine type stimulant induced Takotsubo cardiomyopathy.

Introduction

4-fluoroamphetamine (4-FA) is a novel psychoactive stimulant with a global presence on the drug market. Despite the popularity of 4-FA, data on severe adverse effects are scarce. We present a case of laboratory confirmed 4-FA mono intoxication causing acute heart failure due to a reverse type Takotsubo cardiomyopathy.

Case

A 20-year-old male with no previous medical history and no reported previous drug use, presented to the emergency department (ED) with complaints of headache, nausea and vomiting, approximately 4.5 h after the ingestion of a single 4-FA pill. After 30 min his condition deteriorated with severe hypertension, tachycardia and respiratory failure. Echocardiography showed a reverse type Takotsubo cardiomyopathy. The patient was successfully treated with mechanical ventilation, a phosphodiesterase-3-inhibitor (PDE3-inhibitor) and diuretics. Three months after hospital admission, the patient was free of complaints and his left ventricular function fully recovered.

Conclusion

Recreational use of 4-FA may result in acute onset life-threatening cardiorespiratory toxicity, preceded by severe hypertension, even in drug-naïve patients without any medical history. Emergency physicians and cardiologists should be cautious not to underestimate life-threatening 4-FA complications.

Transient Left Ventricular Acute Failure after Cocaine Use

BACKGROUND

Cocaine is one of the most widely used illicit drugs, and it is the most common cause of drug-related death. The association of cocaine use with acute heart failure is a rare occurrence.

CASE REPORT

We report the case of a 31 years-old woman who presented Takotsubo cardiomyopathy with severe cardiogenic shock after cocaine abuse. That required the use of high doses of positive inotropic amines and mechanical ventilation. The evolution was quickly favorable after the cessation of cocaine.

DISCUSSION

Takotsubo cardiomyopathy is often related to a stressful trigger, and several cases have been described with the use of several psychostimulants. As such, it is not surprising that cocaine use can be associated with the development of Takotsubo cardiomyopathy when it results in excess release of catecholamines and excitation of adrenergic receptors.

CONCLUSION

In critical care unit, Takotsubo cardiomyopathy is a rare complication of cocaine abuse. This etiological diagnosis can be difficult especially in the absence of the concept of toxic intake as it was initially the case for our patient, but the treatment does not differ from other causes of cardiomyopathy and Cessation of cocaine use has been associated with improvement in cardiac function.

Autonomic nervous system in Takotsubo syndrome

Takotsubo syndrome (TTS) is an acute and usually reversible heart failure syndrome with symptoms resembling acute myocardial infarction, however, without obstruction of coronary arteries. In the majority of cases, TTS is preceded by emotional or physical stress and the disease concerns mainly postmenopausal women. Although several hypotheses have been introduced, the pathogenesis of TTS is controversial and still remains to be determined. As reported in recent studies, the role of the autonomic nervous system (ANS) seems to be pivotal in the pathogenesis of TTS. Therefore, the aim of this article is to summarize and discuss the current knowledge of the pathogenesis of TTS with a special focus on the ANS.

International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology

Takotsubo syndrome (TTS) is a poorly recognized heart disease that was initially regarded as a benign condition. Recently, it has been shown that TTS may be associated with severe clinical complications including death and that its prevalence is probably underestimated. Since current guidelines on TTS are lacking, it appears timely and important to provide an expert consensus statement on TTS. The clinical expert consensus document part I summarizes the current state of knowledge on clinical presentation and characteristics of TTS and agrees on controversies surrounding TTS such as nomenclature, different TTS types, role of coronary artery disease, and etiology. This consensus also proposes new diagnostic criteria based on current knowledge to improve diagnostic accuracy.

Cocaine Abuse: An Attack to the Cardiovascular System-Insights from Cardiovascular MRI

Cocaine is the most commonly used illicit drug in the European Union. Its cardiac effects are numerous and diverse, both in acute and chronic abuse, and include myocardial infarction, myocarditis, catecholamine-induced cardiomyopathy, and chronic cardiomyopathy (subclinical, hypertrophic, and dilated phases). Their clinical manifestations are vastly overlapping, and differential diagnosis should be performed using a thorough diagnostic workup featuring clinical history, laboratory tests, electrocardiography, stress test, noninvasive imaging modalities, and coronary angiography. Cardiac MRI has the unique ability of in vivo tissue characterization. This unique feature can play a pivotal role in the differential diagnosis through proper characterization of the myocardial tissue. Especially in acute settings, cardiac MRI makes it possible to distinguish between cocaine-induced myocardial infarction, cocaine-induced myocarditis, and catecholamine-induced cardiomyopathy. Conversely, in chronic cardiomyopathy, cardiac MRI permits evaluation of ventricular function and myocardial tissue, allowing the investigation of the underlying cause. On the one hand, assessing the ventricular function permits differentiation among subclinical, hypertrophic, and dilated phases of chronic cardiomyopathy; on the other hand, cardiac MRI could classify the causes underlying remodeling, including chronic ischemic injury, chronic myocarditis, and cardiac motion impairment. This review analyzes the relationship between pathophysiology, histology, and disease using the existing literature on cardiac MRI cocaine abuse evaluation. © RSNA, 2019.

International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology

Takotsubo syndrome (TTS) is a poorly recognized heart disease that was initially regarded as a benign condition. Recently, it has been shown that TTS may be associated with severe clinical complications including death and that its prevalence is probably underestimated. Since current guidelines on TTS are lacking, it appears timely and important to provide an expert consensus statement on TTS. The clinical expert consensus document part I summarizes the current state of knowledge on clinical presentation and characteristics of TTS and agrees on controversies surrounding TTS such as nomenclature, different TTS types, role of coronary artery disease, and etiology. This consensus also proposes new diagnostic criteria based on current knowledge to improve diagnostic accuracy.

The Cardiovascular Effects of Cocaine

Cocaine is the leading cause for drug-abuse-related visits to emergency departments, most of which are due to cardiovascular complaints. Through its diverse pathophysiological mechanisms, cocaine exerts various adverse effects on the cardiovascular system, many times with grave results. Described here are the varied cardiovascular effects of cocaine, areas of controversy, and therapeutic options.

Cobalt Cardiomyopathy Secondary to Hip Arthroplasty: An Increasingly Prevalent Problem

A forty-year-old man experienced worsening heart failure four years following bilateral complicated total hip replacement. His condition was extensively worked up but no underlying pathology was immediately evident. Given the cobalt-chromium alloy component present in the hip arthroplasties, the raised cobalt blood levels, and a fitting clinical picture coupled with radiological findings, the patient underwent right hip revision. Evidence of biotribocorrosion was present on direct visualisation intraoperatively. The patient subsequently experienced symptomatic improvement (NYHA class III to class I) and echocardiography showed recovery of ejection fraction. Cobalt exists as a bivalent and trivalent molecule in circulation and produces a cytotoxicity profile similar to nanoparticles, causing neurological, thyroid, and cardiological pathology. Blood levels are not entirely useful as there is no identifiable conversion factor for levels in whole blood, serum, and erythrocytes which seem to act independently of each other. Interestingly cobalt cardiomyopathy is frequently compounded by other possible causes of cardiomyopathy such as alcohol and a link has been postulated. Definitive treatment is revision of the arthroplasty as other treatments are unproven.

Drug-Induced Takotsubo Cardiomyopathy

BACKGROUND

The most plausible hypothesis for takotsubo cardiomyopathy (TCM) is a catecholamine surge. Direct administration of catecholamines or medications causing catecholamine surge is frequently used in clinical practice.

METHODS

A Medline/PubMed database search was conducted for case reports or series of drug-induced TCM. All reported cases of drug-induced TCM were systemically identified and analyzed.

RESULTS

We identified 157 cases of drug-induced TCM. Fifty-seven (36.3%) cases were related to the administration of exogenous catecholamines. In 50 (31.9%) other cases, there was potential adrenergic effect. This included drugs with adrenergic vasoconstriction properties (3.2%), hyperadrenergic state due to alcohol or opioid withdrawal (7.7%), inhibitors of catecholamine reuptake (14.7%), anaphylactic reaction that is accompanied by catecholamine release (3.2%), and psychological or somatic stress coinciding with the administration of a drug that was thought to be the culprit (3.2%). Overall, 68.2% of these drug-induced TCM cases were catecholamine related. In 14 (8.9%) cases, the likely etiology of cardiomyopathy was chemotherapy-induced coronary vasospasm.

CONCLUSION

Our systematic review showed that over two-thirds of drug-induced TCM cases were due to direct or indirect catecholamine stimulation. The lowest effective dose and shortest duration of catecholamines should be utilized, and alternative therapies should be considered if feasible.

Heart-Brain Axis: Effects of Neurologic Injury on Cardiovascular Function

A complex interaction exists between the nervous and cardiovascular systems. A large network of cortical and subcortical brain regions control cardiovascular function via the sympathetic and parasympathetic outflow. A dysfunction in one system may lead to changes in the function of the other. The effects of cardiovascular disease on the nervous system have been widely studied; however, our understanding of the effects of neurological disorders on the cardiovascular system has only expanded in the past 2 decades. Various pathologies of the nervous system can lead to a wide range of alterations in function and structure of the cardiovascular system ranging from transient and benign electrographic changes to myocardial injury, cardiomyopathy, and even cardiac death. In this article, we first review the anatomy and physiology of the central and autonomic nervous systems in regard to control of the cardiovascular function. The effects of neurological injury on cardiac function and structure will be summarized, and finally, we review neurological disorders commonly associated with cardiovascular manifestations.

The Sympathetic Nervous System in the Pathogenesis of Takotsubo Syndrome

Takotsubo syndrome is a unique clinical condition of acute heart failure and reversible left ventricular dysfunction frequently precipitated by sudden emotional or physical stress. There is growing evidence that exaggerated sympathetic stimulation is central to the pathogenesis of this syndrome. Precisely how catecholamines mediate myocardial stunning in takotsubo syndrome remains incompletely understood; but possible mechanisms include epicardial spasm, microvascular dysfunction, direct adrenergic-receptor-mediated myocyte injury, and systemic vascular effects that alter ventricular-arterial coupling. Risk factors that increase sympathetic tone and/or catecholamine sensitivity may render individuals particularly susceptible to takotsubo syndrome during episodes of acute stress.

A Case Report of Reversible Takotsubo Cardiomyopathy after Amphetamine/Dextroamphetamine Ingestion in a 15-Year-Old Adolescent Girl

Stimulant medications are used in the treatment of attention deficit hyperactivity disorder and serious cardiac complications can occur when these medications are abused. We present a 15-year-old adolescent girl who was found to have a Takotsubo cardiomyopathy after acute amphetamine/dextroamphetamine ingestion.

Takotsubo cardiomyopathy systematic review: Pathophysiologic process, clinical presentation and diagnostic approach to Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC) is characterized by transient left ventricular apical ballooning with the absence of coronary occlusion, which typically occurs in older women after emotional or physical stress. The pathophysiology of TTC is not well established, though several possible causes such as catecholamine cardiotoxicity, metabolic disturbance, coronary microvascular impairment and multivessel epicardial coronary artery spasm have been proposed. A number of diagnostic criteria have been suggested in the world and not unified as single, but the most common accepted one is Mayo Clinic proposed criteria. Since the clinical presentation of TTC is usually similar to acute coronary syndrome, differential diagnosis is essential to exclude other diseases and also for its treatment. Imaging modality including echocardiogram, angio CT and cardiac MRI, and lab tests for catecholamine, troponin T, creatine kinase MB and B-type natriuretic peptide can be useful to differentiate TTC from other diseases. Prognosis is generally favorable and in-hospital mortality is from 0% to within 10%.

Takotsubo cardiomyopathy following electroconvulsive therapy: an increasingly recognised phenomenon

Treatment of patients with severe depressive illnesses requiring electroconvulsive therapy (ECT) is challenging. This is compounded by the presence of physical comorbidities and potential complications. We report the case of a patient, on long-term bisoprolol, who developed acute epigastric pain and dyspnoea shortly after receiving ECT for treatment-refractory depression. An ECG showed new-onset ischaemic changes and a troponin-I level was elevated at 12 h. A diagnosis of Takotsubo cardiomyopathy was reached following angiography, which demonstrated left ventricular hypokinesia in the absence of coronary artery disease. With supportive treatment the patient made a good recovery. This report highlights the risk of developing Takotsubo cardiomyopathy following ECT despite β-adrenergic receptor blockade, and adds to a growing number of cases reporting this complication. Clinicians involved in the care of patients undergoing ECT must be aware of this complication and should consider Takotsubo cardiomyopathy in patients who develop atypical chest pain after ECT.

Heart and lung, a dangerous liaison-Tako-tsubo cardiomyopathy and respiratory diseases: A systematic review

AIM: To investigate the possible association between Tako-tsubo cardiomyopathy (TTC)-a reversible clinical condition mimicking an acute myocardial infarction characterized by multifactorial pathophysiologic mechanisms- and respiratory system diseases.

METHODS: We systematically searched PubMed and EMBASE medical information sources, to identify the different triggering causes, limiting our search to articles in English. The search keywords were: “tako-tsubo cardiomyopathy”, “takotsubo”, “takotsubo cardiomyopathy”, “broken heart syndrome”, “stress-induced cardiomyopathy”, “apical ballooning syndrome”, and “ampulla cardiomyopathy in combination with respiratory diseases, lung, pulmonary disease. For each kind of disease, we registered: author, year and country of study, patient sex, age, concurring situation, and outcome.

RESULTS: Out of a total of 1725 articles found, we selected 37 papers reporting a total of 38 patients. As expected, most patients were women (81.6%), mean age was 65 ± 10 years. Outcome was favorable in 100% of cases, and all the patients have been discharged uneventfully in a few days.

CONCLUSION: An association between respiratory diseases and TTC is likely to exist. Patients with severe respiratory diseases, due to the high dosages of β₂-agonists used or to the need of invasive procedures, are highly exposed to the risk of developing TTC.

Long term effects of cocaine on the heart assessed by cardiovascular magnetic resonance at 3T

BACKGROUND

Cocaine is an addictive, sympathomimetic drug with potentially lethal effects. The prevalence and features of cocaine cardiotoxicity are not well known. We aimed to assess these effects using a comprehensive cardiovascular magnetic resonance (CMR) protocol in a large group of asymptomatic cocaine users.

METHODS

Consecutive (n = 94, 81 males, 36.6 ±7 years), non-selected, cocaine abusers were recruited and had a medical history, examination, ECG, blood test and CMR. The CMR study included measurement of left and right ventricular (LV, RV) dimensions and ejection fraction (EF), sequences for detection of myocardial oedema and late gadolinium enhancement (LGE). Images were compared to a cohort of healthy controls.

RESULTS

Years of regular cocaine use were 13.9 ± 9. When compared to the age-matched healthy cohort, the cocaine abusers had increased LV end-systolic volume, LV mass index and RV end-systolic volume, with decreased LVEF and RVEF. No subject had myocardial oedema, but 30% had myocardial LGE indicating myocardial damage.

CONCLUSIONS

CMR detected cardiovascular disease in 71% of this cohort of consecutive asymptomatic cocaine abusers and mean duration of abuse was related to probability of LV systolic dysfunction.

Iatrogenic takotsubo cardiomyopathy induced by locally applied epinephrine and cocaine

A 67-year-old man underwent surgery under general anaesthesia to obtain a biopsy from a tumour in the left maxillary sinus. Before the procedure a mucosal detumescence containing epinephrine and cocaine was applied onto the nasal mucosa. Shortly after termination of anaesthesia the patient developed tachycardia and an abrupt rise in blood pressure followed by a drop to critical levels. The patient turned pale and clammy but denied chest pain at any time. An ECG showed inferolateral ST-segment elevation, and troponin T was elevated at 0.773 ng/mL. An acute coronary angiography demonstrated normal coronary arteries; however, left ventriculography showed apical ballooning of the left ventricle, and the diagnosis of takotsubo cardiomyopathy was made. This was confirmed by a subsequent transthoracic echocardiography. Four days later the patient had complete resolution of the symptoms, and a new echocardiography showed normalisation of the left ventricular systolic function with no signs of apical ballooning.

Takotsubo Cardiomyopathy following a L2-L5 Laminectomy and Fusion In Situ with Bone Morphogenic Protein

Takotsubo cardiomyopathy (TC) is a rare, transient cardiomyopathy, with symptoms mimicking myocardial infarction. It has been reported to typically occur in postmenopausal women and is often triggered by an intense physical or emotional event with stimulation of the sympathetic response; the exact etiology, however, is uncertain. Bone morphogenic protein (BMP) is widely used in spinal fusions and has been associated with numerous perioperative complications. BMP is known to stimulate sympathetic pathways. In this paper, we present the case of a patient with a 7-hour episode of TC after a spinal fusion with bone morphogenic protein. The patient's symptoms resolved and long-term followup has been uneventful. This is the first paper to describe TC in the setting of spine or other major orthopaedic surgery and it suggests another possible area for further investigation in peri-operative events potentially associated with the use of bone morphogenic protein.

Drug-induced takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC), also known as stress cardiomyopathy, is an increasingly recognized clinical syndrome of acute reversible left ventricular dysfunction precipitated by intense emotional or physical stress. Excessive sympathetic stimulation is believed to be central to the pathogenesis of this condition; thus, drugs with sympathetic effect could precipitate TTC. This review outlines previous reports regarding drugs that may induce TTC. Some reports link the use of the drug-primarily associated with sympathetic overstimulation-with the development of TTC Consequently, drug-induced TTC should be considered in patients diagnosed with TTC.

Takotsubo cardiomyopathy: a novel beta-adrenergic blocker withdrawal syndrome

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

Takotsubo cardiomyopathy: definition and clinical profile

Takotsubo cardiomyopathy (TTC) is an increasingly recognized, reversible cardiomyopathy with a clinical presentation that mimics an acute coronary syndrome but without evidence of obstructive coronary lesions. Typical presentation involves chest pain and/or dyspnea, transient ST-segment elevation on the electrocardiogram, and a modest increase in cardiac troponin. Cardiac imaging demonstrates wall-motion abnormalities that extend beyond the territory of a single epicardial coronary artery, and the absence of obstructive coronary lesions. Supportive treatment leads to spontaneous, rapid recovery of ventricular function, but about 10% of patients have recurrent events. This article reviews the defining features and clinical profile of TTC.

Norepinephrine transporter function and human cardiovascular disease

Approximately 80-90% of the norepinephrine released in the brain or in peripheral tissues is taken up again through the neuronal norepinephrine transporter (NET). Pharmacological studies with NET inhibitors showed that NET has opposing effects on cardiovascular sympathetic regulation in the brain and in the periphery. Furthermore, NET is involved in the distribution of sympathetic activity between vasculature, heart, and kidney. Genetic NET dysfunction is a rare cause of the postural tachycardia syndrome. The condition is characterized by excessive adrenergic stimulation of the heart, particularly with standing. Conversely, NET inhibition may be beneficial in hypoadrenergic states, such as central autonomic failure or neurally mediated syncope, which results from acute sympathetic withdrawal. Biochemical studies suggested reduced NET function in some patients with essential hypertension. Furthermore, cardiac NET function appears to be reduced in common heart diseases, such as congestive heart failure, ischemic heart disease, and stress-induced cardiomyopathy. Whether NET dysfunction is a consequence or cause of progressive heart disease in human subjects requires further study. However, studies with the nonselective NET inhibitor sibutramine suggest that reduced NET function could have an adverse effect on the cardiovascular system. Given the widespread use of medications inhibiting NET, the issue deserves more attention.

Status migrainosus as a potential stressor leading to takotsubo cardiomyopathy

Background:

Takotsubo cardiomyopathy is a form of non-ischemic cardiomyopathy that may be acutely precipitated by stress. A number of neurologic conditions have been implicated in precipitating this disease such as subarachnoid hemorrhage, stroke, and seizures. Its association with status migrainosus, however, has never been described before.

Case:

We report a case of a 25-year-old female presenting with status migrainosus followed by takotsubo cardiomyopathy. Supportive management was instituted in this patient and she made an excellent recovery.

Conclusion:

The intense pain associated with migraine may have acted as a stressor, thereby precipitating takotsubo cardiomyopathy. To our knowledge, this is the first reported case demonstrating a relationship between status migrainosus and takotsubo cardiomyopathy.

Stress cardiomyopathy: diagnosis, pathophysiology, management, and prognosis

Stress cardiomyopathy is now a well-recognized reversible cardiomyopathy, with a clinical presentation mimicking Acute Coronary syndrome in the absence of significant coronary artery disease. It is often encountered in postmenopausal females and is usually precipitated by acute emotional or physical stressors. In this review, we have attempted to summarize relevant data regarding diagnosis, typical and atypical presentations, pathophysiology, management options, and prognosis. Typically, patients present with chest pain and shortness of breath, transient electrocardiographic changes, moderate troponin elevation, and are found to have wall motion abnormalities (apical and midventricular akinesis with preserved basal segment systolic function) without obstructive coronary lesions, with complete resolution in next few weeks. The precise pathophysiology remains unclear, but excessive catecholamine stimulation, metabolic disturbances, and dysfunction of microcirculation are thought to be the underlying mechanisms.

Pathogenesis of the Takotsubo syndrome: a unifying hypothesis

The takotsubo syndrome (TS) is defined by a constellation of clinical observations in a subgroup of patients with acute coronary syndromes. Separating patients with TS from the general population with acute ischemic events are 2 important findings: obstructive coronary artery disease is missing, but the sine qua non is a distinctive pattern of abnormal left ventricular contraction. As with many newly recognized clinical syndromes, TS seems not to conform to accepted pathogenetic mechanisms. Thus, physicians are challenged to identify previously unrecognized mechanisms of disease. Two schools of thought have emerged in this regard. Most consider its pathogenesis to be a stress-induced neurohormonal phenomenon, while a smaller but substantial group believe that the transient occlusion of an epicardial coronary artery is responsible and that the syndrome is simply an unusual manifestation of coronary atherosclerosis. This editorial outlines briefly the evidence for each of these positions and presents a novel construct that may encompass the 2 views. Central to this unifying hypothesis is the belief that a neurohormonal surge triggers the hallmark left ventricular contraction abnormality, the sine qua non of the TS. In conclusion, the authors postulate that this pattern will result regardless of the state of the epicardial coronary arteries and can be observed in patients with angiographically normal coronary arteries, as well as those with obstructed or occluded arteries.

Disruption of coronary vasomotor function: the coronary spasm syndrome

Abnormal coronary vasoconstriction, or coronary spasm, can be the result of several factors, including local and neuroendocrine aberrations. It can manifest clinically as a coronary syndrome and plays an important role in the genesis of myocardial ischemia. Over the past half century, coronary angiography allowed the in vivo demonstration of spasm in patients who fit the initial clinical description of the condition as reported by Prinzmetal et al. Several clinical, basic, and more recently, genetic studies have provided insight into the pathogenesis, manifestations, and therapy of this condition. It is not uncommonly encountered in patients with coronary syndromes and absence of clearly pathologic lesions on angiography. Provocation tests utilizing pharmacologic and nonpharmacologic stimuli combined with imaging (echocardiography or coronary angiography) can help make the correct diagnosis. The use of calcium channel blockers and long-acting nitrates is currently considered standard of care and the overall prognosis appears to be good. The recent discovery of genetic abnormalities predisposing to abnormal spasm of the coronaries has stimulated interest in the development of targeted therapies for the management of this condition.

Takotsubo Cardiomyopathy: A Review of the Literature

Although takotsubo cardiomyopathy is a rare entity, it is an important differential in patients presenting with symptoms, signs, and electrocardiographic changes suggestive of an acute myocardial infarction. Since it was first recognized in 1991, it has gained increasing attention worldwide; however, its etiology and consequently the optimal management still remains unclear. Here, the authors provide a review of the current literature accompanied with images of a typical case from our department.

A new ECG criterion to identify takotsubo cardiomyopathy from anterior myocardial infarction: role of inferior leads

With the exception of contrast-enhanced cardiovascular magnetic resonance imaging, clear distinction of takotsubo cardiomyopathy from anterior wall myocardial infarction cannot be achieved currently by simple and noninvasive tests. The aim of this study was to examine the role of inferior ECG leads in distinguishing these two conditions. From January 2004 to June 2006, eight female patients suffering from takotsubo cardiomyopathy were identified by the Mayo Clinic criteria. The clinical and ECG features were compared with 27 consecutive sex- and age-matched patients with anterior wall myocardial infarction admitted to the Coronary Care Unit within the same period. The observed ECG features were then verified with that of 62 published cases of takotsubo cardiomyopathy. Takotsubo cardiomyopathy patients had similar left ventricular ejection fraction (35.0% +/- 5.7% vs 38.2% +/- 6.4%, P = 0.829), lower peak creatinine kinase level (461 +/- 330 U/l vs 2723 +/- 1826 U/l, P = 0.020), more ST-segment elevation in the inferior leads (50% vs 7.4%, P = 0.016), and virtually no ST-segment depression in inferior leads (0% vs 48.2%, P = 0.015) compared with patients who had anterior wall myocardial infarction. ST-segment elevation of >or=1.0 mm in lead II had 62.5% sensitivity and 92.6% specificity in detecting takotsubo cardiomyopathy. The observed ECG characteristics were comparable with those in the literature. In patients who present with anterior wall myocardial infarction, the absence of ST-segment depression or ST-segment elevation in inferior leads, especially if the ST-segment in lead II >or= III, is highly suggestive of takotsubo cardiomyopathy.

Management of Tako-tsubo syndrome

INTRODUCTION

This manuscript reviews the current evidence for proposed pathophysiological mechanisms of Tako-tsubo syndrome and its management.

DISCUSSION

The Tako-tsubo syndrome is defined by the presence of transient left ventricular apical ballooning after an acute coronary syndrome in patients with angiographically normal coronary arteries. Intriguingly, only the apex is affected and compensatory basal hypercontractility is seen. Several mechanisms have been offered as explanations for the characteristic clinical presentation and echocardiographic appearance of this syndrome.

CONCLUSION

Tako-tsubo syndrome encompasses heterogeneous patient populations and it is likely that different pathogenic mechanisms may operate in different patients. Treatment of the condition is at present empirical and aimed at preserving ventricular function.

Takotsubo cardiomyopathy: state-of-the-art review

Takotsubo cardiomyopathy (TC) is characterized by transient, often severe, left ventricular dysfunction and electrocardiographic changes that might mimic acute myocardial infarction in the absence of significant obstructive coronary artery disease. It is often encountered in elderly women after physical or emotional stress. Excessive catecholamine stimulation, metabolic abnormalities, and microcirculatory dysfunction are thought to be responsible for the manifestations of this disorder. This comprehensive review summarizes relevant published data, atypical presentations, pathophysiology, and management strategy. It also includes a review of 789 patients with TC including nine illustrative cases encountered at our institution.