Takotsubo syndrome: Advances in the understanding and management of an enigmatic stress cardiomyopathy

Diagnosis and Management of Takotsubo Syndrome in Acute Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Review

Takotsubo syndrome (TS) is a frequent complication of subarachnoid hemorrhage (SAH), especially in massive SAH with severe neurological damage. The initial presentation of TS is similar to acute coronary syndrome, causing differential diagnostic issues. Unnecessary diagnostic steps and uncertainty in therapy may delay the definitive treatment of the aneurysm, therefore increasing the risk of rebleeding. The purpose of this review is to summarize the latest knowledge on the diagnosis and therapy of TS in SAH and to provide a diagnostic and therapeutic algorithm for the acute phase, promoting the early definitive treatment of the aneurysm. Rapid hemodynamic stabilization and early aneurysm securing are key points in reducing the risk of delayed cerebral ischemia and improving outcomes. In acute SAH noninvasive bedside diagnostic methods are preferred and securing the aneurysm is the priority. The combination of electrocardiography, cardiac biomarkers, and echocardiography is of great importance in differentiating TS from acute myocardial infarction. The risk-benefit ratio of coronary angiography should be carefully and individually considered and its use should be limited to patients with strong evidence of myocardial ischemia, after the successful endovascular treatment of the aneurysm. Invasive hemodynamic monitoring may be beneficial in cases of cardiogenic shock or pulmonary edema. In patients with hemodynamical instability secondary to TS, the use of non-catecholamine inotropes, especially levosimendan is recommended. In refractory hypotension, mechanical support should be considered. The left ventricular function improves within days to months after the acute event, low initial ejection fraction may predispose to delayed recovery.

Multicenter retrospective database evaluation of Takotsubo syndrome in subjects undergoing catheter ablation for atrial fibrillation

Background

Intracardiac catheter ablation for atrial fibrillation with pulmonary vein isolation may result in Takotsubo syndrome (TS), but the frequency, predisposing factors (age, sex, mental health disorders), and outcomes are currently unknown. This study sought to assess the frequency, predisposing factors, and outcomes of subjects who underwent intracardiac catheter ablation for atrial fibrillation with pulmonary vein isolation and were diagnosed with TS.

Methods

This was a retrospective observational cohort study utilizing TriNetX® electronic health record (EHR) data. We included subjects aged older than 18 years who underwent intracardiac catheter ablation for atrial fibrillation with pulmonary vein isolation. The study population was divided into two groups (no TS diagnostic code presence and TS diagnostic code presence). We analyzed the distributions of age, sex, race, diagnostic codes, common terminology procedures (CPT), and vasoactive medication codes and examined mortality rate within 30 days.

Results

We included 69,116 subjects. Of these, 27 (0.04%) had a TS diagnostic code, the cohort was comprised mostly of females [17 (63.0%)], and 1 (3.7%) death within 30 days was reported. There were no significant differences in age and frequency of mental health disorders between those patients in TS and non-TS cohorts. Adjusting for age, sex, race, ethnicity, patient regionality, and mental health disorder diagnostic code, those patients who developed TS had a significantly higher odds of dying in 30 days after catheter ablation compared to those without TS (OR = 15.97, 95% CI: 2.10-121.55, p = .007).

Conclusions

Approximately 0.04% of subjects who underwent intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation had a subsequent diagnostic code of TS. Further study is needed to determine whether there are predisposing factors associated with the development of TS in subjects who undergo catheter ablation of atrial fibrillation by pulmonary vein isolation.

Management Challenge: An Atypical Variant of Takotsubo Presenting With Multiple Complications

An 84-year-old woman with depression, who witnessed the suicide of a close friend, presented with symptoms of chest pain, palpitations, and cold and clammy extremities. An electrocardiogram showed alternating tachycardia and bradycardia. Urgent transthoracic echocardiogram demonstrated left greater than right ventricular dysfunction, moderate mitral regurgitation, global hypokinesis, and an estimated ejection fraction of 20%. Cardiac catheterization demonstrated non-obstructive coronary artery disease and decreased cardiac output. Findings were consistent with Takotsubo cardiomyopathy complicated with cardiogenic shock, acute mitral regurgitation, and sinus node dysfunction. Management of this patient required the use of a mechanical device intra-aortic balloon pump, and pacemaker insertion for persistent symptomatic arrhythmia. This case highlights the challenging management of potentially fatal acute complications of Takotsubo cardiomyopathy and inadequate data on how to approach them.

Marijuana Use and Stress Cardiomyopathy in the Young

Background

Increased accessibility, recreational use, and regional legalization of marijuana (cannabis) have been paralleled by widespread recognition of its serious cardiovascular complications (acute myocardial infarction, stroke, sudden death) particularly in the young. We aimed to examine trends in hospital admissions and outcomes of adults with stress cardiomyopathy (SC) in temporal relation to marijuana use.

Methods and results

A search of the 2003-2011 Nationwide Inpatient Sample (NIIS) database identified 33,343 admissions for SC of which 210 (0.06%) were temporally related to marijuana use. Demographics, clinical characteristics, and outcomes of marijuana users (MU) and non-marijuana users (NMU) with SC were compared. MU were younger (44±14 vs. 66±13 years), more often male (36% vs. 8%), and had lower prevalence of hypertension (38% vs. 62%), diabetes (2.4% vs. 17.6%), and hyperlipidemia (16% vs. 52%) while more often suffered from depression (33% vs. 15%), psychosis (12% vs. 4%), anxiety disorder (28% vs. 16%), alcohol use disorder (13% vs. 3%), tobacco use (73% vs. 29%), and polysubstance abuse (11% vs. 0.3%) [all p<0.001]. In addition, MU more often suffered a cardiac arrest and required placement of a defibrillator while congestive heart failure was more frequent in NMU. Logistic regression analysis on the entire database (n=71,753,900), adjusted for known risk factors for SC, identified marijuana use as an independent predictor of SC (OR=1.83; 95% CI=1.57-2.12, p<0.0001). Among MU, older age (>48 years) was a strong predictor of any major adverse cardiac event (OR=7.8; 95% CI=2.88-21.13; p<0.0001).

Conclusions

Marijuana use is linked to SC in younger individuals and is associated with significant morbidity despite being younger in age and having a more favorable cardiac risk factor profile in affected individuals.

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.

Serum Metabolomic Analysis Suggests Impairment of Myocardial Energy Production in Takotsubo Syndrome

INTRODUCTION

Takotsubo syndrome is a complex entity that, although it usually has a good prognosis, can be life threatening. While recent advances have improved the knowledge of takotsubo syndrome, many aspects of its etiology still remain uncertain. Metabolomics, a hypothesis generating approach, could provide novel pathophysiology information about this disease.

METHODS AND RESULTS

Serum samples were obtained from takotsubo (n = 19) and acute myocardial infarction patients (n = 8) at the cath lab and, in the case of takotsubo, again once the patient had recovered, 3 months after the main event. ¹H NMR spectra of the serum were acquired at 9.4T using a CPMG pulse sequence (32 ms effective delay). Supervised and unsupervised pattern recognition approaches where applied to the data. Pattern recognition was able to differentiate between takotsubo and acute myocardial infarction during the acute phase with 95% accuracy. Myocardial infarction patients showed an increase in lipid signals, a known risk factor for the disease while takotsubo patients showed a relative increase in acetate that could suggest a reduced turnover of the Krebs cycle. When comparing acute and recovered phases, we could detect an increase in alanine and creatine once patients recovered.

CONCLUSIONS

Our results demonstrate that takotsubo syndrome is metabolically different than AMI, showing limited myocardial energy production capacity during the acute phase. We achieved high classification success against AMI; however, this study should be considered as a proof of concept regarding clinical application of metabolic profiling in takotsubo cardiomyopathy.

Cannabis-induced basal-mid-left ventricular stress cardiomyopathy: A case report

Cannabis, popularly known as marijuana, is a recreational drug derived from the plant Cannabis Sativa. It has been recognized as the most widely used mood-altering substance in the world and is falsely perceived as a safe substance by the public at large. This is mostly due to lack of awareness of its adverse effects as well as successful attempts for legalization of its use in many states. We present a unique case of a 56-year-old man who presented with neurological deficits concerning for stroke. Soon after presentation, he required endotracheal intubation for airway protection due to worsening mental status changes and pulmonary edema. Echocardiogram revealed severe hypokinesis of the basal and mid-left ventricular (LV) walls with hyperdynamic motion of the apex (reverse takotsubo). Coronary angiography revealed no obstructive disease. Urine toxicology screen was positive for Δ-9-tetrahydrocannabinol. The patient then stated to have used excess marijuana before the symptom onset, while denying any recent emotional stressors. The findings were consistent with stress cardiomyopathy (SC) triggered by marijuana use. Myocardial infarction, stroke, and peripheral arteriopathy have been increasingly reported in younger individuals using marijuana. SC appears to be another unique complication of marijuana use triggered through its effects on the autonomic nervous and endocannabinoid systems.

Takotsubo syndrome in bipolar affective disorder with alcohol withdrawal syndrome

A 40-year-old woman presented to the emergency department with epigastric pain and agitation. She recently separated from her husband and was consuming 30 units of alcohol daily for 5 days. She had a history of bipolar affective disorder, borderline personality disorder and alcohol dependence syndrome. Investigations revealed the following: elevated troponin I levels, ST elevation, early Q waves and prolonged QTc. Emergency angiogram confirmed Takotsubo's appearance. Medications with QTc prolongation propensity were held. A multidisciplinary apporach was required. She was discharged 10 days later when medically stabilised. It was later discovered that she died unexpectedly the following month. Takotsubo syndrome is a rare but unique cause of cardiac failure. This case highlights the need to consider the differential of Takotsubo syndrome in people presenting with possible acute ischaemic events, particularly in those with a history of combined emotional and physical stressors and a background history of mood disorder.

Takotsubo syndrome: The past, the present and the future

Takotsubo syndrome is a wide spectrum disease with a dramatic clinical presentation mimicking acute coronary syndrome albeit without obstructive coronary disease and typically manifests in the backdrop of intense emotional or physical trigger. Pathophysiology is incompletely understood with multifactorial mechanistic pathways circling around a heart-brain-endocrine axis. Several anatomic and phenotypic variants exist with varied clinical manifestations. The aftermath of Takotsubo syndrome is not always benign and both short- and long-term complications can occur which may impact its prognosis. Several gaps in knowledge exist providing an impetus for tremendous future research opportunities.

Traumatic Takotsubo Cardiomyopathy in a Patient with Extensive Coronary Artery Disease

Takotsubo Cardiomyopathy (TCM) should be considered in the differential diagnosis for patients with cardiovascular symptoms not only following emotional trauma but also following motor vehicle accidents. A 45-year-old woman presented with chest pain following a motor vehicle accident. While she had an elevated troponin level and an extensive history of cardiac disease, her electrocardiogram was normal. Echocardiogram, however, demonstrated transiently reduced left ventricular systolic function with mid to apical hypokinesis consistent with TCM. We emphasize the use of a diagnostic score and point of care focused cardiac ultrasound (FOCUS) to expedite the recognition, evaluation, and treatment of suspected TCM in an Emergency Department setting.

Electrocardiographic predictors of adverse in-hospital outcomes in the Takotsubo syndrome

BACKGROUND

Takotsubo syndrome (TS) is a life-threatening acute heart failure syndrome. However, little is known about risk factors for worse outcomes in TS and no high-risk ECG criteria have been defined. We sought to identify ECG predictors of life-threatening in-hospital complications in TS.

METHOD AND RESULT

Using the nationwide Swedish Angiography and Angioplasty Registry (SCAAR) we obtained data on all consecutive patients undergoing coronary angiography at Sahlgrenska University Hospital between June 2008 and February 2019. For all patients with TS we conducted in-depth chart reviews to confirm the TS diagnosis. For those with confirmed TS we then evaluated all ECGs obtained during the index hospitalization. The primary endpoint was the occurrence of in-hospital major adverse cardiac event (MACE), defined as the composite of death, ventricular tachycardia or fibrillation (VT/VF), or atrioventricular block ≥2 or asystole ≫10 s. We identified 215 patients with TS (mean age 69 ± 13 years; 93% women). MACE occurred in 34 patients (16%), of whom 20 had VT/VF (9,3%). Patients with MACE were less likely than those without MACE to have sinus rhythm (85% versus 96%, p = 0.025) or T-wave inversion (29% versus 51%, p = 0.025). After propensity score adjustment T-wave inversion was independently associated with lower MACE risk (adjusted odds ratio [AdjOR] 0.28, 95% confidence interval [CI] 0.10-0.76, p = 0.012) and VT/VF (AdjOR 0.24, 95% CI 0.06-0.94, p = 0.041).

CONCLUSION

T-wave inversion is common in TS and is associated with lower risk of MACE, driven by a lower risk of VT/VF.

Impact of T-inversion on the outcome of Takotsubo syndrome as compared to acute coronary syndrome

BACKGROUND

Previous studies revealed that patients with Takotsubo syndrome (TTS) have a higher mortality rate than the general population and a comparable mortality to acute coronary syndrome (ACS). Repolarisation abnormalities, namely T-wave amplitude, may provide incremental prognostic information, in addition to traditional risk factors in ACS. This study was performed to determine the short- and long-term prognostic impact of inverted T-waves in TTS patients, as compared to ACS patients.

METHODS AND RESULTS

Our institutional database constituted a collective of 138 patients diagnosed with TTS from 2003 to 2017, as well as 532 patients suffering from ACS. Patients with TTS or with ACS (n = 138 per group) were matched for age and sex and assessed retrospectively and prospectively and divided into two groups, TTS with inverted T-waves (n = 123) and ACS with inverted T-waves (n = 80). In-hospital complications such as respiratory failure with the need of respiratory support (60.2% vs 6.3%; P < 0.01), thromboembolic events (13.8% vs 2.5%; P < 0.01) and cardiogenic shock (18.9% vs 8.8%; P = 0.05) were significantly more presented in TTS as compared to ACS patients. Among cardiovascular risk factors diabetes mellitus (23.6% vs 45.0%; P < 0.01) and arterial hypertension (57.7% vs 78.8%; P < 0.01) were more presented in ACS patients as compared to TTS patients. Short-term mortality was similar, however the long-term mortality of 5 years was significantly higher in the TTS group (25.2% vs 7.5%; P < 0.01). In univariate analysis were male gender, EF < 35%, GFR < 60 mL/min, cardiogenic shock, inotropic drugs and history of cancer predictors of 5-year mortality. The multivariate analysis showed only male gender (HR 2.7, 95% CI 1.1-6.5; P = 0.02), GFR < 60 mL/min (HR 2.8, 95% CI 1.2-6.0; P = 0.01) and history of cancer (HR 3.6, 95% CI 1.4-9.3; P < 0.01) as independent predictors of 5-year mortality.

CONCLUSION

Rates of long-term mortality were significantly higher in TTS patients showing inverted T-waves compared with patients diagnosed with ACS with inverted T-waves. However, T-inversion was not an independent predictor of 5-year mortality in the multivariate analysis.

Impact of ST-segment elevation on the outcome of Takotsubo syndrome

Background

Recent studies have highlighted that Takotsubo syndrome (TTS), mimicking acute coronary syndrome (ACS), is associated with poor clinical outcome. TTS is associated with different repolarization disorders including ST-segment elevation. ST elevation myocardial infarction (STEMI) in ACS is associated with declined prognosis. However, the clinical and prognostic impact of ST-segment elevation on TTS remains lacking.

Aim

The aim of this study was to determine the short- and long-term prognostic impact of ST-segment elevation on TTS patients as compared with STEMI patients.

Patients and methods

Our institutional database constituted a consecutive cohort of 138 TTS patients and 138 ACS patients matched for age and sex. TTS patients (n=41) with ST-segment elevation were compared with ACS patients with ST-segment elevation (n=64).

Results

Chest pain was significantly more documented in STEMI patients as compared with TTS patients (48.8% vs 78.1%; P<0.01). Cardiovascular risk factors such as diabetes mellitus (12.2% vs 29.7%; P=0.02) were significantly more presented in STEMI patients. Although the initial left ventricular ejection fraction (LVEF) was more declined in TTS patients (39%±9% vs 45%±16%; P<0.01), the LVEF was more declined in STEMI patients at follow-up (54%±10% vs 45%±16%; P=0.04). Inhospital complications such as respiratory failure were significantly more presented in TTS patients (68.3% vs 20.3%; P<0.01). The short-term as well as the long-term morality was similar in both groups. In univariate analysis, male sex, ejection fraction (EF) <35%, glomerular filtration rate (GFR) <60 mL/min, cardiogenic shock, inotropic drugs, and history of cancer were predictors of 5-year mortality.

Conclusion

Rates of the long-term mortality in TTS patients with ST elevations are comparable with STEMI patients.

Takotsubo syndrome: State-of-the-art review by an expert panel - Part 1

Takotsubo syndrome (TTS) is an acute cardiac condition independent of epicardial coronary obstruction that mimics acute coronary syndrome and is characterized by acute heart failure with reversible ventricular motion abnormalities. This consensus paper is the result of a multinational effort aiming to summarize the current state of the art on TTS. Experts in the field provide a thorough and detailed review of this syndrome. Several novel and unique sections are emphasized in this document, including the current state of the art on genetics of takotsubo syndrome, microRNAs (miRs), racial differences, role of cardiac spectroscopy and intracoronary imaging, as well as mechanical circulatory support. In part 1 of this two-part manuscript, we discuss how TTS came to be known, several patterns and forms it can take in patients, epidemiology and pathophysiology of the syndrome, and clinical presentation.

Added value of contrast echocardiography in characterization of nonischemic cardiomyopathy

Nonischemic cardiomyopathy (NICM) is a group of noncoronary heterogonous myocardial diseases. The heterogonous nature of NICM has impeded its diagnosis. In the present case series, we demonstrate the added value of using contrast echocardiography in the characterization of NICM. Two patients of advanced age were admitted for possible acute coronary syndrome, which was subsequently excluded by coronary angiography. Conventional and contrast echocardiography revealed characteristic structural and dynamic features of the left ventricle that were compatible with two distinct NICM diseases: stress-induced cardiomyopathy and noncompaction of the ventricular myocardium. Contrast echocardiography characterizes the cardiac structure and allows for real-time assessment of myocardial motion and perfusion. It may help to distinguish diseases with different etiologies.

[Antagonistic function of the heart muscle : Part II: Clinical implications]

In the hypertrophic heart the myostructural afterload in the form of endoepicardial networks is predominant, which enhances myocardial hypertrophy. The intrinsic antagonism is derailed. Likewise, the connective tissue scaffold, i.e. the stromatogenic afterload, is enriched in the response to the derailment of antagonism in a hypertrophic heart up to regional captivation of the heart musculature. Due to the selective susceptibility of the auxotonic, contracting oblique transmural myocardial network for low dose negative inotropic medication, this promises to attenuate progress in myocardial hypertrophy. Volume reduction surgery is most effective in reducing wall stress as long as the myocardium is not critically fettered by fibrosis. The use of external mechanical circulatory support is then effective if the heart is supported in its resting mode, which means around a middle width and at minimal amplitude of motion. The takotsubo cardiomyopathy might possibly reflect an isolated, extreme stimulation of the intrinsic antagonism as a response to hormonally induced sensitization of the myocardium to catecholamine. A particular significant conclusion with respect to the diseased heart is that clinical diagnostics need new impulses with a focus on the analysis of local motion patterns and on myocardial stiffness reflecting disease-dependent antagonistic intensity. This would become a relevant diagnostic marker if corresponding (noninvasive) measurement techniques would become available.

Effect of Myocardial Infarction With Nonobstructive Coronary Arteries on Physical Capacity and Quality-of-Life

Patients with myocardial infarction with nonobstructive coronary arteries (MINOCA), including Takotsubo syndrome (TS), are considered to have a better survival compared with those with coronary heart disease (CHD). Studies of patients with MINOCA measuring physical and mental function including matched control groups are lacking. The aim of this study was to determine the physical capacity and quality of life in patients with MINOCA. One-hundred patients with MINOCA along with TS (25%) were investigated from 2007 to 2011. A bicycle exercise stress test was performed 6 weeks after hospitalization and QoL was investigated by the Short Form Survey 36 at 3 months' follow-up. Both a healthy and a CHD group that were age and gender matched were used as controls. The MINOCA group had a lower physical capacity (139 ± 42 W) compared with the healthy control group (167 ± 53 W, p <0.001) but better than the CHD control group (124 ± 39 W, p = 0.023). Patients with MINOCA had lower physical and mental component summary scores compared with the healthy controls (p <0.001) and lower mental component summary (p = 0.012), mental health (p = 0.016), and vitality (p = 0.008) scores compared with the CHD controls. In conclusion, the findings of this first study on exercise capacity and QoL in patients with MINOCA showed both physical and mental distress from 6 weeks to 3 months after the acute event similar to CHD controls and in some perspectives even lower scores especially in the mental component of QoL.