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Templin C, Hänggi J, Klein C, Topka MS, Hiestand T, Levinson RA, Jurisic S, Lüscher TF, Ghadri JR, Jäncke L. Altered limbic and autonomic processing supports brain-heart axis in Takotsubo syndrome. Eur Heart J 2020; 40:1183-1187. [PMID: 30831580 PMCID: PMC6462306 DOI: 10.1093/eurheartj/ehz068] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 08/30/2018] [Accepted: 02/25/2019] [Indexed: 12/16/2022] Open
Abstract
Aims Takotsubo syndrome (TTS) is characterized by acute left ventricular dysfunction often triggered by emotional or physical stress. Severe activation of the sympathetic nervous system with catecholamine release caused by a dysfunctional limbic system has been proposed as a potential mechanism. We hypothesize that brain regions responsible for autonomic integration and/or limbic processing might be involved in the development of TTS. Here, we investigated alterations in resting state functional connectivity in TTS patients compared with healthy controls. Methods and results Using brain functional magnetic resonance imaging (fMRI), resting state functional connectivity has been assessed in 15 subjects with TTS and 39 healthy controls. Network-based statistical analyses were conducted to identify subnetworks with altered resting state functional connectivity. Sympathetic and parasympathetic networks have been constructed in addition to the default mode network and whole-brain network. We found parasympathetic- and sympathetic-associated subnetworks both showing reduced resting state functional connectivity in TTS patients compared with controls. Important brain regions constituting parasympathetic- and sympathetic-associated subnetworks included the amygdala, hippocampus, and insula as well as cingulate, parietal, temporal, and cerebellar regions. Additionally, the default mode network as well as limbic regions in the whole-brain analysis demonstrated reduced resting state functional connectivity in TTS, including the hippocampus, parahippocampal, and medial prefrontal regions. Conclusion For the first time, we demonstrate hypoconnectivity of central brain regions associated with autonomic functions and regulation of the limbic system in patients with TTS. These findings suggest that autonomic-limbic integration might play an important role in the pathophysiology and contribute to the understanding of TTS.
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Affiliation(s)
- Christian Templin
- University Heart Center, Department of Cardiology, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Jürgen Hänggi
- Division Neuropsychology, Department of Psychology, University of Zurich, Binzmuehlestrasse 14, Zurich, Switzerland
| | - Carina Klein
- Division Neuropsychology, Department of Psychology, University of Zurich, Binzmuehlestrasse 14, Zurich, Switzerland
| | - Marlene S Topka
- Division Neuropsychology, Department of Psychology, University of Zurich, Binzmuehlestrasse 14, Zurich, Switzerland
| | - Thierry Hiestand
- University Heart Center, Department of Cardiology, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Rena A Levinson
- University Heart Center, Department of Cardiology, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Stjepan Jurisic
- University Heart Center, Department of Cardiology, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Thomas F Lüscher
- Center for Molecular Cardiology, Schlieren Campus, University of Zurich, Wagistrasse 12, Schlieren, Switzerland.,Royal Brompton and Harefield Hospitals Trust and Imperial College, Cardiology, Sydney Street, London, UK
| | - Jelena-Rima Ghadri
- University Heart Center, Department of Cardiology, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Lutz Jäncke
- Division Neuropsychology, Department of Psychology, University of Zurich, Binzmuehlestrasse 14, Zurich, Switzerland.,University Research Priority Program (URPP), Dynamic of Healthy Aging, University of Zurich, Andreasstrasse 15, Zurich, Switzerland
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Ghadri JR, Sarcon A, Diekmann J, Bataiosu DR, Cammann VL, Jurisic S, Napp LC, Jaguszewski M, Scherff F, Brugger P, Jäncke L, Seifert B, Bax JJ, Ruschitzka F, Lüscher TF, Templin C. Happy heart syndrome: role of positive emotional stress in takotsubo syndrome. Eur Heart J 2016; 37:2823-2829. [PMID: 26935270 PMCID: PMC5841222 DOI: 10.1093/eurheartj/ehv757] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 12/08/2015] [Accepted: 12/22/2015] [Indexed: 11/17/2022] Open
Abstract
Aims Takotsubo syndrome (TTS) is typically provoked by negative stressors such as grief, anger, or fear leading to the popular term ‘broken heart syndrome’. However, the role of positive emotions triggering TTS remains unclear. The aim of the present study was to analyse the prevalence and characteristics of patients with TTS following pleasant events, which are distinct from the stressful or undesirable episodes commonly triggering TTS. Methods and results Takotsubo syndrome patients with preceding pleasant events were compared to those with negative emotional triggers from the International Takotsubo Registry. Of 1750 TTS patients, we identified a total of 485 with a definite emotional trigger. Of these, 4.1% (n = 20) presented with pleasant preceding events and 95.9% (n = 465) with unequivocal negative emotional events associated with TTS. Interestingly, clinical presentation of patients with ‘happy heart syndrome’ was similar to those with the ‘broken heart syndrome’ including symptoms such as chest pain [89.5% (17/19) vs. 90.2% (412/457), P = 1.0]. Similarly, electrocardiographic parameters, laboratory findings, and 1-year outcome did not differ. However, in a post hoc analysis, a disproportionate higher prevalence of midventricular involvement was noted in ‘happy hearts’ compared with ‘broken hearts’ (35.0 vs. 16.3%, P = 0.030). Conclusion Our data illustrate that TTS can be triggered by not only negative but also positive life events. While patient characteristics were similar between groups, the midventricular TTS type was more prevalent among the ‘happy hearts’ than among the ‘broken hearts’. Presumably, despite their distinct nature, happy and sad life events may share similar final common emotional pathways, which can ultimately trigger TTS.
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Affiliation(s)
- Jelena R. Ghadri
- Department of Cardiology, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Annahita Sarcon
- University of Southern California, Keck School of Medicine, Division of Cardiovascular Medicine, Los Angeles, CA, USA
| | - Johanna Diekmann
- Department of Cardiology, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Dana Roxana Bataiosu
- Department of Cardiology, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Victoria L. Cammann
- Department of Cardiology, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Stjepan Jurisic
- Department of Cardiology, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Lars Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Milosz Jaguszewski
- Department of Cardiology, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Frank Scherff
- Department of Cardiology, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Peter Brugger
- Department of Neurology, Neuropsychology Unit, University Hospital Zurich, Zurich, Switzerland
| | - Lutz Jäncke
- Department of Neuropsychology, Psychological Institute, University of Zurich, Zurich, Switzerland
| | - Burkhardt Seifert
- Division of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Jeroen J. Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Thomas F. Lüscher
- Department of Cardiology, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Christian Templin
- Department of Cardiology, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
- *Corresponding author. Tel: +41 44 255 9585, Fax: +41 44 255 4401,
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Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy-related mortality, but how to predict which patients are at risk and how to prevent it remain uncertain. The underlying pathomechanisms of SUDEP are still largely unknown, but the general consensus is that seizures somehow disrupt normal cardiac or respiratory physiology leading to death. However, the proportion of SUDEP cases exhibiting cardiac or respiratory dysfunction as a critical factor in the terminal cascade of events remains unresolved. Although many general risk factors for SUDEP have been identified, the development of reliable patient-specific biomarkers for SUDEP is needed to provide more accurate risk prediction and personalized patient management strategies. Studies in animal models and patient groups have revealed at least nine different brain-heart genes that may contribute to a genetic susceptibility for SUDEP, making them potentially useful as genomic biomarkers. This review summarizes data on the relationship between these neurocardiac genes and SUDEP, discussing their brain-heart expression patterns and genotype-phenotype correlations in mouse models and people with epilepsy. These neurocardiac genes represent good first candidates for evaluation as genomic biomarkers of SUDEP in future studies. The development of validated reliable genomic biomarkers for SUDEP has the potential to transform the clinical treatment of epilepsy by pinpointing patients at risk of SUDEP and allowing optimized, genotype-guided therapeutic and prevention strategies.
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