Takotsubo cardiomyopathy: real life management in the intensive coronary care unit

AIM

Takotsubo cardiomyopathy is a cardiac syndrome characterized by reversible left ventricular dysfunction, ischemic changes on electrocardiogram, elevation of cardiac biomarkers, absence of obstructive coronary artery disease in the setting of various stressing conditions. To date, little is known on best clinical management of this syndrome in coronary care units. Whe thus aimed to present our experience in a real life takotsubo population.

METHODS

We identified all patients with Takotsubo cardiomyopathy at our center Maria Vittoria Hospital, Turin, between October 2006 and February 2012. Patients where considered to have Takotsubo syndrome if they presented chest pain on admission, new elettrocardiographic changes suggestive of myocardial ischemia, evidence of apical balloning with hyperkinesis of basal segments on echocardiography, rise in troponin I and, after coronary angiography, no coronary artery disease. We adjudicated the following clinical events: death and recurrence of ischemic events; we also made a detailed analysis of the stressing conditions leading to clinical syndrome.

RESULTS

A total of 26 patients were included, 4 (15%) males and 22 (85%) females; mean age was 71±13. After more than 1 year median follow-up the incidence of death was 7.7% (2 deaths), with all deaths, due to cardiogenic shock, occurring in the first 10 days of hospitalization; 2 patients (8%) experienced recurrence of ischemic event. Leading cause of Takostubo was major depressive episode (16%), followed by mourning (12%), falling down with difficulties in standing up (12%), vomiting (8%) and pulmonary infection (8%). In the coronary care unit major complications of patients with Takotsubo syndrome were acute hearth failure (62%), cardiogenic shock (27%), sepsis (31%), pulmonary aedema (27%) and anemia (12%). Two patients needed non-invasive ventilation support and one intra-aortic balloon conterpulasation. In addition one patient developed rabdomyolysis and one left heart thrombus. Cornerstone drug therapy was as follows: 96% of patients took aspirin, 58% beta blockers, 54% nitroglicerine, 46% intravenous heparin, 27% dopamine.

CONCLUSION

Takotsubo syndrome is an important safety issue occurring predominantly in post-menopausal women undergoing specific stressing condition. Heart failure and cardiogenic shock are the most serious clinical complication and leading cause of death in the short period, good prognosis is seen thereafter.

Omega-3 polyunsatured fatty acids role in postmyocardial infarction therapy

Largely initiated by studies among Eskimos in the early 1970s, great attention has been given to possible effects of omega-3 polyunsatured fatty acids (PUFA) in cardiovascular diseases. A series of positive effects on pathogenetic mechanisms of cardiovascular disease has been discovered from laboratory studies in cell cultures, animal models and in humans. omega-3 PUFA can reduce platelets and leucocytes activities as well as plasma triglycerides. Moreover they can have antiarrhythmic properties. Nowadays patients who experienced myocardial infarction have decreased risk of total and cardiovascular mortality by treatment with omega-3 PUFA (1 g daily). This effect is present irrespective of high or low fish intake or simultaneous intake of other drugs for secondary prevention of coronary heart disease. Mainly on the basis of GISSI Prevention trial results, dietary supplementation with omega-3 PUFA is now recommended as a new component of secondary prevention after myocardial infarction in national and international guidelines.