Apical Ballooning Syndrome

Abstract

HomeCirculationVol. 115, No. 5Apical Ballooning Syndrome Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessReview ArticlePDF/EPUBApical Ballooning SyndromeAn Important Differential Diagnosis of Acute Myocardial Infarction Abhiram Prasad, MD, FRCP, FESC Abhiram PrasadAbhiram Prasad From the Division of Cardiovascular Diseases and Department of Internal Medicine, and Mayo Clinic and Mayo Foundation, Rochester, Minn. Search for more papers by this author Originally published6 Feb 2007https://doi.org/10.1161/CIRCULATIONAHA.106.669341Circulation. 2007;115:e56–e59Case presentation: A 60-year-old woman presented to the emergency department 2 hours after the onset of severe retrosternal chest pain that started soon after she was told that her son had died in a car accident. A 12-lead ECG demonstrated ST-elevation in the precordial leads (Figure 1), and the plasma troponin T level was elevated at 0.07 ng/mL. A diagnosis of acute ST-elevation myocardial infarction was made, and the patient was admitted for emergency coronary angiography, which revealed normal coronary arteries. The left ventriculogram showed severe systolic dysfunction involving the mid and apical segments (Data Supplement Movie I). Download figureDownload PowerPointFigure 1. Twelve-lead ECG demonstrating ST-segment elevation in precordial leads.Recognition of Clinical SyndromePhysicians have long been aware of the possible association between stress and cardiovascular events. Awareness has increased of a distinct cardiac syndrome that was originally described in the Japanese population and was called Takotsubo cardiomyopathy, named after the octopus-trapping pot with a round bottom and narrow neck that resembles the left ventriculogram during systole in these patients.1,2 Other names used to describe the condition include apical ballooning syndrome (ABS), broken heart syndrome, and stress or ampulla cardiomyopathy. The precise incidence of ABS is unknown, but it may account for 1% to 2% of patients who present with an acute myocardial infarction.3Clinical FeaturesThe majority of patients have a clinical presentation that is indistinguishable from an acute coronary syndrome. Most present with chest pain at rest, although some patients have dyspnea alone as their initial presenting symptom. Rarely, patients present with syncope or an out-of-hospital cardiac arrest.4 ABS appears to occur almost exclusively in postmenopausal women; however, a few cases have been reported in younger women and males.4 The patients are usually hemodynamically stable, but clinical findings of mild-to-moderate congestive heart failure commonly coexist. In a minority of patients, hypotension may occur from reduced stroke volume and occasionally from dynamic left ventricular outflow tract obstruction. Cardiogenic shock may be a rare complication. A unique feature of ABS is the occurrence of a preceding emotionally or physically stressful event in approximately two thirds of patients. Importantly, such a trigger is not observed in all individuals, and its absence does not exclude the diagnosis.DiagnosisThe most frequent finding on the admission ECG is mild ST-segment elevation, which occurs in approximately 50% to 60% of patients. It is typically present in the precordial leads, but the ECG can be normal or can show nonspecific T-wave abnormality or major ST elevation across the precordial and limb leads. In general, the 12-lead ECG alone is not helpful in differentiating ABS from an ST-elevation myocardial infarction.5 Characteristic evolutionary changes that occur over 2 to 3 days include resolution of the ST-segment elevation and subsequent development of diffuse and often deep T-wave inversion that involves most leads (Figure 2). New pathological Q waves may be seen occasionally, and there is frequent prolongation of the corrected QT interval. Most, if not all, patients have a small early increase in cardiac biomarkers, especially when cardiac troponins are measured. Transthoracic echocardiography can detect the regional wall-motion abnormality, but the diagnosis is frequently made in the cardiac catheterization laboratory because the patients are initially suspected of suffering from an acute coronary syndrome and are referred for urgent or emergency coronary angiography. Patients with ABS typically do not have obstructive coronary artery disease. The left ventriculogram shows characteristic regional wall-motion abnormalities involving the mid and usually the apical segments. There is sparing of the basal systolic function, and the wall-motion abnormality extends beyond the distribution of any 1 single coronary artery (Data Supplement Movie I). Apical sparing variants have also been described (Data Supplement Movie II).6 Cardiac magnetic resonance imaging may be helpful in excluding myocardial infarction, because delayed gadolinium hyperenhancement is not a feature of ABS.7Download figureDownload PowerPointFigure 2. Twelve-lead ECG demonstrating resolution of ST-segment elevation and development of diffuse T-wave inversion.On the basis of our experience, we have previously proposed criteria for making a clinical diagnosis of ABS, and all 4 criteria must be present. The Table illustrates a modified version of the criteria that incorporates contemporary knowledge about the syndrome.4 The diagnosis of ABS is most likely to be made at institutions where primary percutaneous coronary intervention and an early invasive strategy are practiced for the management of acute coronary syndromes. The absence of obstructive coronary artery disease and the characteristic regional wall-motion abnormality are likely to lead to the diagnosis. Diagnosis of ABS in patients who present at hospitals without cardiac catheterization laboratories requires a high index of suspicion. The diagnosis should be considered in a postmenopausal woman who presents with cardiac symptoms that are temporally related to an emotional or physical stressor, with positive cardiac biomarkers or an abnormal ECG. Establishing the diagnosis is particularly important if fibrinolytic therapy is being considered for a presumed diagnosis of ST-elevation myocardial infarction. Inappropriate administration of fibrinolytics to a patient with ABS may lead to harm, and it would be appropriate to transfer a patient suspected of having ABS for emergency coronary angiography. Proposed Mayo Clinic Criteria for the Clinical Diagnosis of ABS*There are rare exceptions to these criteria, such as those patients in whom the regional wall-motion abnormality is limited to a single coronary territory.†It is possible that a patient with obstructive coronary atherosclerosis may also develop ABS. However, this is very rare in our experience and in the published literature, perhaps because such cases are misdiagnosed as an acute coronary syndrome.In both of the above circumstances, the diagnosis of ABS should be made with caution, and a clear stressful precipitating trigger must be sought.1. Transient hypokinesis, akinesis, or dyskinesis of the left ventricular mid segments with or without apical involvement. The regional wall-motion abnormalities extend beyond a single epicardial vascular distribution.*2. Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture.†3. New ECG abnormalities (either ST-segment elevation and/or T-wave inversion) or elevated cardiac troponin.4. Absence of: recent significant head trauma intracranial bleeding pheochromocytoma myocarditis hypertrophic cardiomyopathyManagementThe optimal management of ABS has not been established, but supportive therapy invariably leads to spontaneous recovery. Because the presentation in these patients is indistinguishable from an acute coronary syndrome, initial management should be directed toward the treatment of myocardial ischemia, with continuous ECG monitoring and administration of aspirin, intravenous heparin, and β-blockers. Once the diagnosis of ABS has been made, aspirin can be discontinued unless there is coexisting coronary atherosclerosis. β-Blocker therapy may be continued, if tolerated, especially because an excess of catecholamines may play a role in precipitating the conditions. Diuretics are effective for the treatment of congestive heart failure. The right ventricle is also involved in approximately one third of cases, and these patients are sicker and more likely to develop congestive heart failure (Data Supplement Movie III).8 On rare occasions, when there is significant hypotension, it is important to exclude dynamic left ventricular outflow tract obstruction with echocardiography. If present, a cautious trial of β-blockers may help by reducing the hypercontractility of the base of the left ventricle. Alternatively, an infusion of phenylephrine may be effective by increasing the afterload and left ventricular cavity size. Inotropes would be contraindicated in this situation. In contrast, cardiogenic shock owing to pump failure is treated with standard therapies that include inotropes and intra-aortic balloon counterpulsation. Anticoagulation should be considered in cases of severe left ventricular systolic dysfunction to prevent thromboembolism until there has been recovery.PrognosisPatients with ABS generally have a good prognosis in the absence of significant underlying comorbid conditions. The systolic dysfunction and the regional wall-motion abnormalities are transient and resolve completely within a matter of days to a few weeks. This is such a uniform finding that an alternative diagnosis should be considered in patients in whom the cardiomyopathy does not resolve. Typically, assessment of the ejection fraction should be performed at approximately 4 to 6 weeks after discharge from the hospital to document recovery of function. At this time, the ECG usually shows complete resolution, although T-wave inversion may persist for a longer period of time. In-hospital mortality from ABS is very low and unlikely to be greater than 1% to 2%. The recurrence rate of ABS is no more than 10%.9 In our practice, in the absence of contraindications, we recommend chronic β-blocker therapy, with the aim of reducing the likelihood of a recurrent episode. Annual clinical follow-up is advisable because the natural history of ABS remains unknown.PathophysiologyThe pathophysiology of ABS is poorly understood. Several mechanisms for the reversible cardiomyopathy have been proposed, including multivessel epicardial spasm, coronary microvascular spasm, catecholamine-induced myocardial stunning, and myocarditis. Multivessel epicardial coronary artery spasm has not been observed in any of the patients at our institution, but it is possible that the routine administration of nitrates for ischemic chest pain may obscure its presence. Microvascular dysfunction is present in at least two thirds of patients at the time of presentation, and its severity correlates with the magnitude of troponin elevation and ECG abnormalities.10 It remains to be established whether impairment in microvascular function is the primary mechanism for the injury or is an epiphenomenon. Catecholamines may play a role in triggering the syndrome.11Case ConclusionThe left ventricular end-diastolic pressure was 30 mm Hg, and the patient was markedly hypotensive. An intra-aortic balloon was inserted. Her symptoms and hypotension resolved over 48 hours. She was discharged on the fourth day with a prescription for an ACE inhibitor and β-blocker. An echocardiogram 4 weeks later revealed normal left ventricular function. The ACE inhibitor was discontinued, and she remains well 1 year after her admission.The online-only Data Supplement, consisting of movies, is available with this article at http://circ.ahajournals.org/cgi/content/full/115/5/e56/DC1.DisclosuresNone.FootnotesReprint requests to Abhiram Prasad, MD, Cardiac Catheterization Laboratory, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail [email protected] References 1 Sato H, Tateishi H, Uchida T, Dote K, Ishihara M, Sasaki K. Tako-tsubo-like left ventricular dysfunction due to multivessel coronary spasm. In: Kodama K, Haze K, Hori M, eds. Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure [in Japanese]. Tokyo, Japan: Kagakuhyoronsha Publishing Co; 1990: 56–64.Google Scholar2 Tsuchihashi K, Ueshima K, Uchida T, Oh-mura N, Kimura K, Owa M, Yoshiyama M, Miyazaki S, Haze K, Ogawa H, Honda T, Hase M, Kai R, Morii I. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction: Angina Pectoris-Myocardial Infarction Investigations in Japan. J Am Coll Cardiol. 2001; 38: 11–18.CrossrefMedlineGoogle Scholar3 Bybee KA, Prasad A, Barsness G, Wright RS, Rihal CS. Clinical characteristics, outcomes, and impaired myocardial microcirculation in patients with transient left ventricular apical ballooning syndrome: a case-series from a U.S. medial center. Am J Cardiol. 2004; 94: 343–346.CrossrefMedlineGoogle Scholar4 Bybee KA, Kara T, Prasad A Lerman A, Barsness GW, Wright RS, Rihal CS. Transient left ventricular apical ballooning syndrome: a mimic of ST-segment elevation myocardial infarction. Ann Intern Med. 2004; 141: 858–865.CrossrefMedlineGoogle Scholar5 Bybee K, Motiei A, Syed I, Kara T, Prasad A, Lennon RJ, Murphy JG, Hammill SC, Rihal CS, Wright RS. Electrocardiography cannot reliably differentiate transient left ventricular apical ballooning syndrome from anterior ST-segment elevation myocardial infarction. J Electrocardiol. 2007; 40: 38.e1–e6.Google Scholar6 Hurst RT, Askew JW, Reuss CS, Lee RW, Sweeney JP, Fortuin FD, Oh JK, Tajik AJ. Transient midventricular ballooning syndrome: a new variant. J Am Coll Cardiol. 2006; 48: 579–583.CrossrefMedlineGoogle Scholar7 Sharkey SW, Lesser JR, Zenovich AG, Maron MS, Lindberg J, Longe TF, Maron BJ. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation. 2005; 111: 472–479.LinkGoogle Scholar8 Elesber A, Prasad A, Bybee KA, Valeti U, Motiei A, Lerman A, Chandrasekaran K, Rihal CS. Transient cardiac apical ballooning syndrome: prevalence and clinical implications of right ventricular involvement. J Am Coll Cardiol. 2006; 47: 1082–1083.CrossrefMedlineGoogle Scholar9 Elesber AA, Prasad A, Wright S, Lerman A, Rihal C. Recurrence rate and long term prognosis of the apical ballooning syndrome. Circulation. 2006; 114 (suppl II): II-625. Abstract.Google Scholar10 Elesber A, Lerman A, Bybee KA, Murphy JG, Barsness G, Singh M, Rihal CS, Prasad A. Myocardial perfusion in apical ballooning syndrome: correlate of myocardial injury. Am Heart J. 2006; 152: 469.e9–e13.CrossrefGoogle Scholar11 Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, Wu KC, Rade JJ, Bivalacqua TJ, Champion HC. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005; 352: 539–548.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Xu Y, Liu M, Li J and Rong J (2022) Takotsubo cardiomyopathy as an overlooked cause of cardiac arrest in a patient undergoing ureteral stenting: a case report and literature review, Journal of International Medical Research, 10.1177/03000605221099255, 50:5, (030006052210992), Online publication date: 1-May-2022. Gürol T (2021) Management of Takotsubo cardiomyopathy before non-cardiac surgery: A case report, Turkish Journal of Thoracic and Cardiovascular Surgery, 10.5606/tgkdc.dergisi.2021.21660, 29:2, (271-274) Taher Z and Kinsara A The Myth of Myocardial Infarction With Normal Coronary Angiography, Cureus, 10.7759/cureus.13662 Amadio P, Porro B, Cavalca V, Barbieri S, Eligini S, Fiorelli S, Di Minno A, Gorini A, Giuliani M, Werba J, Cosentino N, Olivares P, Barbieri S, Veglia F, Tremoli E and Trabattoni D (2021) Persistent long-term platelet activation and endothelial perturbation in women with Takotsubo syndrome, Biomedicine & Pharmacotherapy, 10.1016/j.biopha.2021.111259, 136, (111259), Online publication date: 1-Apr-2021. Rifei L, Yuanmei Z, Chengkai Z, Xuenian H and Shangwei D (2021) Contrast Echocardiography Evaluation of Microcirculation of Myocardial Infarction Caused by Takotsubo Syndrome: Case Report and Literature Review, ADVANCED ULTRASOUND IN DIAGNOSIS AND THERAPY, 10.37015/AUDT.2021.210016, 5:3, (258), . Abdu F, Mohammed A, Liu L, Xu Y and Che W (2020) Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA): A Review of the Current Position, Cardiology, 10.1159/000509100, 145:9, (543-552), . Pérez Díaz P, del Río J, Frías García R, Morón Alguacil A and Jurado Román A (2020) Infarto de miocardio tras la administración de adrenalina intragingival ¿Una nueva causa de infarto agudo de miocardio sin enfermedad coronaria aterosclerótica obstructiva?, Revista Colombiana de Cardiología, 10.1016/j.rccar.2019.12.013, 27:5, (477-480), Online publication date: 1-Sep-2020. Wang X, Pei J and Hu X (2020) The Brain-Heart Connection in Takotsubo Syndrome: The Central Nervous System, Sympathetic Nervous System, and Catecholamine Overload, Cardiology Research and Practice, 10.1155/2020/4150291, 2020, (1-5), Online publication date: 9-Mar-2020. Yazdi D and Sharim J (2019) A Nearly Stressful Situation—A Case of Wellens Syndrome, JAMA Internal Medicine, 10.1001/jamainternmed.2019.0216, 179:5, (704), Online publication date: 1-May-2019. Ali Z, Zain M, Khan M, Ahmad A, Abbas H and Ashfaq A (2019) “Takotsubo cardiomyopathy presenting with QT prolongation: an atypical presentation.”, Journal of Community Hospital Internal Medicine Perspectives, 10.1080/20009666.2019.1598229, 9:2, (171-174), Online publication date: 4-Mar-2019. Scalone G, Niccoli G and Crea F (2018) Editor’s Choice- Pathophysiology, diagnosis and management of MINOCA: an update, European Heart Journal: Acute Cardiovascular Care, 10.1177/2048872618782414, 8:1, (54-62), Online publication date: 1-Feb-2019. Prasad A (2019) Stress (Takotsubo) Cardiomyopathy Cardiac Intensive Care, 10.1016/B978-0-323-52993-8.00020-5, (204-207.e2), . Casale M, Quattrocchi S, Bitto R and Dattilo G (2018) Cardiac implantable devices and takotsubo syndrome. A rare but potential eventuality, Cor et Vasa, 10.1016/j.crvasa.2017.04.001, 60:5, (e500-e502), Online publication date: 1-Oct-2018. Carbonara R, Giardinelli F, Pepe M, Luzzi G, Panettieri I, Vulpis V, Bortone A and Ciccone M (2017) Correlation between endothelial dysfunction and myocardial damage in acute phase of Tako-Tsubo cardiomyopathy: brachial flow mediated dilation as a potential marker for assessment of patient with Tako-Tsubo, Heart and Vessels, 10.1007/s00380-017-1062-8, 33:3, (291-298), Online publication date: 1-Mar-2018. Tiritilli A, Tritar A, Rehal K, Iaria P, Benali T, Olezac A, Sayah S, Codjia R, Barhoum P, Viard P and Aouate P (2018) Un cas inhabituel de cardiomyopathie de Takotsubo après implantation de pacemaker, Annales de Cardiologie et d'Angéiologie, 10.1016/j.ancard.2018.09.005, 67:5, (374-380), Online publication date: 1-Nov-2018. Japundžić-Žigon N, Šarenac O, Lozić M, Vasić M, Tasić T, Bajić D, Kanjuh V and Murphy D (2017) Sudden death: Neurogenic causes, prediction and prevention, European Journal of Preventive Cardiology, 10.1177/2047487317736827, 25:1, (29-39), Online publication date: 1-Jan-2018. Ansari U, El-Battrawy I, Fastner C, Behnes M, Sattler K, Huseynov A, Baumann S, Tülümen E, Borggrefe M and Akin I (2018) Clinical outcomes associated with catecholamine use in patients diagnosed with Takotsubo cardiomyopathy, BMC Cardiovascular Disorders, 10.1186/s12872-018-0784-6, 18:1, Online publication date: 1-Dec-2018. El-Battrawy I, Borggrefe M and Akin I (2017) Endothelial dysfunction in takotsubo syndrome, International Journal of Cardiology, 10.1016/j.ijcard.2016.11.232, 234, (101), Online publication date: 1-May-2017. Sun T, Ming Z, Liu Z, Lennon R, Yang S, Kwon T, Park K, Lerman L and Lerman A (2017) Prevalence of diastolic function and clinical impact on long-term outcome in takotsubo cardiomyopathy, International Journal of Cardiology, 10.1016/j.ijcard.2017.06.068, 244, (7-12), Online publication date: 1-Oct-2017. Agarwal S, Bean M, Hata J and Castresana M (2017) Perioperative Takotsubo Cardiomyopathy: A Systematic Review of Published Cases, Seminars in Cardiothoracic and Vascular Anesthesia, 10.1177/1089253217700511, 21:4, (277-290), Online publication date: 1-Dec-2017. Ansari U and El-Battrawy I (2017) The Clinical Manifestations, Diagnosis and Management of Takotsubo Syndrome Interventional Cardiology, 10.5772/68037 Efferth T, Banerjee M and Paul N (2017) Broken heart, tako-tsubo or stress cardiomyopathy? Metaphors, meanings and their medical impact, International Journal of Cardiology, 10.1016/j.ijcard.2016.12.129, 230, (262-268), Online publication date: 1-Mar-2017. Giza D, Lopez-Mattei J, Vejpongsa P, Munoz E, Iliescu G, Kitkungvan D, Hassan S, Kim P, Ewer M and Iliescu C (2017) Stress-Induced Cardiomyopathy in Cancer Patients, The American Journal of Cardiology, 10.1016/j.amjcard.2017.09.009, 120:12, (2284-2288), Online publication date: 1-Dec-2017. Giza D, Moudgil R, Lopez-Mattei J, Kim P and Iliescu C (2017) Association between ibrutinib and mid-cavitary Takotsubo cardiomyopathy: a case report and a review of chemotherapy-induced Takostubo’s cardiomyopathy, European Heart Journal - Case Reports, 10.1093/ehjcr/ytx006, 1:2, Online publication date: 1-Dec-2017. Saranteas T, Mavrogenis A, Mandila C, Poularas J and Panou F (2017) Ultrasound in cardiac trauma, Journal of Critical Care, 10.1016/j.jcrc.2016.10.032, 38, (144-151), Online publication date: 1-Apr-2017. Ahmed A, Serafi A, Sunni N, Younes H and Hassan W (2017) Recurrent takotsubo with prolonged QT and torsade de pointes and left ventricular thrombus, Journal of the Saudi Heart Association, 10.1016/j.jsha.2016.07.004, 29:1, (44-52), Online publication date: 1-Jan-2017. Lyon A, Bossone E, Schneider B, Sechtem U, Citro R, Underwood S, Sheppard M, Figtree G, Parodi G, Akashi Y, Ruschitzka F, Filippatos G, Mebazaa A and Omerovic E (2015) Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology, European Journal of Heart Failure, 10.1002/ejhf.424, 18:1, (8-27), Online publication date: 1-Jan-2016. Smeijers L, Szabó B and Kop W (2016) Psychological distress and personality factors in takotsubo cardiomyopathy, Netherlands Heart Journal, 10.1007/s12471-016-0861-3, 24:9, (530-537), Online publication date: 1-Sep-2016. Zalewska-Adamiec M, Bachorzewska-Gajewska H, Tomaszuk-Kazberuk A, Nowak K, Drozdowski P, Bychowski J, Krynicki R, Musial W and Dobrzycki S (2016) Takotsubo cardiomyopathy: serious early complications and two-year mortality – a 101 case study, Netherlands Heart Journal, 10.1007/s12471-016-0857-z, 24:9, (511-519), Online publication date: 1-Sep-2016. Auzel O, Mustafic H, Pillière R, El Mahmoud R, Dubourg O and Mansencal N (2016) Incidence, Characteristics, Risk Factors, and Outcomes of Takotsubo Cardiomyopathy With and Without Ventricular Arrhythmia, The American Journal of Cardiology, 10.1016/j.amjcard.2016.01.017, 117:8, (1242-1247), Online publication date: 1-Apr-2016. Patel N, Shenoy A, Dous G, Kamran H and El-Sherif N (2016) Sepsis-Induced Takotsubo Cardiomyopathy Leading to Torsades de Pointes, Case Reports in Cardiology, 10.1155/2016/2384752, 2016, (1-6), . Zuin M, Dal Santo P, Picariello C, Conte L, Zuliani G, D'Elia K and Roncon L (2016) Takotsubo Cardiomyopathy in an Elderly Woman with Alzheimer's Disease: A Rare Association. Case Report and Mini-Review of the Literature, Journal of the American Geriatrics Society, 10.1111/jgs.14071, 64:4, (916-917), Online publication date: 1-Apr-2016. Derk G, Aboulhosn J and Reardon L (2016) Takotsubo Cardiomyopathy in a 22-Year-Old Single-Ventricle Patient, Texas Heart Institute Journal, 10.14503/THIJ-14-4151, 43:1, (61-64), Online publication date: 1-Feb-2016. Abdallah A, Vallurupalli S and Kunthur A (2015) Pazopanib- and bevacizumab-induced reversible heart failure in a patient with metastatic renal cell carcinoma: A case report, Journal of Oncology Pharmacy Practice, 10.1177/1078155215585189, 22:3, (561-565), Online publication date: 1-Jun-2016. Otani Y, Tokunaga K, Kawauchi S, Inoue S, Watanabe K, Kiriyama H, Sakane K, Maekawa K, Date I and Matsumoto K (2016) Cerebral Infarction Arising from Takotsubo Cardiomyopathy: Case Report and Literature Review, NMC Case Report Journal, 10.2176/nmccrj.cr.2016-0034, 3:4, (119-123), . Ono R and Falcão L (2016) Takotsubo cardiomyopathy systematic review: Pathophysiologic process, clinical presentation and diagnostic approach to Takotsubo cardiomyopathy, International Journal of Cardiology, 10.1016/j.ijcard.2016.02.012, 209, (196-205), Online publication date: 1-Apr-2016. Harris Z, Alonso A and Kennedy T (2016) Adrenergic Inhibition with Dexmedetomidine to Treat Stress Cardiomyopathy during Alcohol Withdrawal: A Case Report and Literature Review, Case Reports in Critical Care, 10.1155/2016/9693653, 2016, (1-9), . Soffler M, McGregor A and Safdar B (2016) It’s not all Chest Pain: Sex and Gender in Acute Care Cardiology Sex and Gender in Acute Care Medicine, 10.1017/CBO9781107705944.004, (6-23) Naegele M, Flammer A, Enseleit F, Roas S, Frank M, Hirt A, Kaiser P, Cantatore S, Templin C, Fröhlich G, Romanens M, Lüscher T, Ruschitzka F, Noll G and Sudano I (2016) Endothelial function and sympathetic nervous system activity in patients with Takotsubo syndrome, International Journal of Cardiology, 10.1016/j.ijcard.2016.09.008, 224, (226-230), Online publication date: 1-Dec-2016. Belluschi I, Cioni M, Moriggia S and Alfieri O (2016) Takotsubo Cardiomyopathy Following Pericardiocentesis After Aortic Valve Repair and Ascending Aorta Replacement, The Annals of Thoracic Surgery, 10.1016/j.athoracsur.2016.02.021, 102:4, (e291-e293), Online publication date: 1-Oct-2016. Ng K, Dearden C and Gruber P (2015) Rituximab-induced Takotsubo syndrome: more cardiotoxic than it appears?, Case Reports, 10.1136/bcr-2014-208203, 2015:mar02 1, (bcr2014208203-bcr2014208203), Online publication date: 2-Mar-2015. Gabe E and Ambrose J (2015) Takotsubo Cardiomyopathy – An Interesting and Somewhat Unexplained Clinical Entity Controversies in Cardiology, 10.1007/978-3-319-20415-4_8, (99-109), . Sun T (2015) Infection-related stress phenomenon induced takotsubo cardiomyopathy mimicking ST elevation myocardial infarction, Journal of Clinical Gerontology and Geriatrics, 10.1016/j.jcgg.2014.10.001, 6:3, (106-109), Online publication date: 1-Sep-2015. Koh J, Kim S, Lee H, Chu S, Shin Y, Sir J, Choi S and Joo S (2015) Takotsubo Cardiomyopathy Associated with Chronic Psychiatric Stress in Major Depressive Disorder in an Elderly Patient, Journal of the Korean Geriatrics Society, 10.4235/jkgs.2015.19.3.181, 19:3, (181-184), Online publication date: 30-Sep-2015. Pongetti G and Fabbrizioli A (2015) Takotsubo Cardiomyopathy Clinical Cases in Cardiology, 10.1007/978-3-319-19926-9_5, (41-51), . Shresthra S, Juneau D, Hermann D and Wells G (2015) Apical Ballooning Syndrome: Recent Insights from a Consecutive Series of 104 Patients, Health, 10.4236/health.2015.71002, 07:01, (9-13), . Sénior J, Tamayo Artunduaga N, Fernández Cadavid A and Rodríguez Dimuro A (2015) Cardiomiopatía de Takotsubo, IATREIA, 10.17533/udea.iatreia.v28n2a11, 28:2, Online publication date: 9-Apr-2015. Cao X, Zhou C, Chong J, Fu L, Zhang L, Sun D, Hou H, Zhang Y, Li D and Sun H (2015) Estrogen resisted stress-induced cardiomyopathy through increasing the activity of β2AR–Gαs signal pathway in female rats, International Journal of Cardiology, 10.1016/j.ijcard.2015.02.113, 187, (377-386), Online publication date: 1-May-2015. Kazakauskaitė E, Jankauskas A, Lapinskas T, Ordienė R and Ereminienė E (2014) Takotsubo cardiomyopathy: The challenging diagnosis in clinical routine, Medicina, 10.1016/j.medici.2014.05.009, 50:1, (1-7), . Prasad A, Dangas G, Srinivasan M, Yu J, Gersh B, Mehran R and Stone G (2013) Incidence and angiographic characteristics of patients With apical ballooning syndrome (takotsubo/stress cardiomyopathy) in the HORIZONS-AMI trial, Catheterization and Cardiovascular Interventions, 10.1002/ccd.23441, 83:3, (343-348), Online publication date: 15-Feb-2014. Núñez D, Bermejo R and Rodríguez-Velasco A (2014) Cardiomiopatía de Takotsubo en el contexto de sepsis por Staphylococcus aureus, Revista Española de Anestesiología y Reanimación, 10.1016/j.redar.2013.02.015, 61:3, (150-153), Online publication date: 1-Mar-2014. Im H, Lee J, Yeo H, Lee H, Byun K and Kim M (2014) A Case of Persistent Apical Ballooning in a Patient with SLE, Journal of Rheumatic Diseases, 10.4078/jrd.2014.21.2.91, 21:2, (91), . Maekawa H and Hadeishi H (2013) Takotsubo cardiomyopathy following subarachnoid haemorrhage, Practical Neurology, 10.1136/practneurol-2013-000629, 14:4, (252-255), Online publication date: 1-Aug-2014. Pérez Pérez F and Sánchez Salado J (2014) Síndrome de Tako-Tsubo. Discinesia transitoria del ventrículo izquierdo, SEMERGEN - Medicina de Familia, 10.1016/j.semerg.2013.01.014, 40:2, (73-79), Online publication date: 1-Mar-2014. Coupez E, Eschalier R, Pereira B, Pierrard R, Souteyrand G, Clerfond G, Citron B, Lusson J, Mansencal N and Motreff P (2014) A single pathophysiological pathway in Takotsubo cardiom