Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy

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Back to table of contents Previous article Next article Clinical and Research NewsFull Access‘Broken Heart Syndrome’ Shows Strong Associations With Psychiatric DisordersNick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:4 Dec 2015https://doi.org/10.1176/appi.pn.2015.10b13AbstractPatients with takotsubo (stress) cardiomyopathy were three times as likely as those who had had a typical heart attack to have received an acute or chronic psychiatric diagnosis.The connections between the heart and mind are becoming better understood, but most of this knowledge is related to common cardiovascular problems like acute heart attack and stroke. A lesser known cardiac condition on which more insight has recently been gained is takotsubo (stress) cardiomyopathy, often referred to as “broken heart syndrome.”Takotsubo Poses Risks for People with Neuropsychiatric Conditions: Named for its resemblance to the bulbous pots used to trap octopi, takotsubo (stress) cardiomyopathy causes the heart to contract abnormally and balloon out. Though long associated with emotional triggers like anxiety, data from a new registry points to a potential link between takotsubo (stress) cardiomyopathy and other psychiatric and neurological disorders.Satoshi Kurisu, M.D.Takotsubo cardiomyopathy involves the ballooning of the heart’s apex (the lower tip), resulting from a weakening of the surrounding heart muscle. Though takotsubo can lead to heart failure or arrhythmias, it is generally viewed as a benign heart condition. This disease predominantly affects older women, and emotional stress or anxiety (for example, loss of a loved one) is believed to be a common trigger.However, the data obtained from 1,750 patients as part of the International Takotsubo Registry found that this condition may not be so benign after all, noted study author Abhiram Prasad, M.D., a professor of interventional cardiology at St George’s University Hospital in London and an adjunct professor of medicine at the Mayo Clinic.“We found that the rates of serious complications during hospitalization, including death, were similar for takotsubo cardiomyopathy as for a typical heart attack,” he said. “Overall, nearly one-fifth of the patients experienced some serious event. And people with a psychiatric or neurologic diagnosis are at increased risk for one of these complications.”This increased risk is noteworthy since acute or chronic psychiatric issues were found to be three times as prevalent among takotsubo patients (42.3 percent) compared with people who experienced a typical heart attack (14.3 percent). Mood disorders were the most common diagnosis, present in about 20 percent of patients, while anxiety disorders were present in 10 percent.Neurological issues, particularly seizures or chronic migraines, were also more prevalent among takotsubo patients. Some 27.5 percent of patients with takotsubo (stress) cardiomyopathy reported an acute or chronic neurological problem, compared with 14.5 percent of heart attack patients.“These findings suggest a potential link between neuropsychiatric disorders and takotsubo cardiomyopathy and should prompt prospective studies,” Prasad said.Another take-home message of this study, Prasad noted, is that takotsubo cardiomyopathy affects more than older women. Also, previous reports on takotsubo cardiomyoptahty may have overemphasized this group of patients, thus leading to the mindset that takotsubo is a benign disease. “Yes, older women are the most prominent population group affected, and the analysis shows that the textbook takotsubo manifestation, an older woman who has an event following an emotional trigger like anxiety, does have a low risk of complications,” he said. “However, 20 percent of the patients were either men of any age or women under 50. In addition, physical events such as respiratory problems or sinus infections are more common triggers than emotional stimuli, while nearly one-third of patients appear to have no triggers at all. And these groups—younger adults, events without an emotional trigger, and people with a psychiatric diagnosis—are at risk for serious health problems.”The International Takotsubo Registry is a consortium of 26 centers in Europe and the United States set up to investigate clinical features, prognostic predictors, and health outcomes of takotsubo cardiomyopathy. This study was supported by research grants from the Mach-Gaensslen Foundation, Prof. Otto Beisheim Foundation, Swiss Heart Foundation, the Olten Heart Foundation, University of Zurich, Swiss National Science Foundation, and Foundation for Cardiovascular Research–Zurich Heart House. ■An abstract of “Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy” can be accessed here. ISSUES NewArchived

Case 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). Figure 1. Twelve-lead ECG demonstrating ST-segment elevation in precordial leads. Physicians 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.3 The 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 …

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We assessed Takotsubo (ampulla) cardiomyopathy compared with acute coronary syndrome (ACS) using two-dimensional echocardiography and 99mTc-tetrofosmin myocardial SPECT. We examined 10 patients with Takotsubo cardiomyopathy and 16 with ACS at the time of emergency admission (acute phase), at three to nine days after the attack (subacute phase) and at one month after the attack (chronic phase). The left ventricle was divided into nine regions on echocardiograms and SPECT images, and the degree of abnormalities in each region was scored in five grades from normal (0) to severely abnormal (4). Coronary angiography revealed total or subtotal occlusion in patients with ACS but no stenotic legions in those with Takotsubo cardiomyopathy. The amount of ST segment elevation (mm) was 7.9 +/- 3.4 in patients with Takotsubo cardiomyopathy and 7.3 +/- 3.7 in those with ACS (N.S.). Abnormal wall motion scores on echocardiograms were 13.8 +/- 4.4, 4.4 +/- 3.8 and 1.8 +/- 2.3 during the acute, subacute and chronic phases in patients with Takotsubo cardiomyopathy, and 13.9 +/- 4.0, 11.7 +/- 3.7, 7.6 +/- 4.2, respectively in patients with ACS. The value of MB fraction of creatine phosphokinase (IU/l) was 34 +/- 23 in patients with Takotsubo cardiomyopathy and 326 +/- 98 in those with ACS (p < 0.001). Abnormal myocardial perfusion scores on 99mTc-tetrofosmin myocardial SPECT were 11.4 +/- 3.2, 3.2 +/- 3.3 and 0.7 +/- 1.1 during the acute, subacute and chronic phases respectively, in patients with Takotsubo cardiomyopathy, and 15.8 +/- 4.1, 13.5 +/- 4.4, 8.2 +/- 4.4, respectively, in those with ACS. The numbers of myocardial segments that did not uptake 99mTc-tetrofosmin during the acute phase were 0.5 +/- 0.8 and 3.6 +/- 2.8 in patients with Takotsubo cardiomyopathy and ACS, respectively. Impaired coronary microcirculation might be a causative mechanism of Takotsubo cardiomyopathy.

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