Coronary vasomotor dysfunction in apical ballooning (Takotsubo) syndrome: An innocent bystander or a prime suspect?

Abstract

TakoTsubo syndrome/cardiomyopathy (TTS) is a mimic of acute myocardial infarction (MI) with an estimated prevalence of 2% among patients initially suspected of an acute MI [ [1] Prasad A. Lerman A. Rihal C.S. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am. Heart J. 2008; 155: 408-417 Abstract Full Text Full Text PDF PubMed Scopus (1289) Google Scholar ]. Since its initial description by Sato et al. [ [2] Sato H.T.H. Dote K. Uchida T. Ishihara M. Tako-tsubo-like cardiomyopathy due to multivessel coronary spasm. in: Kodama K. Haze K. Hori M. Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure. Kagakuhyoronsha Publishing Co., Tokyo1990: 56-64 Google Scholar ], animal and clinical studies have attempted to elucidate the pathophysiology of this unique condition. Stress mediated activation of the sympathetic nervous system and subsequent neurocardiogenic stunning in susceptible patients are believed to be central features. Multiple potential mechanisms have been proposed for the observed neurocardiogenic stunning including: direct cardiomyocyte catecholamine toxicity, diffuse vascular spasm [ [2] Sato H.T.H. Dote K. Uchida T. Ishihara M. Tako-tsubo-like cardiomyopathy due to multivessel coronary spasm. in: Kodama K. Haze K. Hori M. Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure. Kagakuhyoronsha Publishing Co., Tokyo1990: 56-64 Google Scholar ], and microvascular dysfunction [ 3 Patel S.M. Lerman A. Lennon R.J. Prasad A. Impaired coronary microvascular reactivity in women with apical ballooning syndrome (Takotsubo/stress cardiomyopathy). Eur. Heart J. Acute Cardiovasc. Care. 2013; 2: 147-152 Crossref PubMed Scopus (67) Google Scholar , 4 Williams R. Arri S. Prasad A. Current concepts in the pathogenesis of Takotsubo syndrome. Heart Fail. Clin. 2016; 12: 473-484 Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar ]. The syndrome is common in estrogen deficiency state as seen in postmenopausal women. Estrogen hormone has been shown to modulate coronary microcirculation, attenuate stress-induced activation of sympathetic outflow to target organs, and upregulate cardiac levels of cardioprotective pathways [ 5 Pelliccia F. Kaski J.C. Crea F. Camici P.G. Pathophysiology of Takotsubo syndrome. Circulation. 2017; 135: 2426-2441 Crossref PubMed Scopus (334) Google Scholar , 6 Vitale C. Rosano G.M. Kaski J.C. Role of coronary microvascular dysfunction in Takotsubo cardiomyopathy. Circ. J. 2016; 80: 299-305 Crossref PubMed Scopus (43) Google Scholar ]. However, the precise mechanisms leading to the typical left ventricular dysfunction remain unclear. Abnormal coronary vasoreactivity in transient left ventricular apical ballooning (tako-tsubo) syndromeInternational Journal of CardiologyVol. 250PreviewThe exact etiology and pathophysiologic mechanisms of tako-tsubo syndrome (TTS) remain controversial. Full-Text PDF