Takotsubo syndrome triggered by a pleasant emotional event: a case report

Early stressful experiences are associated with reduced neural responses to naturalistic emotional and social content in children

Use of Cardiac Magnetic Resonance Imaging to Distinguish Between Acute Myocarditis and Takotsubo Cardiomyopathy

Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Ospedale Sant'Orsola (Bologna) Background Takotsubo syndrome (TTS) is an acute and transient heart failure syndrome characterized by a temporary wall motion abnormality of the left ventricle. Cardiac magnetic resonance (CMR) has a crucial role to assess ventricles function, regional wall motion abnormalities (RWMA), myocardial edema, late gadolinium enhancement (LGE) and complications. To date, there is a lack of how trigger events impact CMR parameters. Purpose To evaluate the clinical presentation, triggers of TTS and CMR parameters in patients hospitalized for Takotsubo Syndrome (TTS). Methods In our study we evaluated 128 patients hospitalized with TTS between January 2016 and December 2021 in Italy. Diagnosis of Takotsubo syndrome was based on the international Takotsubo diagnostic criteria (InterTAK Diagnostic Criteria). Results The mean age of the study population was 68.7 ± 11.1 years, and 81 % were females. Concerning the event trigger of TTS, 44% of patients experimented with an emotional event and 56% with physical stress. CMR was available in 66 patients, performed 7.5 ± 3.7 days after admission during hospitalization. CMR confirmed that most patients had typical TTS with apical ballooning (87%) while only 4.5% had a midventricular pattern. Left ventricular ejection fraction (LV-EF) mean was 55.3 ± 10.9 %. Mean LV-EF did not significant differ between emotional and physical trigger populations (51±12.5 vs 56.3±7.7; p = 0.12). Myocardial edema was present in 64.2% of patients and the mean number of segments involved was 6.2. ± 5.9. No statistical correlation between TTS trigger and the presence of edema at T2-weighted imaging was noticed. Spotty LGE was observed in 23.1 % of CMR exams, most evidenced in lateral (11.9 %) and inferior segments (10.4 %). LGE was evidenced more frequently in TTS triggered by physical events (38.1% vs 13%; p value=0.04) unlike pericardial effusion (0% vs 14%; p value= 0.04). Moreover, Hs-troponin I peak value was higher in the TTS physical triggered population than TTS with emotional trigger (3413 ± 4457 ng/l vs 2018 ± 2064 ng/l; p value= 0.04). Conclusions Early execution of CMR is essential in suspected TTS because several parameters are relatively time-dependent and derived from dynamic alterations that might resolve over time (such as myocardial edema). In our study patients with a physical trigger had a higher Hs-Troponin I max peak value and, more frequently spotty LGE on CMR. This could be the manifestation of more consistent myocardial damage compared to emotional triggers. However, the physiopathological and prognostic role of LGE in TTS remains unclear.

Takotsubo Cardiomyopathy presenting with different morphological patterns in the same patient: a case report and review of the literature

Takotsubo syndrome (TTS), also known as Takotsubo cardiomyopathy, is a transient left ventricular wall dysfunction that is often triggered by physical or emotional stressors. Although TTS is a rare disease with a prevalence of only 0.5% to 0.9% in the general population, it is often misdiagnosed as acute coronary syndrome. A diagnosis of TTS can be made using Mayo diagnostic criteria. The initial management of TTS includes dual antiplatelet therapy, anticoagulants, beta-blockers, angiotensin-converting enzyme inhibitors or aldosterone receptor blockers, and statins. Treatment is usually provided for up to three months and has a good safety profile. For TTS with complications such as cardiogenic shock, management depends on left ventricular outflow tract obstruction (LVOTO). In patients without LVOTO, inotropic agents can be used to maintain pressure, while inotropic agents are contraindicated in patients with LVOTO. In TTS with thromboembolism, heparin should be started, and patients should be bridged to warfarin for up to three months to prevent systemic emboli. Our comprehensive review discussed the management in detail, derived from the most recent literature from observational studies, systematic review, and meta-analyses.

Frequency of Takotsubo Cardiomyopathy in Postmenopausal Women Presenting With an Acute Coronary Syndrome: Still Underdiagnosed

This research project posits a model of repression that incorporates both repressive personality and repressive social behavior. The 1st parameter of the model specifies the motivation for repressors' distancing of themselves from emotional events. Experiment 1 demonstrates that repressors are hypersensitive--in their cognitive attention--to both negative and positive emotional events. The 2nd parameter of the model specifies the conditions under which repressors distance themselves from emotional events. Experiments 2 and 3 demonstrate that repressors psychologically distance themselves when the situation threatens their self-evaluation and provides opportunity for them to attend to and process self-relevant and non-self-relevant information. This 2-factor model extends the current conceptualization of repression in that it identifies motivation (dispositional emotional sensitivity) and context (situational threats to self-evaluation and distraction availability) for repressors' distancing of themselves from negative and positive emotional events.

This research project posits a model of repression that incorporates both repressive personality and repressive social behavior. The 1st parameter of the model specifies the motivation for repressors' distancing of themselves from emotional events. Experiment 1 demonstrates that repressors are hypersensitive--in their cognitive attention--to both negative and positive emotional events. The 2nd parameter of the model specifies the conditions under which repressors distance themselves from emotional events. Experiments 2 and 3 demonstrate that repressors psychologically distance themselves when the situation threatens their self-evaluation and provides opportunity for them to attend to and process self-relevant and non-self-relevant information. This 2-factor model extends the current conceptualization of repression in that it identifies motivation (dispositional emotional sensitivity) and context (situational threats to self-evaluation and distraction availability) for repressors' distancing of themselves from negative and positive emotional events.

Background: Distinguishing Takotsubo syndrome (TTS) from acute anterior wall myocardial infarction is often difficult based on clinic characteristics, biomarkers, electrocardiograms and noninvasive images, leading to dilemmas regarding treatment decisions. The aim of this study was to determine whether deep learning (DL) neural networks can reduce erroneous human “judgment calls” on bedside echocardiograms and improve differential diagnostic accuracy. Methods: We developed deep convolution neural networks (DCNNs), including a single-channel (DCNN[2D SCI]), a multi-channel (DCNN[2D MCI]) and a 3-dimensional (DCNN[2D+t]) network, and a recurrent neural network (RNN) based on the same database consisting of 17,280 still-frame images and 540 videos from 2-dimensional (2D) echocardiograms in a 12-year retrospective cohort of 540 patients in the University of Iowa (UI) and eight other medical centers in the United States. The diagnosis of anterior wall ST segment elevation myocardial infarction (STEMI) and TTS were all confirmed by the coronary angiography. Echocardiograms from 450 UI patients were randomly divided into training and testing sets for internal training, testing, and model construction. Echocardiograms of 90 patients from the other medical centers were used for external validation to evaluate the model generalizability. A total of 49 board-certified human readers (22 cardiologists, 11 senior echocardiographers, and 8 point-of-care ultrasound-trained clinicians) performed human-side classification on the same echocardiography dataset to compare the diagnostic performance and help data visualization. Findings: The DCNN (2D SCI), DCNN (2D MCI), DCNN(2D+t), and RNN models established based on UI dataset for the control versus disease prediction showed mean diagnostic accuracy of 78%, 83%, 92%, and 81% respectively. The DCNN (2D SCI), DCNN (2D MCI), DCNN(2D+t), and RNN models established based on UI dataset for TTS versus STEMI prediction showed mean diagnostic accuracy 73%, 75%, 80%, and 75% respectively, and the mean diagnostic accuracy of 74%, 74%, 77%, and 73%, respectively, on the external validation. The area under the receiver operating characteristic curve (AUC) analysis showed that DCNN(2D+t) (0·787 vs. 0·699, P = 0·015) and RNN models (0·774 vs. 0·699, P = 0·033) consistently outperformed human readers in differentiating TTS and STEMI by reducing the erroneous judgement calls on TTS from human readers. Interpretation: Spatio-temporal hybrid DL neural networks reduce erroneous human “judgement calls” in distinguishing TTS from anterior wall STEMI based on bedside echocardiographic videos, demonstrating the potential of DL neural networks to support frontline triage and management of cardiovascular emergencies. Funding: University of Iowa Obermann Center for Advanced Studies Interdisciplinary Research Grant, and Institute for Clinical and Translational Science Grant. Declaration of Interest: We declare no competing interests. Ethical Approval: The research protocols and waiver of informed consent were approved by the human subjects committee of the UI institutional review board.

TAKOTSUBO CARDIOMYOPATHY SECONDARY TO ACUTE BACTERIAL MENINGITIS

Processus émotionnel dans la schizophrénie : étude de la composante d’évaluation

Transient left ventricular (LV) systolic dysfunction is a challenging complication of septic shock. Although Levosimendan, a calcium sensitizer has been reported to have a therapeutic role, digoxin, which increases intra-myocardial calcium level and cardiac contractility has no available data even though digoxin has abundant clinical experience. We retrospectively reviewed medical records of septic shock patients who developed transient LV systolic dysfunction and were treated with loading dose of digoxin between 01 Oct 2016 and 31 Dec 2017. Digoxin loading was given to 18 septic shock patients with mechanical ventilator and high dose vasopressors. Echocardiographic assessment was available in 6 patients. Mean age was 65.0 ± 10.2 years and 4 patients (66.7%) were female. Coronary angiography was performed in 2 patients with no lesion (33.3%). Four patients exhibited typical regional wall motion abnormality of Takotsubo syndrome (TS) and 1 patient reversed type of TS and 1 patient global hypokinesia. Bedside echocardiography revealed increased stroke volume after loading dose of digoxin. Detailed echocardiographic strokevolume measurement beforeand after digoxin loading are shown in table 1. In conclusion, in septic shock patients with transient LV dysfunction such as TS, digoxin loading can be a feasible treatment. Further clinical study is needed.

Takotsubo cardiomyopathy (TCM) is characterized by transient left ventricular dysfunction in the absence of significant coronary artery disease. First described in Japan in the 1990s by Sato et al., this unique reversible cardiomyopathy typically occurs in post-menopausal women and is frequently triggered by physical or physiological stress. Despite numerous studies, the pathogenesis and etiology of TCM are incompletely understood. However, the overlap in the initial clinical presentation of TCM and acute coronary syndrome (ACS), the increasing incidence of TCM, particularly after the COVID-19 pandemic, and the comparable long-term mortality risk of TCM patients highlight the importance of a better understanding of this condition. Less common triggers, including gastrointestinal disturbances, have been associated with TCM, as will be discussed in this case report. This case presents a 46-year-old female who was admitted to the hospital with epigastric pain and vomiting and later developed chest pain with elevated cardiac biomarkers and ECG changes. Following a diagnosis of suspected non-ST elevation myocardial infarction (NSTEMI), coronary angiography revealed unobstructed coronary arteries and magnetic resonance imaging confirmed TCM. This case highlights that TCM can be triggered by non-classical stressors such as prolonged gastrointestinal symptoms. Early recognition and appropriate management can lead to a favorable prognosis.

Takotsubo syndrome (TTS) is characterized by transient left ventricular dysfunction and associated with considerable morbidity and mortality. We sought to evaluate the association between change in cardiac mechanics after diagnosis of TTS with 1-year incidence of major adverse cardiovascular events (MACE). We retrospectively identified 85 patients with apical TTS based on ICD 9/10 codes and chart adjudication, who had a follow-up echocardiogram within 6 months of diagnosis. Echocardiograms were analyzed for left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), GLS ratio, global circumferential strain (GCS), and global radial strain (GRS). Multivariable logistic regression was performed to identify parameters associated with MACE (all-cause mortality, heart failure, stroke, and coronary artery disease [CAD] requiring percutaneous coronary intervention [PCI]) at 1 year. Event-free survival was assessed in patients with GLS (≤-18% vs. >18%) and LVEF (≥53% vs. <53%). Within 1 year of diagnosis, MACE occurred in 15 (18%) patients. Between baseline and follow-up echocardiogram (median 15 [range 1-151] days), there were significant differences in change in LVEF and GLS in patients with versus without incident MACE. In multivariate analysis, change in LVEF (odds ratio [OR]=.93 [.87, .98], p=.013) and change in GLS (OR=1.32 [1.04, 1.67], p=.022) were independently associated with MACE; however, the association with change in GLS was attenuated (odds ratio [OR]=1.13 [.94, 1.36], p=.21) after adjustment for baseline and change in LVEF. Among patients with normalized LVEF at follow-up, there were five (14.7%) MACE; whereas, there were no events among patients with normalized GLS. In patients with apical TTS, recovery in GLS and LVEF at follow-up was associated with significantly lower MACE at 1 year. Normalization of GLS at follow-up was better able to discriminate event-free survival than normalization of LVEF.

Takotsubo Syndrome in a Newborn