Why Sex Matters in Takotsubo Syndrome

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Midventricular variant of transient apical ballooning: a likely demonstration of its pathophysiologic mechanism.

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 …

COVID-19-Associated Stress (Takotsubo) Cardiomyopathy.

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

Usefulness of Sum of ST-Segment Elevation on Electrocardiograms (Limb Leads) for Predicting In-Hospital Complications in Patients With Stress (Takotsubo) Cardiomyopathy

Stress Cardiomyopathy: The Midventricular Variant

Reply: Takotsubo Cardiomyopathy After Receiving mRNA COVID-19 Vaccination is Very Rare

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

Acute stress-induced (takotsubo) cardiomyopathy can result in a heart failure phenotype with a prognosis comparable with that of myocardial infarction. In this study, we hypothesized that inflammation is central to the pathophysiology and natural history of takotsubo cardiomyopathy. In a multicenter study, we prospectively recruited 55 patients with takotsubo cardiomyopathy and 51 age-, sex-, and comorbidity-matched control subjects. During the index event and at the 5-month follow-up, patients with takotsubo cardiomyopathy underwent multiparametric cardiac magnetic resonance imaging, including ultrasmall superparamagnetic particles of iron oxide (USPIO) enhancement for detection of inflammatory macrophages in the myocardium. Blood monocyte subpopulations and serum cytokines were assessed as measures of systemic inflammation. Matched control subjects underwent investigation at a single time point. Subjects were predominantly middle-aged (64±14 years) women (90%). Compared with control subjects, patients with takotsubo cardiomyopathy had greater USPIO enhancement (expressed as the difference between pre-USPIO and post-USPIO T2*) in both ballooning (14.3±0.6 milliseconds versus 10.5±0.9 milliseconds; P<0.001) and nonballooning (12.9±0.6 milliseconds versus 10.5±0.9 milliseconds; P=0.02) left ventricular myocardial segments. Serum interleukin-6 (23.1±4.5 pg/mL versus 6.5±5.8 pg/mL; P<0.001) and chemokine (C-X-C motif) ligand 1 (1903±168 pg/mL versus 1272±177 pg/mL; P=0.01) concentrations and classic CD14++CD16- monocytes (90±0.5% versus 87±0.9%; P=0.01) were also increased whereas intermediate CD14++CD16+ (5.4±0.3% versus 6.9±0.6%; P=0.01) and nonclassic CD14+CD16++ (2.7±0.3% versus 4.2±0.5%; P=0.006) monocytes were reduced in patients with takotsubo cardiomyopathy. At 5 months, USPIO enhancement was no longer detectable in the left ventricular myocardium, although persistent elevations in serum interleukin-6 concentrations ( P=0.009) and reductions in intermediate CD14++CD16+ monocytes (5.6±0.4% versus 6.9±0.6%; P=0.01) remained. We demonstrate for the first time that takotsubo cardiomyopathy is characterized by a myocardial macrophage inflammatory infiltrate, changes in the distribution of monocyte subsets, and an increase in systemic proinflammatory cytokines. Many of these changes persisted for at least 5 months, suggesting a low-grade chronic inflammatory state. URL: https://www.clinicaltrials.gov . Unique identifier: NCT02897739.

Comparison of Complications and In-Hospital Mortality in Takotsubo (Apical Ballooning/Stress) Cardiomyopathy Versus Acute Myocardial Infarction

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Stress cardiomyopathy (SC) is a newly reported condition of older women, triggered by emotionally and physically stressful events, characterized by acute heart failure with a distinctive angiographic profile, and regarded as a reversible process. To date, extended follow-up of SC patients is largely unavailable. We have assembled a substantial consecutive group of patients with SC to assess short and long-term clinical consequences of this condition. Between 2001–2008, we prospectively identified and followed (mean 2.0 years, range 0–6.7) 113 consecutive women with SC at a tertiary care United States hospital. Patients were female, aged 32–92 years (mean 68±13), and 16 (14%) were &lt; 55 years. In 105 (93%) a triggering stressful event (emotional in 50, acute illness in 55) was identified; however, in 8 patients (7%) no such event preceded SC. The ECG showed ST-segment elevation in 58(51%) patients and ejection fraction (EF) was 31±11%. Troponin was elevated in 109 (96%); peak troponin (T) was 0.64±0.76 ng/ml. Of the 113 patients, 110(97%) survived the acute event: 3 patients (3%) died in-hospital (cardiogenic shock in 2; subarachnoid hemorrhage in 1). Other complications included: cardiac arrest 2 (2%), hypotension requiring inotropic drug and/or intra-aortic balloon pump in 22 (19%), pulmonary or cerebral embolism in 3 (3%), left ventricular (LV) or right ventricular thrombus in 7 (6%) and LV outflow obstruction in 13 (12%). CMR findings included absent delayed hyperenhancement (gadolinium) in 82/83 (99%), normal LV apical contraction in 46%, RV akinesia in 22%, and pleural effusions due to heart failure in 46%. At follow-up, EF returned to normal in all patients, but one or more SC events recurred in 7 (6%) patients (complicated by non-fatal cardiac arrest in 1), of whom 3 were taking beta-blockers. Post-hospital death occurred in 15 (13%) patients of which 14 were noncardiac and 1 of unknown cause. Among this large cohort of women, some SC events occurred atypically either without a stress trigger or in younger premenopausal patients. SC also led to death in the acute phase or to later non-fatal recurrences of SC or cardiac arrest in about 10%. Therefore, the clinical profile of SC is much broader than previously regarded.

ThyroidVol. 17, No. 2 Images in ThyroidologyLeft Ventricular Apical Ballooning (Takotsubo Cardiomyopathy) in ThyrotoxicosisAlexander M. Rossor, Simon H.S. Pearce, and Philip C. AdamsAlexander M. RossorSearch for more papers by this author, Simon H.S. PearceSearch for more papers by this author, and Philip C. AdamsSearch for more papers by this authorPublished Online:14 Mar 2007https://doi.org/10.1089/thy.2006.0102AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail "Left Ventricular Apical Ballooning (Takotsubo Cardiomyopathy) in Thyrotoxicosis." , 17(2), pp. 181–182FiguresReferencesRelatedDetailsCited byThe association between Takotsubo cardiomyopathy and thyrotoxicosis: A systematic review26 August 2022 | Endocrine, Vol. 78, No. 3Association of Endocrine Conditions With Takotsubo Cardiomyopathy: A Comprehensive ReviewJournal of the American Heart Association, Vol. 7, No. 19Congestive Heart Failure Secondary to a TSH-Secreting Pituitary Adenoma Aggravated by Takotsubo Cardiomyopathy in an Elderly PatientAACE Clinical Case Reports, Vol. 4, No. 2Comorbidities Frequency in Takotsubo Syndrome: An International Collaborative Systematic Review Including 1109 PatientsThe American Journal of Medicine, Vol. 128, No. 6Takotsubo cardiomyopathy and endocrine disorders: a mini-review of case reportsThe American Journal of Emergency Medicine, Vol. 32, No. 11Takotsubo Cardiomyopathy Associated with Thyrotoxicosis: A Case Report and Review of the Literature Myrto Eliades, Diala El-Maouche, Chitra Choudhary, Bruce Zinsmeister, and Kenneth D. Burman11 February 2014 | Thyroid, Vol. 24, No. 2Broken heart syndrome triggered by an obstructive goiter not associated with thyrotoxicosis11 July 2013 | Canadian Journal of Anesthesia/Journal canadien d'anesthésie, Vol. 60, No. 8A case of asymptomatic patient with hyperthyroidism documented the onset of Takotsubo cardiomyopathy by holter monitoringInternational Journal of Cardiology, Vol. 151, No. 3Stress CardiomyopathyCritical Pathways in Cardiology: A Journal of Evidence-Based Medicine, Vol. 10, No. 3Transient Left Ventricular Systolic Dysfunction with Thrombus and Subsequent Cardioembolic Stroke in Short-Term Overt HypothyroidismCardiology, Vol. 119, No. 1Takotsubo cardiomyopathy in thyrotoxicosisInternational Journal of Cardiology, Vol. 145, No. 3Takotsubo Cardiomyopathy: A Unique Cardiomyopathy With Variable Ventricular MorphologyJACC: Cardiovascular Imaging, Vol. 3, No. 6An Association Between Takotsubo Cardiomyopathy and Thyroid Storm13 March 2015 | Postgraduate Medicine, Vol. 121, No. 3Takotsubo cardiomyopathy associated with autoimmune polyendocrine syndrome IIJournal of Cardiology, Vol. 53, No. 2Takotsubo cardiomyopathy: State-of-the-art review20 January 2009 | Journal of Nuclear Cardiology, Vol. 16, No. 1Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): A mimic of acute myocardial infarctionAmerican Heart Journal, Vol. 155, No. 3 Volume 17Issue 2Feb 2007 InformationCopyright 2007, Mary Ann Liebert, Inc.To cite this article:Alexander M. Rossor, Simon H.S. Pearce, and Philip C. Adams.Left Ventricular Apical Ballooning (Takotsubo Cardiomyopathy) in Thyrotoxicosis.Thyroid.Feb 2007.181-182.http://doi.org/10.1089/thy.2006.0102Published in Volume: 17 Issue 2: March 14, 2007PDF download

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.