Stress-induced Takotsubo Cardiomyopathy Research Articles

A Case Study of a Transplant Candidate With Stress-Induced Takotsubo Cardiomyopathy.

A Case Study of a Transplant Candidate With Stress-Induced Takotsubo Cardiomyopathy.

Abstract 14162: Impact of Migraine Headaches on Stress Induced Takotsubo Cardiomyopathy

Introduction: Takotsubo cardiomyopathy (TTC) is an acute process, characterized by ventricular dysfunction, typically due to a neuro-cardiogenic mechanism. Although many stressors have previously been identified and can precipitate TTC, there have been no reports citing the association or effects of migraines attacks. Hypothesis: Migraines predispose a protective effect on TTC patients Methods: We conducted a US-wide analysis of TTC hospitalizations from 2013 to 2017 by querying the National Inpatient Sample database. Patients admitted with a principal diagnosis of TTC with a history of migraines were identified using the ICD-10 codes. TTC patients with migraines were then compared to TTC patients without migraines regarding mortality and acute inpatient complications (intubation, cardiac arrest, heart failure exacerbation, acute kidney injury). A logistic regression model was constructed to account for potential confounders. Results: A total of 172025 TTC patients were identified, of those patients, 3610 were found to have suffered from migraines. After accounting for potential confounders, TTC patients with a diagnosis of migraine were associated with a lower odds for mortality (OR: 0.388; [0.311-0.485]; p <0.001) and acute complications (OR: 0.511 [0.471-0.554]); p <0.001) compared to those without migraines. In terms of mortality, the presence of acute complications had the highest odds for mortality (7.830 [7.439-8.240]; p <0.001), followed by cerebrovascular disease, cancer, and age. Depression, Diabetes, smoking, and obesity were associated with a decreased odds for mortality. Conclusions: TTC patients with migraines were associated with lower mortality and better inpatient outcomes.

Prolonged QTc Interval In Stress-Induced Takotsubo Cardiomyopathy

Takotsubo Cardiomyopathy is a non-ischemic cardiomyopathy characterized by reversible apical ballooning of the left ventricle presenting with a clinical syndrome mimicking acute coronary syndrome in the absence of significant coronary disease.

SAT-225 A Rare Cause of Cardiogenic Shock

Background: Rare cases of pheochromocytoma are associated with stress induced Takotsubo cardiomyopathy, occurring in approximately 3% of secreting pheoochromocytoma and paraganglioma (PPGL). Case: A 39-year-old female with a history of hypertension and anxiety disorder, re-presented to the ED within 24 hours with headache, vomiting and severe hypertension (BP 205/70 mmHg). She rapidly developed acute pulmonary oedema and cardiogenic shock. ECG revealed dynamic ST-segment abnormalities and troponin rise peaked at 38,000 ng/L (N < 16ng/L). The coronary angiography excluded any coronary artery lesion. Echocardiography revealed severe global hypokinesis with an ejection fraction of 5% and evidence of apical ballooning. A bedside abdominal ultrasound revealed 7cm left adrenal mass confirmed by computed tomography (CT). Investigations revealed a metanephrine level of > 13,760 pmol/L (N < 900 pmol/L) and normetanephrine of > 60,780 pmol/L (N < 500 pmol/L). Her clinical status deteriorated despite on diuretics, inotropes and mechanical ventilation. Extra-corporeal membrane oxygenation (ECMO) was implanted. Alpha adrenergic blockades were initiated followed by beta blockers, during which control of blood pressure was achieved. Her haemodynamic status improved and ECMO removed 8 days post-implantation. Two weeks after discharge from hospital, she underwent uncomplicated open adrenalectomy; histologic examination of the mass confirmed the pheochromocytoma diagnosis. Reference 1. Gagnon N, Mansour S, Bitton Y et al. Takotsubo-like cardiomyopathy in a large cohort of patients with pheoochromocytoma and paraganglioma. Endocrine Practice.2017;10: 1178-1192

Lamotrigine-induced hemophagocytic lymphohistiocytosis with Takotsubo cardiomyopathy: a case report

BackgroundHemophagocytic lymphohistiocytosis is a rare hematological syndrome characterized by excessive and uncontrolled activation of the immune system. The often nonspecific nature of early symptoms and the potential for progression to multiorgan failure and death if appropriate therapy is not started promptly, highlight the importance of heightened recognition for this uncommon disease. Although there are well-described associations of hemophagocytic lymphohistiocytosis with infectious, malignant, and autoimmune diseases and an established treatment protocol for these cases, the link between medications and hemophagocytic lymphohistiocytosis is less clearly established and the optimal treatment of these cases less well defined.Case presentationHere we describe the case of a 45-year-old caucasian woman presenting with signs and symptoms consistent with hemophagocytic lymphohistiocytosis, induced by recent exposure to lamotrigine. She had a rapidly progressive clinical course, complicated by multiorgan failure including stress-induced Takotsubo cardiomyopathy and cardiac arrest. With dexamethasone and etoposide therapy, she made a full and sustained recovery.ConclusionsThis case highlights that medication-induced hemophagocytic lymphohistiocytosis appears to respond similarly to the same dexamethasone and etoposide treatment regimen developed for other non-drug-induced forms of hemophagocytic lymphohistiocytosis. With the continued cessation of the offending agent there has not been need for maintenance therapy and no relapse to date. In addition, given the risk for cardiomyopathy, a clinical complication not classically associated with hemophagocytic lymphohistiocytosis, echocardiogram and telemetry monitoring should be considered in the initial workup of suspected hemophagocytic lymphohistiocytosis.

Emotional Stress-induced Takotsubo Cardiomyopathy, Acute Heart Failure, and Atrial Fibrillation in the Same Patient

Takotsubo cardiomyopathy is characterized by transient systolic dysfunction of apical and central parts of the left ventricle in the absence of obstructive coronary artery disease. Usually, it is triggered by intense emotional or physical stress. The prognosis tends to be good. Rare complications include heart failure, cardiogenic shock, left ventricular free wall rupture, and cardiac arrhythmia. We present a patient with takotsubo cardiomyopathy complicated by acute heart failure and atrial fibrillation. The symptoms appeared due to emotional stress. This case highlights acute emotional stress as a potent trigger for transient myocardial dysfunction with acute heart failure and rhythm disturbance.

Takotsubo Cardiomyopathy Resulting in Cardiac Arrest in a Patient Undergoing Liver Transplantation

Cardiac complications during and after liver transplantation are a common cause of death. Although considered to be uncommon, takotsubo cardiomyopathy, which is characterized by reversible left ventricular akinesis without coronary artery obstruction, is becoming increasingly reported. Herein we have presented a case of reversible stress-induced takotsubo cardiomyopathy resulting in cardiac arrest in a patient undergoing liver transplantation.

A novel miR-371a-5p-mediated pathway, leading to BAG3 upregulation in cardiomyocytes in response to epinephrine, is lost in Takotsubo cardiomyopathy.

Molecular mechanisms protecting cardiomyocytes from stress-induced death, including tension stress, are essential for cardiac physiology and defects in these protective mechanisms can result in pathological alterations. Bcl2-associated athanogene 3 (BAG3) is expressed in cardiomyocytes and is a component of the chaperone-assisted autophagy pathway, essential for homeostasis of mechanically altered cells. BAG3 ablation in mice results in a lethal cardiomyopathy soon after birth and mutations of this gene have been associated with different cardiomyopathies including stress-induced Takotsubo cardiomyopathy (TTC). The pathogenic mechanism leading to TTC has not been defined, but it has been suggested that the heart can be damaged by excessive epinephrine (epi) spillover in the absence of a protective mechanism. The aim of this study was to provide more evidence for a role of BAG3 in the pathogenesis of TTC. Therefore, we sequenced BAG3 gene in 70 TTC patients and in 81 healthy donors with the absence of evaluable cardiovascular disease. Mutations and polymorphisms detected in the BAG3 gene included a frequent nucleotide change g2252c in the BAG3 3′-untranslated region (3′-UTR) of Takotsubo patients (P<0.05), resulting in loss of binding of microRNA-371a-5p (miR-371a-5p) as evidenced by dual-luciferase reporter assays and argonaute RNA-induced silencing complex catalytic component 2/pull-down assays. Moreover, we describe a novel signaling pathway in cardiomyocytes that leads to BAG3 upregulation on exposure to epi through an ERK-dependent upregulation of miR-371a-5p. In conclusion, the presence of a g2252c polymorphism in the BAG3 3′-UTR determines loss of miR-371a-5p binding and results in an altered response to epi, potentially representing a new molecular mechanism that contributes to TTC pathogenesis.

Stress-induced takotsubo cardiomyopathy complicated with wall rupture and thrombus formation

Stress-induced takotsubo cardiomyopathy complicated with wall rupture and thrombus formation

Anxiety trait in patients with stress-induced cardiomyopathy: a case–control study

Stress-induced Tako-tsubo cardiomyopathy (TTC) is an acute cardiac syndrome, mimics ST elevation myocardial infarction (STEMI), largely confined to postmenopausal women, frequently precipitated by a stressful event. The pathogenesis of TTC is still unknown. Some authors hypothesized a possible connection between TTC and anxiety disease, but no previous study analyzed the relationship between anxiety trait and TTC. This study sought to assess the potential role of anxiety trait in the development and clinical course of TTC. We included in the present prospective case-control study 50 consecutive patients admitted to our Hospital with a diagnosis of TTC according to the Mayo Clinic criteria. Fifty control patients with anterior STEMI matched for clinical characteristics such as age, gender, and hypertension were selected. During the hospitalization, all patients were asked to complete the Spielberger Trait Anxiety Inventory (STAI) scale for measuring self-reported trait anxiety (Trait-A). Outcome measures at follow-up were death, TTC recurrence, and rehospitalization. The mean value of STAI scale was 46 ± 12 in TTC patients and 45 ± 14 in STEMI patients (p = 0.815). High-anxiety trait (STAI scale value ≥ 40) was documented in 30 (60%) TTC patients and in 26 (52%) STEMI patients (p = 0.387). At multivariate analysis, predictors of TTC were lower peak creatine kinase value (HR 0.999; 95% CI 0.998-0.999; p = 0.018) and an antecedent stressful trigger event (HR 45.487; 95% CI 6.471-319.759; p = 0.001), but anxiety trait was not. There were no differences in outcome measures between TTC patients with or without high-anxiety trait. In TTC patients, high-anxiety trait is a common finding but it is not significantly more frequent than in patients with STEMI. Moreover, a high-anxiety trait seems to be neither associated with a worse clinical outcome nor a predictor of TTC. Our study do not support the routine evaluation of anxiety trait in patients with TTC.

Cardiac and vascular gene profiles in an animal model of takotsubo cardiomyopathy

We investigated cardiac and vascular gene profiles in response to immobilization stress (IMO) in rats, an animal model of emotional stress-induced takotsubo cardiomyopathy using microarray analysis, followed by re-confirmation with real-time reverse transcription-polymerase chain reaction. Expression levels of the identified genes were further estimated by pretreatment with an α1-adrenoceptor blocker and/or a β1-adrenoceptor blocker. In response to IMO, expression of 46 genes was significantly altered in the heart and that of 49 genes was significantly altered in the aorta. Pathway analysis with DAVID Bioinformatics Resources indicated that regulation of transcription and response to endogenous stimulation were the top two scoring pathways. Altered expression of cardiac genes was blunted by pretreatment with a β1-adrenoceptor blocker or α1 + β1-adrenoceptor blockers. In contrast, that of aortic genes was blunted by pretreatment with an α1-adrenoceptor blocker or α1 + β1-adrenoceptor blockers. Activation of α1-adrenoceptor in the blood vessels or activation of β1-adrenoceptors in the heart were mainly responsible for emotional stress-induced alteration of cardiac and vascular gene profiles.

Presentation of Tako‐tsubo Cardiomyopathy in Men and Women

Recent studies have demonstrated that stress-induced Tako-tsubo cardiomyopathy is likely to occur in elderly female patients. The purpose of this study was to evaluate gender differences in the clinical characteristics of patients with Tako-tsubo cardiomyopathy. This study consisted of 102 patients with Tako-tsubo cardiomyopathy. It was characterized by akinesia/hypokinesia of the mid-to-distal portion of the left ventricular chamber, with normokinesia/hyperkinesia of the basal portion with an ejection fraction of less than 50% on transthoracic echocardiography. There were 13 male and 89 female patients. In 10 male patients (77%), Tako-tsubo cardiomyopathy occurred during or immediately after receiving medical treatment or examination for an underlying disease. In 9 male patients (69%), objective symptoms such as abnormality of monitoring or low blood pressure, but not subjective symptoms increased the chance of the patient being diagnosed with Tako-tsubo cardiomyopathy. There was no significant difference in age, body weight, hypertension, or diabetes except for height between male and female patients. The incidence of in-hospital onset was significantly higher in male patients than in female patients (77% vs 17%, P < 0.01). There was no significant difference in in-hospital mortality (15% vs 6%, P = not significant). These results suggested that physical stress might have more to do with the occurrence of Tako-tsubo in male than female patients.

Apical ballooning in takotsubo cardiomyopathy

Stress-induced takotsubo cardiomyopathy exhibiting transient left ventricular apical ballooning with chest symptoms, electrocardiogram changes and minimal myocardial enzymatic release has become accepted worldwide as a distinct clinical entity. The present paper describes three patients who underwent left ventriculography because of chest symptoms and electrocardiogram abnormalities immediately after experiencing emotional stress. Left ventriculography revealed apical akinesia and basal hyperkinesia without coronary artery disease (Figure 1). End-systolic ventriculograms resembled a takotsubo, which is a round-bottomed, narrow-necked Japanese fishing pot used for trapping octopi. Interestingly, the size of apical ballooning varied during the early phase, and the asynergy disappeared within two weeks in all patients. The precise mechanism of this disorder remains unclear, as are the determinants of the magnitude of apical ballooning. Figure 1) End-systolic ventriculogram immediately after emotional stress in three cases. The size of apical ballooning varied during the early phase, and this asynergy disappeared within two weeks in all patients

Takotsubo cardiomyopathy in a Caucasian Italian woman: Case report

BackgroundTakotsubo cardiomyopathy is an acute cardiac syndrome characterized by transient LV regional wall motion abnormalities (with peculiar apical ballooning appearance), chest pain or dyspnea, ST-segment elevation and minor elevations of cardiac enzyme levelsCase presentationA 68-year-old woman was admitted to the Emergency Department because of sudden onset chest pain occurred while transferring her daughter, who had earlier suffered a major seizure, to the hospital. The EKG showed sinus tachycardia with ST-segment elevation in leads V2–V3 and ST-segment depression in leads V5–V6, she was, thus, referred for emergency coronary angiography. A pre-procedural transthoracic echocardiogram revealed regional systolic dysfunction of the LV walls with hypokinesis of the mid-apical segments and hyperkinesis of the basal segments. Coronary angiography showed patent epicardial coronary arteries; LV angiography demonstrated the characteristic morphology of apical ballooning with hyperkinesis of the basal segments and hypokinesis of the mid-apical segments. The post-procedural course was uneventful; on day 5 after admission the echocardiogram revealed full recovery of apical and mid-ventricular regional wall-motion abnormalities.ConclusionTakotsubo cardiomyopathy is a relatively rare, unique entity that has only recently been widely appreciated. Acute stress has been indicated as a common trigger for the transient LV apical ballooning syndrome, especially in postmenopausal women. The present report is a typical example of stress-induced takotsubo cardiomyopathy in a Caucasian Italian postmenopausal woman.

Emotional stress-induced Tako-tsubo cardiomyopathy: animal model and molecular mechanism.

Emotional or physical stress triggers Tako-tsubo cardiomyopathy in postmenopausal females, which is characterized by an elevation of the ST segment in the electrocardiogram (ECG) and left ventricular apical ballooning in the left ventriculogram (LVG). Immobilization stress (IMO) of rats can reproduce these ECG and LVG changes, both of which are normalized by combined blockade of alpha- and beta-adrenoceptors. An increase of serum estrogen partially attenuated these cardiac changes. IMO induced a rapid activation of p44/p42 mitogen-activated protein kinase, followed by a transient upregulation of immediate early genes (IEG) in the coronary artery and myocardium. Blocking of both alpha- and beta-adrenoceptors eliminated the upregulation of IEG induced by stress, while alpha- or beta-agonists upregulated IEG in the perfused heart. Heat shock protein 70 was induced in the aorta, coronary artery, and the myocardium. Natriuretic peptide genes (ANP and BNP) were also upregulated in the myocardium. Sequential gene expression can be considered as an adaptive response to stress. Activation of alpha- or beta-adrenoceptors is the primary trigger of emotional stress-induced cardiac changes.