Takotsubo Research Articles

Myocardial strain changes over a 1-month follow-up in Takotsubo syndrome: a case report

Among various diagnostic methods, echocardiography (EchoCG) is most often used to identify Takotsubo syndrome. Left ventricular apical ballooning and the absence of permanent local contractility disturbances makes it possible to confirm the diagnosis. Currently, the available literature provides insufficient data on longitudinal strain (LS) of various cardiac chambers in this condition. The current case report demonstrates complete restoration of left heart LS within 1 month with its initial significant decrease.

Takotsubo pathophysiology and complications: what we know and what we do not know.

Takotsubo cardiomyopathy or stress cardiomyopathy (SCM), was first described in 1990 and initially, it was thought to be only associated with short-term complications and mortality with a benign long-term prognosis comparable to a healthy population. However recent investigations have proven otherwise and have shown SCM patients might have comparable long-term morbidity and mortality to ST-elevation myocardial infarction (STEMI) patients. Many emotional, or physical stressors can trigger SCM, and have been able to describe an interplay of neurohormonal and inflammatory mechanisms as the pathophysiology of this disease. Additionally, given the significantly higher prevalence of SCM in post-menopausal women, estrogen levels have been thought to play a role in the pathogenesis of this disease. Furthermore, there is an elusive disparity in prognosis depending upon different triggers. Currently, many questions remain unanswered regarding the long-term management of these patients to reduce morbidity, mortality, and improve quality of life, such as the need for long-term anticoagulation. In this paper, we review the findings of most recent published investigations regarding etiologies, pathophysiology, diagnostic criteria, prognosis, short-term and in more detail, long-term complications of SCM. Finally, we will discuss what future research is needed to learn more about this disease to improve the long-term prognosis, even though as of now, data for long-term management is still lacking.

Biventricular Takotsubo Syndrome: Clinical Characteristics, Management Strategies, and Outcomes: a Systematic Review

Biventricular Takotsubo Syndrome: Clinical Characteristics, Management Strategies, and Outcomes: a Systematic Review

Encasement of the left anterior descending coronary artery: association with Takotsubo syndrome, and diagnostic and therapeutic options

Myocardial bridging is a rare event, which leads to chest pain, arrhythmias and discussable Takotsubo syndrome (cardiomyopathy). We enrolled 41 patients (33 females, mean age 68.4 years), the majority of whom had Takotsubo cardiomyopathy in any form, and 6 had echocardiographic midventricular hypokinesia along with chest pain. Thirty patients had apical ballooning, 3 had midventricular ballooning, and 1 had basal ballooning, according to left ventricular angiography. Intravascular ultrasonography and fractional flow reserve with either an adenosine or dobutamine injection are the best methods for accurately diagnosing myocardial bridging. Beyond atherosclerosis, myocardial bridging is a prominent cause of chest pain, although ischemia is difficult to verify.

Encasement of the left anterior descending coronary artery: association with Takotsubo syndrome, and diagnostic and therapeutic options

Myocardial bridging is a rare event, which leads to chest pain, arrhythmias and discussable Takotsubo syndrome (cardiomyopathy). We enrolled 41 patients (33 females, mean age 68.4 years), the majority of whom had Takotsubo cardiomyopathy in any form, and 6 had echocardiographic midventricular hypokinesia along with chest pain. Thirty patients had apical ballooning, 3 had midventricular ballooning, and 1 had basal ballooning, according to left ventricular angiography. Intravascular ultrasonography and fractional flow reserve with either an adenosine or dobutamine injection are the best methods for accurately diagnosing myocardial bridging. Beyond atherosclerosis, myocardial bridging is a prominent cause of chest pain, although ischemia is difficult to verify.

Encasement of the left anterior descending coronary artery: association with Takotsubo syndrome, and diagnostic and therapeutic options

Myocardial bridging is a rare event, which leads to chest pain, arrhythmias and discussable Takotsubo syndrome (cardiomyopathy). We enrolled 41 patients (33 females, mean age 68.4 years), the majority of whom had Takotsubo cardiomyopathy in any form, and 6 had echocardiographic midventricular hypokinesia along with chest pain. Thirty patients had apical ballooning, 3 had midventricular ballooning, and 1 had basal ballooning, according to left ventricular angiography. Intravascular ultrasonography and fractional flow reserve with either an adenosine or dobutamine injection are the best methods for accurately diagnosing myocardial bridging. Beyond atherosclerosis, myocardial bridging is a prominent cause of chest pain, although ischemia is difficult to verify.

Insulin resistance in Takotsubo syndrome.

Takotsubo syndrome (TTS) is an acute heart failure (AHF) syndrome mimicking the symptoms of acute myocardial infarction. Impaired outcome has been shown, making risk stratification and novel therapeutic concepts a necessity. We hypothesized insulin resistance with elevated plasma glucose and potentially myocardial glucose deprivation to contribute to the pathogenesis of TTS and investigated the therapeutic benefit of insulin in vivo. First, we retrospectively analysed patient data of n=265 TTS cases (85.7% female, mean age 71.1±14.1years) with documented initial plasma glucose from the Department of Cardiology of the University Hospital Heidelberg in Germany (May 2011 to May 2021). Median split of the study population according to glucose levels (≤123mg/dL vs. >123mg/dL) yielded significantly elevated mean heart rate (80.75±18.96 vs. 90.01±22.19b.p.m., P<0.001), left ventricular end-diastolic pressure (LVEDP, 18.51±8.35 vs. 23.09±7.97mmHg, P<0.001), C-reactive protein (26.14±43.30 vs. 46.4±68.6mg/L, P=0.006), leukocyte count (10.12±4.29 vs. 15.05±9.83/nL, P<0.001), peak high-sensitive Troponin T (hs-TnT, 515.44±672.15 vs. 711.40±736.37pg/mL, P=0.005), reduced left ventricular ejection fraction (EF, 34.92±8.94 vs. 31.35±8.06%, P<0.001), and elevated intrahospital mortality (2.3% vs. 12.1%, P=0.002) in the high-glucose group (Student's t-test, Mann-Whitney U test, or chi-squared test). Linear regression indicated a significant association of glucose with HR (P<0.001), LVEDP (P=0.014), hs-TnT kinetics from admission to the next day (P<0.001), hs-TnT the day after admission (P<0.001), as well as peak hsTnT (P<0.001). Logistic regression revealed significant association of glucose with a composite intrahospital outcome including catecholamine use, respiratory support, and resuscitation [OR 1.010 (1.004-1.015), P=0.001]. To further investigate the potential role of glucose in TTS pathophysiology experimentally, we utilized an in vivo murine model of epinephrine (EPI)-driven reversible AHF. For this, male mice underwent therapeutic injection of insulin (INS, 1IU/kg) or/and glucose (GLU, 0.5g/kg) after EPI (2.5mg/kg), both of which markedly improved mean EF (EPI 34.3% vs. EPI+INS+GLU 43.7%, P=0.025) and significantly blunted mean hs-TnT (EPI 14393pg/mL vs. EPI+INS 6864pg/mL at 24h, P=0.039). Particularly, insulin additionally ameliorated myocardial pro-inflammatory gene expression, suggesting an anti-inflammatory effect of acute insulin therapy. Elevated initial plasma glucose was associated with adverse outcome-relevant parameters in TTS and may present a surrogate parameter of heightened catecholaminergic drive. In mice, insulin- and glucose injection both improved EPI-induced AHF and myocardial damage, indicating insulin resistance rather than detrimental effects of hyperglycaemia itself as the underlying cause. Future studies will investigate the role of HbA1c as a risk stratifier and of insulin-based therapy in TTS.

Follow-Up of Post Myocardial Infarction Using Telemedicine: Stakeholders’ Education, Results and Customer Satisfaction

Background. There are few studies about post myocardial infarction follow-up using telemedicine. We organized a post-discharge telemedicine service with a dedicated team. To do this, it was necessary that all stakeholders involved in the organization and use of the telemedicine service were properly educated and informed. Methods. We designed a theoretical–practical mini-course to train healthcare personnel and increase skills, with excellent learning outcomes and satisfaction. Thereafter, we enrolled patients affected by acute myocardial infarction with ST elevation (STEMI), MINOCA (myocardial infarction with no obstructive coronary atherosclerosis), Takotsubo syndrome or spontaneous coronary dissection, and high-risk acute myocardial infarction without ST elevation (NSTEMI). At discharge, the cardiology technician performed counselling for the patient, using regional platforms, such as televisit, at 1 and 4 months, allowed us to monitor major adverse cardiac events (MACE), heart failure, arrhythmias, unstable angina and non-cardiovascular events, therapy adherence, target therapy and customer satisfaction. Results. Between November 2021 and February 2023, we enrolled 110 patients: 72% affected by STEMI, 22% by NSTEMI. At the 1-month follow up, 12 patients did not reach the pressure target and 23 patients did not reach the LDL target. We observed three patients requiring hospital readmission, three requiring hospital visits for further investigation, and one death. To date, a four month follow up was performed for 54 patients. No readmissions or deaths occurred. We detected a rate of 96% of customer satisfaction. Conclusions. A health coordination center with a dedicated team makes televisit safe as a follow-up for post-myocardial infarction patients. Beforehand, it is fundamental for healthcare professionals to acquire theoretical knowledge and updates, and the acquisition of manual, technical and practical skills.

Trends and cardiovascular outcomes of Takotsubo syndrome with cardiogenic shock vs. mixed cardiogenic and septic shock: a nationwide propensity matched analysis

ABSTRACT Introduction Takotsubo syndrome (TTS), also known as stress-induced cardiomyopathy, can be complicated by shock. The outcomes of patients with TTS complicated with cardiogenic shock (CS) versus mixed cardiogenic and septic shock (MS) is not known. Methods We queried Nationwide Inpatient Sample (NIS) from 2009–2020 to compare TTS patients with CS and MS using International Classification of Disease, Ninth & Tenth Edition, Clinical Modification (ICD- 9 & 10-CM) coding. In-hospital outcomes were compared using one: one propensity score matched (PSM) analysis. The primary outcome was in-hospital mortality. Results Of 23,126 patients with TTS 17,132 (74%) had CS, and 6,269 (26%) had MS. The mean age was 67 years in CS and 66 years in MS, and majority of patients were female (n = 17,775, 77%). On adjusted multivariate analysis, MS patients had higher odds of in-hospital mortality (aOR 1.44, 95% CI 1.36–1.52), AKI (aOR 1.53, 95% CI 1.48–1.58), pressor requirement (aOR 1.37, 95% CI 1.25–1.50). However, had lower odds of MCS use (aOR 0.44, 95% CI 0.40–0.48) and cardiac arrest (aOR: 0.81, 95% CI 0.73–0.90) (p-value <0.0001). Mean LOS and inflation-adjusted hospital charges were higher in MS. Conclusion MS in the setting of TTS have higher rates of in-hospital mortality, AKI, and pressor requirements.

Combination of Takotsubo cardiomyopathy with cardiac myxoma: a case report

Introduction. In the Russian literature, we have not found data on the combination of takotsubo syndrome (TTS) and left atrial (LA) myxoma. The work analyzed our own clinical case. TTS is diagnosed in 1,0-2,5% of patients hospitalized with suspected acute coronary syndrome (ACS). Primary cardiac tumors occur in cardiology with a frequency of up to 0,2%. The most common of them are LA myxoma.Brief description. The patient was admitted to the clinic with suspected ACS. During the diagnostic search, both ACS and acute myocarditis were ruled out. An incidental finding during an echocardiographic study was LA myxoma.Discussion. Due to a stressful situation, the patient developed symptoms similar to myocardial infarction. Based on coronary angiography data (normal coronary arteries, rapid restoration of myocardial contractility, no characteristic myocardial changes, myocardial infarction and acute myocarditis were excluded and TTS was established. LA myxoma was an unexpected finding.Myxoma may contribute to TTS, presumably through central mechanisms regulating the activity of the cardiovascular system. Also important is the systemic inflammation caused by myxoma, which reduces the threshold for the development of Takotsubo cardiomyopathy in response to stress factors.

Authors’ Response

Dear Editor,We thank Dr. Finsterer and Dr. Stollberger for their interest in our published manuscript which is focused on the collected data from patients hospitalized in our multidisciplinary COVID-19 department who experienced a Tako-Tsubo syndrome (TTS) during the second and third wave of the pandemic...

Correction to: Concomitant Takotsubo syndrome and stroke: two separate disorders or do they share a common aetiology?

Correction to: Concomitant Takotsubo syndrome and stroke: two separate disorders or do they share a common aetiology?

Statin therapy and outcome in Takotsubo syndrome patients: Results from the multicenter international GEIST registry

Background and aimsSeveral studies have shown that endothelial dysfunction plays a role in the pathogenesis of Takotsubo syndrome (TTS). Given the potential benefit of statin therapy on endothelial dysfunction, we hypothesized that such treatment could improve outcome. Aim of our study was to evaluate clinical characteristics and outcome of TTS patients treated with statin therapy. MethodsPatients were enrolled in the international multicenter GEIST (GErman Italian Spanish Takotsubo) registry. Demographic data, clinical features and drug therapy at discharge were recorded. Primary study outcome was the occurrence of all-cause death at follow-up. ResultsStudy population included 2429 consecutive TTS patients: 1293 (53.2%) discharged on statin and 1136 (46.8%) without statin.Patients with statin were older (age 72 ± 11 vs 69 ± 13 years, p < 0.001), with higher prevalence of hypertension (74.3% vs 60.3%, p < 0.001), diabetes (21.1% vs 14.7%, p < 0.001), dyslipidemia (56.1% vs 23.3%, p < 0.001), history of coronary artery disease (13.3% vs 6.3%, p < 0.001) and lower rates of in-hospital complications (14.7% vs 19.3%, p = 0.003). Survival analysis showed similar mortality rates between groups (log rank p = 0.803).At univariable analysis, statin therapy at discharge was not associated with lower mortality (HR: 0.97, 95% CI 0.74–1.26, p = 0.803). At multivariable analysis age (HR: 1.06 95% CI 1.04–1.08, p < 0.001), male sex (HR: 1.83, 95% CI 1.20–2.80, p = 0.005), diabetes (HR: 2.55, 95% CI 1.83–3.54 p < 0.001), malignancies (HR: 2.41, 95% CI 1.68–3.44, p < 0.001) and physical trigger (HR: 2.24, 95% CI 1.62–3.10, p < 0.001) were associated with increased mortality. ConclusionsStatin therapy after a TTS event was not associated with better prognosis at follow-up.

A Systematic Review of COVID-19 Vaccine-Induced Takotsubo Cardiomyopathy: A 2023 Update.

Takotsubo cardiomyopathy (TCM) is a life-threatening transient left ventricular dysfunction triggered by either physical or emotional stressors. Concerns have been raised on reports of TCM after the coronavirus disease 2019 (COVID-19) vaccine. Our study provides comprehensive detail on COVID-19 vaccine-induced TCM. We conducted a systemic literature search using major databases, including PubMed, EMBASE, and Google Scholar up to November 2023, to identify cases of COVID-19 vaccine-induced TCM using the MeSH terms and keywords"covid-19 vaccines" and "takotsubo cardiomyopathy". We identified 15 case reports, including 16 patients with COVID-19 vaccine-induced TCM. The mean age was 55.81 ± 19.13 years, and 75% of the patients were female. The most common presentation was chest pain (62.5%), and the average time to first symptom onset was 3.12 ± 2.24 days. COVID-19 vaccine-induced TCM was reported in 43.75% of patients receiving the first and second dose each, and 87% of patients had messenger ribonucleic acid (mRNA) COVID-19 vaccine (Pfizer, Moderna). The elevated level of cardiac troponins was found in all the patients with a left ventricular ejection fraction (LVEF) of <50% in 15 patients, and T-wave inversion (50%) was the most common electrocardiographic finding. The mean length of the hospital stay was 7.27 ± 3.95 days, and 87% of patients were discharged. COVID-19 vaccine-induced TCM is a rare but life-threatening complication. TCM should be included in the differential diagnosis of chest pain or dyspnea in patients recently receiving the COVID-19 vaccine.

Comments on "Tako-Tsubo syndrome in patients with COVID-19: a single centre retrospective case series".

Dear Editor, We read with interest the article by Alonzo et al. about a retrospective study of four patients with Takotsubo syndrome (TTS), which was attributed to SARS-CoV-2 infection (SC2I)...

QT interval prolongation in Takotsubo syndrome: a frightening feature with no major prognostic impact.

Despite the frequent and often severe repolarization abnormalities seen in Takotsubo syndrome (TTS), the underlying mechanism of life-threatening arrhythmias is incompletely understood, and the risk remains uncertain. TTS is considered a potential cause of acquired long QT syndrome; however, there is no robust evidence that QT prolongation has a major prognostic impact on these patients' outcomes. Our aim was to assess the prevalence and clinical implications of acquired long QT during TTS events and compare in-hospital and long-term outcomes between patients with and without corrected QT interval (QTc) prolongation. This is a retrospective cohort study that included 113 patients admitted to our tertiary care hospital with a diagnosis of TTS. The cohort was divided into two groups: a long QTc group (QTc≥460 milliseconds in any electrocardiogram at admission or during hospitalization) and a normal QTc group. Baseline characteristics, occurrences during hospitalization, and outcome data were obtained from the revision of medical registries and hospital visits. Of the 113 patients, 107 (94.7%) were female. The mean age was 67.6±11.7 years. QTc prolongation was found in 38%. Demographic characteristics, relevant chronic medication, prevalence of cardiovascular risk factors, and other comorbidities were similar between the groups, except for history of atrial fibrillation, which was more common in the long QTc group. Syncope was more prevalent in the long QTc group. In-hospital complications were not statistically different between patients with long and normal QTc (48.8% versus 44.2%, p=0.637), including ventricular arrhythmias and complete atrioventricular block (both 4.7% versus 1.4%, p=0.556). In-hospital mortality was 0.9%, corresponding to one patient in the long QTc group. The mean follow-up time was 4.8±3.8 years. 5-year all-cause mortality and the occurrence of the composite endpoint of major adverse cardiac and cerebrovascular events did not differ between the groups (p=0.511 and p=0.538, respectively). Our study found no association between prolonged QTc interval during TTS events and adverse prognosis, since in-hospital and long-term outcomes were similar between the groups. Our findings suggest that, although QT prolongation is usually a frightening feature on ECG, this repolarization abnormality during the acute phase has no major prognostic implications in the TTS population.

Deep learning from atrioventricular plane displacement in patients with Takotsubo syndrome: lighting up the black-box.

The spatiotemporal deep convolutional neural network (DCNN) helps reduce echocardiographic readers' erroneous 'judgement calls' on Takotsubo syndrome (TTS). The aim of this study was to improve the interpretability of the spatiotemporal DCNN to discover latent imaging features associated with causative TTS pathophysiology. We applied gradient-weighted class activation mapping analysis to visualize an established spatiotemporal DCNN based on the echocardiographic videos to differentiate TTS (150 patients) from anterior wall ST-segment elevation myocardial infarction (STEMI, 150 patients). Forty-eight human expert readers interpreted the same echocardiographic videos and prioritized the regions of interest on myocardium for the differentiation. Based on visualization results, we completed optical flow measurement, myocardial strain, and Doppler/tissue Doppler echocardiography studies to investigate regional myocardial temporal dynamics and diastology. While human readers' visualization predominantly focused on the apex of the heart in TTS patients, the DCNN temporal arm's saliency visualization was attentive on the base of the heart, particularly at the atrioventricular (AV) plane. Compared with STEMI patients, TTS patients consistently showed weaker peak longitudinal displacement (in pixels) in the basal inferoseptal (systolic: 2.15 ± 1.41 vs. 3.10 ± 1.66, P < 0.001; diastolic: 2.36 ± 1.71 vs. 2.97 ± 1.69, P = 0.004) and basal anterolateral (systolic: 2.70 ± 1.96 vs. 3.44 ± 2.13, P = 0.003; diastolic: 2.73 ± 1.70 vs. 3.45 ± 2.20, P = 0.002) segments, and worse longitudinal myocardial strain in the basal inferoseptal (-8.5 ± 3.8% vs. -9.9 ± 4.1%, P = 0.013) and basal anterolateral (-8.6 ± 4.2% vs. -10.4 ± 4.1%, P = 0.006) segments. Meanwhile, TTS patients showed worse diastolic mechanics than STEMI patients (E'/septal: 5.1 ± 1.2 cm/s vs. 6.3 ± 1.5 cm/s, P < 0.001; S'/septal: 5.8 ± 1.3 cm/s vs. 6.8 ± 1.4 cm/s, P < 0.001; E'/lateral: 6.0 ± 1.4 cm/s vs. 7.9 ± 1.6 cm/s, P < 0.001; S'/lateral: 6.3 ± 1.4 cm/s vs. 7.3 ± 1.5 cm/s, P < 0.001; E/E': 15.5 ± 5.6 vs. 12.5 ± 3.5, P < 0.001). The spatiotemporal DCNN saliency visualization helps identify the pattern of myocardial temporal dynamics and navigates the quantification of regional myocardial mechanics. Reduced AV plane displacement in TTS patients likely correlates with impaired diastolic mechanics.

Timing of cardiac magnetic resonance and diagnostic yield in patients with myocardial infarction with nonobstructive coronary arteries

Introduction and objectivesThe present study sought to establish the diagnostic yield of cardiovascular magnetic resonance (CMR) in a large cohort of patients admitted with myocardial infarction (MI) with nonobstructive coronary artery disease (MINOCA) based on the timing of referral to CMR. MethodsConsecutive patients referred to CMR from January 2009 to February 2022 with a working diagnosis of MINOCA were retrospectively evaluated. Cine, T2-weighted, early, and late gadolinium-enhanced images were acquired and analyzed. The frequency of the underlying diagnosis and the association between timing of CMR and relative frequency of each diagnosis were assessed. ResultsWe included 207 patients (median age 50 years, 60% men). Final diagnosis after CMR was achieved in 91% of the patients (myocarditis in 45%, MI in 20%, tako-tsubo cardiomyopathy in 19%, and other cardiomyopathies in 7%). The performance of CMR within 7 days of admission with MINOCA (median, 5 days; 117 patients) allowed a higher diagnostic yield compared with CMR performed later (median, 10 days; 88 patients) (96% vs 86%, P=.02). Although myocarditis was the most frequent diagnosis in both groups according to time to CMR, its frequency was higher among patients with a CMR performed within the first 7 days (53% vs 35%, P=.02). The frequency of other underlying diagnoses was not influenced by CMR timing. ConclusionsCMR led to an underlying diagnosis of MINOCA in 91% of patients and its diagnostic yield increased to 96% when CMR was performed within 7 days of admission. The most frequent diagnosis was myocarditis..

Comparative electrocardiographic analysis of midventricular and typical takotsubo syndrome.

Takotsubo syndrome (TTS) encompasses distinct variants, with midventricular (MV) as the most common atypical subtype. While electrocardiogram (ECG) abnormalities are well documented in typical TTS, they are less explored in MV-TTS. A retrospective case-control study was conducted where ECGs were reviewed at three time points from symptom onset (within the first 12 h, at 48 h, and at 5-7 days) and compared between patients with typical TTS (n = 33) and those with MV-TTS (n = 27), as classified by ventriculography. 12-h ECG findings revealed that typical TTS featured ST-segment elevation through anterior leads V3-V6, with maximal deviation in V3 (0.98 ± 0.99 mm) and V4 (0.91 ± 0.91 mm), whereas MV-TTS featured ST-segment depression in inferior leads (-0.24 ± 0.57 mm in II, -0.30 ± 0.52 mm in III, and -0.32 ± 0.47 mm in aVF) and in precordial leads V4-V6. In 48-h ECG findings, the most significant change was T wave inversion, which was more widespread and deeper in typical TTS, with the most pronounced negative T wave depths, exceeding 3 mm, observed in leads V3-V5; in contrast, in MV-TTS, T wave inversion was evident in fewer leads and showed less depth, with the most pronounced negative T waves reaching 1 mm at most in leads I, aVL, and V2. While the QTc interval was prolonged in both groups at 48 h, this prolongation was more pronounced in typical TTS than in MV-TTS (523 ± 52 ms vs. 487 ± 66 ms; p = 0.029). In ECGs at 5-7 days, results essentially returned to baseline. Patients with MV-TTS exhibited a distinctive pattern of ECG abnormalities, marked by ST-segment depression in inferolateral leads, less profound and less extensive T wave inversion that mostly affected leads I, aVL and V2, and attenuated QT interval prolongation compared to typical TTS.

A Peculiar Cause of Shock: Analysing Two Clinical Cases

Introduction. Pheochromocytoma is a rare neoplasia arising from the adrenal medulla that secretes catecholamines. Those afflicted by this condition can present a wide range of symptoms. One of the most common is paroxysmic hypertension. Interestingly, although rare, some patients present with shock. We describe two cases of pheochromocytoma in which the initial presentation was shock. Case 1. 49 year-old woman, with a history of resistant hypertension, presented to the emergency department with thoracic pain and fever. EKG, echocardiogram (ECC), and myocardial necrosis markers were compatible with Takotsubo syndrome (TS). CT demonstrated a staghorn calculus, hydronephrosis, and signs compatible with xanthogranulomatous pyelonephritis in the right kidney. Additionally, and incidentally, it revealed a 60 mm nodule on the right adrenal gland. Piperacillin/tazobactam was started immediately, and the patient was submitted to urgent upper urinary tract drainage. This procedure was complicated by a cardiorespiratory arrest that was treated with adrenaline administration. The patient was admitted to the ICU due to multifactorial shock and started alpha and, posteriorly, beta blockage. Biochemical adrenal incidentaloma endocrinologic study was negative (under hemodialysis). Multiorgan failure progressively improved. After 2 weeks, the patient was submitted to a laparoscopic transperitoneal right adrenalectomy. No complications were reported. Histological analysis revealed a pheochromocytoma. Case 2. 28-year-old woman presented to the emergency department with headaches and nausea. Vitals were compatible with shock. CT revealed an incidental 72 mm mass on the right adrenal. EKG, ECC, and myocardial necrosis markers were compatible with TS. The patient was started on alpha and, posteriorly, beta blockage. Adrenal incidentaloma endocrinological study demonstrated high urinary catecholamines. Right transperitoneal adrenalectomy was performed. No complications were noted. Histological analysis revealed a pheochromocytoma. Conclusion. Pheochromocytoma can present with complex, enigmatic, and rare clinical pictures. Clinicians should be wary of the possibility of this diagnosis when managing adrenal masses.