Transient Apical Ballooning Syndrome Research Articles

Trauma induced left ventricular apical ballooning syndrome in a 15 year old: A rare case of Tako-tsubo cardiomyopathy

We present a case of a 15 year old girl who developed transient left ventricular apical ballooning syndrome, Tako-tsubo cardiomyopathy, after a significant motor vehicle accident. On post-trauma day three she developed heart failure with mid-to-apical left ventricular wall dysfunction with an EF of 10%–15%. The patient eventually regained full cardiac function by post-trauma day seven. Here we present the first case report of trauma induced left ventricular apical ballooning syndrome in pediatrics.

Clinical characteristics of Takotsubo cardiomyopathy in North America

Background:Takotsubo cardiomyopathy (TC) or transient left ventricular apical ballooning syndrome is an acute cardiac syndrome characterized by transient wall motion abnormalities extending beyond a single epicardial vessel in the absence of significant obstructive coronary artery disease.Aim:This study was to describe the clinical characteristics of TC in North America.Materials and Methods:We identified 10 patients who met the Mayo Clinic criteria for TC using our Electronic Medical Records. We also conducted a systematic review of case series of TC that were done in North America by searching the MEDLINE database. We identified 11 case series that met our eligibility criteria.Results:Our systematic review included 620 patients. Chest pain and ST segment elevation were the cardinal features of this syndrome, but the prevalence was lower than in the European and Asian cohort (50% and 39% as compared with 80% and 70%, respectively). Classic precipitating emotional or physical stress was described in > 80% of patients. Cardiac biomarkers were found to be elevated in >90% of our patients.Conclusions:TC is a worldwide problem and clinical presentation appears to be similar in North American, European, and Asian countries. However, fewer patients in our cohort presented with typical chest pain and electrocardiography (ECG) changes, which might suggest ethnic variations in the syndrome or perhaps a more aggressive diagnostic approach in North American countries.

Abstract 19613: Ventricular Repolarization in Transient Apical And Midventricular Ballooning

The aim of the present study was to assess potential differences in cardiac repolarization dynamics in patients with transient left ventricular apical ballooning syndrome (AB) and the midventricular variant (MB). Even though repolarization abnormalities and QT interval prolongation in the surface electrocardiogram (ECG) have been consistently reported, repolarization dynamics have not yet been investigated in the AB and MB variants. We hypothesized that differences in regional sympathetic denervation may induce differential effects on cardiac repolarization. METHODS: In a prospective single-center study, 49 consecutive patients with transient left ventricular dysfunction syndrome underwent 3-channel-Holter-ECG-recording on the third day after admission. A total of 27 recordings of patients with AB and 10 recordings of patients with MB were valid for beat-to-beat-QT-interval-analyses. RESULTS: There were no significant differences in baseline clinical characteristics between AB and MB patients. Patients with MB showed significantly lower values for mean RR interval (835 ± 104 vs. 908 ± 118 ms; P<.05). Both, Bazett- and Fridericia-corrected QT-intervals were significantly longer in MB patients (QTcB 441.9 ± 38 vs. 483.4 ± 40ms; P<.05; QTcF 435.0 ± 36 vs.469.4 ± 36.5 ms; P<.05). Parameters of QT-interval variability (QTSD) and QT-interval dynamicity (QT/RR-slope) also exhibited significant differences between groups (diagram). CONCLUSION: There are significant differences in cardiac repolarization between AB and MB syndromes. Patients with MB show more prolonged QT-intervals and a higher degree of heterogeneity of ventricular repolarization. Thus, regional midventricular sympathetic denervation may be associated with even higher arrhythmic risk in transient left ventricular dysfunction syndrome.

Takotsubo cardiomyopathy in a cardiology department

Takotsubo cardiomyopathy (TC), also known as transient left ventricular apical ballooning syndrome, stress-induced cardiomyopathy and broken heart syndrome, is characterized by transient left ventricular dysfunction in the absence of obstructive coronary artery disease.It was first described in 1990 in Japan, and gained worldwide recognition following the publication of several series of case reports. Its prevalence is estimated to be 1.7–2.2% of suspected acute coronary syndromes. Although TC has been progressively better characterized, certain aspects remain to be clarified, and it is still under study.In this article, we report a series of ten cases of TC admitted to a cardiology department, and compare the clinical, laboratory, electrocardiographic and imaging characteristics, therapeutic regimens and follow-up of these patients with those described in the latest scientific reviews.

Miocardiopatia de takotsubo num serviço de Cardiologia

Takotsubo cardiomyopathy, also known as transient left ventricular apical ballooning syndrome, stress-induced cardiomyopathy and broken heart syndrome, is characterized by transient left ventricular dysfunction in the absence of obstructive coronary artery disease.It was first described in 1990 in Japan, and gained worldwide recognition following the publication of several series of case reports. Its prevalence is estimated to be 1.7-2.2% of suspected acute coronary syndromes. Although takotsubo cardiomyopathy has been progressively better characterized, certain aspects remain to be clarified, and it is still under study.In this article, we report a series of ten cases of takotsubo cardiomyopathy admitted to a cardiology department, and compare the clinical, laboratory, electrocardiographic and imaging characteristics, therapeutic regimens and follow-up of these patients with those described in the latest scientific reviews.

Takotsubo cardiomyopathy resembling acute high lateral myocardial infarction

A 65-year-old female patient admitted to the emergency department was diagnosed with acute high lateral myocardial infarction, but later Takotsubo cardiomyopathy (TC) was discovered. She had squeezing chest pain that started shortly after an emotional stress. The electrocardiogram revealed a loss of R wave voltage in leads V1 to V4 and an ST-segment elevation in I and aVL. After an urgent coronary angiography and ventriculography, TC was considered, and supportive anti-ischemic treatment was started. The severe left ventricular systolic dysfunction improved and normalized during the follow-up. She was discharged without any complications. TC is a new entity of acute cardiac events, and patients usually recover completely without sequelae with proper diagnosis and management. An exact diagnosis may also prevent an inappropriate application in the setting of recurrences.

Takotsubo Cardiomyopathy after Treatment of Pulmonary Arterial Hypertension

Pulmonary arterial hypertension is a fatal disease. Intravenous prostanoids are often utilized for long-term management of patients. The therapy requires a significant commitment and change in lifestyle for both the patient and family. Takotsubo cardiomyopathy, transient apical ballooning syndrome, has been reported in association with emotional and physical stress. This case report describes a patient with pulmonary arterial hypertension who developed Takotsubo cardiomyopathy after treatment initiation with intravenous treprostinil. Over time, the syndrome resolved and the patient had return of normal left ventricular function. Takotsubo cardiomyopathy should be recognized as a potential, rare complication of therapy initiation due to the severity of the illness and the emotional stress of the disease.

Torsades de Pointes in an Elderly Patient with “Broken Heart Syndrome”

Broken heart syndrome, also called transient left ventricular apical ballooning syndrome (TLVABS), is described as an acute cardiomyopathy characterized by acute, but rapidly reversible, left ventricle systolic dysfunction in the absence of atherosclerotic coronary artery disease which appears to be triggered by intense psychological and physical stress. The syndrome is also named takotsubo syndrome, ampulla cardiomyopathy, or stress-induced cardiomyopathy. We report a woman aged 75 years with dyspnea, ST-segment elevation in the precordial leads, elevation of cardiac enzymes, and normal coronary arteriography. Transient apical systolic left ventricular dysfunction and pneumonia were suspected. Gradual prolongation of QT interval and torsades de pointes (TdP) subsequently occurred. Patients had a complete recovery of cardiac function, normalization of QT interval, and normal apical cardiac wall motion in a few days after lidocaine pump and empiric antibiotics use. Since TdP is rarely reported with TLVABS, we should pay more attention to postmenopausal women with chest pain and elevated cardiac enzymes. We should keep TLVABS in mind and use convenient tools, such as bedside echocardiography, for diagnosis.

Broken heart in elderly patients: two clinical observations

Tako-tsubo cardiomyopathy (idiopathic or transient left ventricular apical ballooning syndrome [ABS]) is a reversible condition frequently precipitated by a stressful trigger that clinically mimics an acute ST-elevation myocardial infarction. Characteristically, hypokinesis or akinesis occurs in the mid- and apical segments of the left ventricle in the absence of epicardial coronary lesions. Preserved or hyperdynamic function of the basal myocardial segments results in apical ballooning, assuming the shape of a Japanese pot used to catch octopus (a takotsubo). We report on 2 well over 70 years old women (78 and 82 years) admitted to the emergency room with chest pain. Clinical signs, ECG alterations and high troponin I in both patients imposed urgent diagnostic testing and management. The electrocardiographic findings were consistent with acute myocardial infarction and transthoracic echocardiography showed in both simultaneous apical akinesia and a hyperkinetic basal area with a moderately reduced left ventricular ejection fraction. Coronary angiography, performed on an emergency basis, in both cases revealed minimal luminal irregularities, with no evidence of plaque rupture or thrombus. The wall motion abnormality extended beyond the distribution of any single coronary artery, making it less likely that an occlusive thrombus had spontaneously dissolved or that intermittent vasospasm had occurred. Taken together, these findings were consistent with ABS, and critical observations on coronary angiography indicated the diagnosis by exclusion. The patients were seen in the clinic 4 weeks after discharge. They had had no recurrent chest pain, and had returned to the normal life they had had before the cardiovascular event. A repeat echocardiography showed a normalized estimated ejection fraction in both patients. ABS is a diagnosis of exclusion and its incidence is probably underestimated in elderly patients in whom coronary angiography is not common.

Repeat recurrence of takotsubo cardiomyopathy related to inhaled beta-2-adrenoceptor agonists

Takotsubo cardiomyopathy (also referred to as transient apical ballooning syndrome, broken heart syndrome or stress cardiomyopathy) is an increasingly recognized entity in the western world typically characterized by reversible left ventricular dysfunction that develops in the setting of acute severe emotional or physical stress. Increased catecholamine levels have been proposed to play a central role in the pathogenesis of the disease, although the specific pathophysiology of this condition remains elusive at the present moment. In recent times, there have been reports of takotsubo cardiomyopathy (TC) following medical interventions such as invasive or surgical procedures or specific medical regimens. In the current report, we present a patient with multiple recurrences of TC triggered by the same medical therapeutic intervention; in our particular case, repetitive exposure to inhaled beta-2-adrenoceptor agonist.

Cardiac Magnetic Resonance Imaging in the Diagnosis of Anterolateral Left Ventricular Ballooning, a Variant of Classic Takotsubo Cardiomyopathy

Transient left ventricular apical ballooning syndrome is characterized by transient akinesis of the left ventricular apex with basal wall hyperkinesis; this is also known as Takotsubo cardiomyopathy. There are three distinct contractile LV patterns described in the literature: apical, midventricular, and basal ballooning. The apical ballooning pattern is the most frequent pattern. We describe the case of a transient anterolateral left ventricular ballooning fulfilling the definition of Takotsubo cardiomyopathy except for the contractile LV pattern. The diagnosis was supported by cardiac magnetic resonance imaging and by the fact that the anterolateral ballooning resolved completely after 6 weeks.

Abstract 17081: Risk Factors for Developing Takotsubo Cardiomyopathy

Background: Takotsubo cardiomyopathy (TTC) has emerged as a new clinical entity which has not been fully understood. Numerous case reports exist regarding association of TTC with high adrenergic state conditions like Pheochromocytoma. Our aim was to explore the association of common medical conditions with TTC. Methods: This was a cross sectional study using the National Inpatient Sample (NIS) 2007 database.TTC or Broken heart syndrome or Reversible left ventricular dysfunction following sudden emotional stress or Stress induced cardiomyopathy or Transient left ventricular apical ballooning syndrome was defined as patients discharged with any ICD code of 429.83 ( http://www.cdc.gov/nchs/data/icd9/agendasept05.pdf ). The common medical conditions were identified by appropriate ICD 9 codes Results: We indentified total 6229 discharges with any discharge diagnosis of TTC. The likelihood of common medical conditions with TTC is shown in Table 1. Conclusions: This is the first study to explore the association of common medical conditions associated with TTC on a nationwide basis. We conclude that the patient with hyperlipidemia, smoking, pulmonary hypertension, sub arachnoid hemorrhage, migraine, hyperthyroidism, collagen vascular diseases, anxiety state, and stress have higher odds of developing TTC. Further research needs to be done for better understanding the causes and pathophysiology of TTC which in turn will help risk stratification and define optimal therapy.

Abstract 9616: Does “Men Are from Mars and Women are from Venus” hold true for Tako-Stubo Cardiomyopathy - A Nationwide Analysis?

Background: Recent case series and smaller registries from around the world have reported higher frequency of Takotsubo Cardiomyopathy (TTC) in females.The aim of this study was to look for gender difference and age - gender interactions for TTC across the nation. Methods: This was a cross sectional study using the Nationwide Inpatient Sample (NIS) 2007 database. TTC or Broken heart syndrome or Reversible left ventricular dysfunction following sudden emotional stress or Stress induced Cardiomyopathy or Transient left ventricular apical ballooning syndrome was defined as patients discharged with any ICD code of 429.83 ( http://www.cdc.gov/nchs/data/icd9/agendasept05.pdf ). Multivariate logistic regression with interaction variable between age and sex was performed. Results: There were 6229 estimated discharges in 2007 NIS. Of these, 5558 (89.2 %) were females and 671 (10.8%) were males. 11.1 % were between 18-50 years, 32% between 50-65 years,58% were more than 65 years. Overall females had significantly higher odds of developing TTC (OR, 7.5; 95% CI, 6.31-9.13). In age group > 55yrs, the odds of developing TTC was 9.5 times higher in females than in males, while in age 55yrs had 2.9 times higher odds of developing TTC while there was no such age difference in males. Conclusions: We conclude that women have 7.5 times higher odds of developing TTC than males. Females with age > 55 years have 2.9 times higher odds of developing TTC than females with age < 55 years. Further research needs to be done on hormonal influence and its effect on TTC.

Recurrent Left Ventricular Apical Ballooning Syndrome in a Patient with Pheochromocytoma

Transient left ventricular apical ballooning syndrome is characterized by reversible left ventricular wall motion abnormalities, chest pain or dyspnea, ST-segment elevation, and mild elevation of cardiac enzyme levels in the absence of obstructive coronary artery disease. The pathophysiology of the syndrome is still unknown. The probable mechanism is supposed to be a catecholamine discharge. We report the case of a 66-year-old woman with recently diagnosed pheochromocytoma who presented with chest pain and ST-segment elevation. Coronary angiography revealed normal coronaries and apical dyskinesia at ventriculography. A similar episode of chest pain occurred 4 years ago with same angiographic findings and reversible inferobasal akinesia. In-hospital course was uneventful and the patient was discharged from the hospital 4 days later with treatment of aspirin 1 × 100 mg, metoprolol 1 × 50 mg, lisinopril 1 × 10 mg, and atorvastatin 1 × 20 mg. At 2 years follow-up after the event, the patient remained asymptomatic.

Terlipressin infusion induces Tako-Tsubo syndrome in a cirrhotic man with hepato-renal syndrome

Dr. Di Micoli, Dr. Buccione, Prof. Trevisani: TakoTsubo cardiomyopathy (TTC), also known as transient left ventricular apical ballooning syndrome, is a clinical entity characterized by (1) reversible left ventricular apical wall motion abnormalities, (2) typical electrocardiographic changes and (3) relatively minor elevation of troponine, creatinine-kinase (CK) and CK-MB that mimics an acute myocardial infarction (AMI) without any acute obstructive coronary disease [1]. Typically, the left ventricular imbalance almost always recovers in a period of days to weeks, so that the management and prognosis of this condition are clearly different from those of AMI [2]. TTC is generally observed in post-menopausal women without prior history of heart disease or clear risk factors for coronary artery disease, who have often experienced recent emotional or physical stress, non-cardiac surgery or extracardiac diseases [1]. Recently, TTC has also been described in critically ill patients without prior heart disease admitted to a medical intensive care unit for severe non-cardiac diseases, such as sepsis, acute respiratory failure, systemic inflammatory response syndrome, anaphylaxis and trauma injuries [3, 4]. Herein, we report a case of TTC occurring in a cirrhotic man, waiting for liver transplantation (LT), probably favored by the intravenous infusion of terlipressin, a synthetic analog of vasopressin (AVP), for the treatment of hepato-renal syndrome (HRS). A 67-year-old Caucasian man with hepatitis B virusrelated cirrhosis and ascites, waiting for LT, was admitted to our unit because of the onset of hepatic encephalopathy, and the worsening of renal sodium retention. As a candidate for LT, he had undergone clinical, laboratory and instrumental tests aimed at excluding extrahepatic diseases precluding surgery. Myocardial single photon emission computed tomography had excluded ischemic damage, and trans-thoracic echocardiography had ruled out dyskinesia of ventricular segments and documented a normal (65%) left ventricular ejection fraction (LVEF). On admission, the patient presented with peripheral edema, ascites and grade III hepatic encephalopathy. Daily diuresis was around 200 mL. The ongoing therapy included oral diuretics (furosemide 25 mg b.i.d. and spironolactone 100 mg b.i.d.), lamivudine and tenofovir for HBV infection control, norfloxacine (400 mg/day) for secondary prophylaxis of the spontaneous peritoneal peritonitis, lactulose, and periodic albumin infusion. The serum creatinine was 2.2 mg/dL and blood urea nitrogen 0.9 g/dL, while serum electrolyte concentrations were normal (sodium 138 mEq/L, potassium 3.5 mEq/L, calcium 8.9 mg/dL and magnesium 2.6 mEq/L). The hemoglobin level was 10.4 g/dL, platelet count 134.000/lL, leukocytes 8.0 9 10/mmc, serum bilirubin 18.8 mg/dL, albumin 3.4 g/dL, INR 2.11. A. Di Micoli D. Buccione V. Santi L. Bastagli M. Bernardi F. Trevisani Dipartimento di Medicina Clinica, Alma Mater Studiorum-Universita degli Studi di Bologna, Bologna, Italy

The Role of Echo cardiography in Diagnosis and Follow Up of Patients with Takotsubo Cardiomyopathy or Acute Ballooning Syndrome

The transient left ventricular apical ballooning syndrome, also known as takotsubo cardiomyopathy was first described in Japan approximately 20 years ago (Satoh and coworkers, 1991). It was later described elsewhere as well and is being increasingly recognized. Takotsubo Cardiomyopathy characterized by transient apical and midventricular LV dysfunction in the absence of significant coronary artery disease that is triggered by emotional or physical stress. Its name refers to a contraption used for catching octopuses and suggests the aspect assumed by the ventricle during the systole due to the typical regional wall motion abnormalities that occur after onset. Takotsubo cardiomiopathy occurring mainly in post-menopausal women, echocardiography in the Takotsubo cardiomyopathy reveals during its acute phase a ballooning resembling the octopus trap configuration--the apex and lateral ventricular segments are hypokinetic while the base is hyperkinetic--along with reduced ejection fraction. Ventricular function will usually recover within a few days/weeks. The objective of this study is to determine the role of echocardiography in detecting and establishing the diagnosis of Takotsubo cardiomiopathy in patients with suspect acute coronary syndrome and during the follow up period. The study covered 12 adult patients the majority are women (92%) who were subjected to echocardiography evaluation as part of the clinical cardiological examination due to suspect acute coronary syndrome or Takotsubo Stress Cardiomyopathy. The patients were examined on an ultrasound machine Philips iE 33 x Matrix, ATL HDI and GE Vived 7 equipped with all cardiologic probes for adults and multi-plan TEE probes. We evaluated clinical characteristics, LV systolic function, biomarkers, and prognosis in all patients. Among all the patients referred for Echocardiographic evaluation for left ventricle motion abnormalities with suspect acute coronary syndrome, the echo exam revealed 12 patients with acute apical ballooning which involving the left ventricular apex and med-ventricle. The triggering factors were physical stress in 4 patients (33%) and emotional stress in 8 patients (67%). The initial symptom was chest pain (n = 8, 67%) rather than dyspnea (n = 4, 33%). An initial electrocardiogram (EKG) presented ST-elevation (n = 10, 83%) and T-wave inversion (n = 2, 17%), other data are shown on Table 2. Among the all patients 8 of them (66%) had normal EF by the 1st follow up (47 +/- 51 days), and the rest 4 patients (34%) had normal EF by 68 +/- 96 days. Widespread uses of echocardiography has contributed to more frequent recognition of Takotsubo stress cardiomyopathy and highlight the central role of this noninvasive method from an echocardiographers' perspective.

Tako-Tsubo Cardiomyopathy Triggered by Misdirection

Tako-Tsubo cardiomyopathy (TTC), also known as transient left ventricular apical ballooning syndrome or stress-induced cardiomyopathy, is a novel reversible cardiomyopathy mimicking acute myocardial infarction without epicardial coronary artery disease. The exact physiopathology of TTC remains unclear. It is usually precipitated by acute physical or emotional stress and it most commonly affects postmenopausal women. The growing number of clinical cases of TTC have demonstrated a wide field of possible etiologies beyond the emotional stress. We report a case of a 67-year-old postmenopausal woman who was being supplemented by enteral feeding via a nasogastric tube and who developed TTC due to misdirection, probably favored by the mechanical blockade by the nasogastric tube, while swallowing the drug pills.

An Atypical Case of Reverse Takotsubo Cardiomyopathy During General Anesthesia in a 30-Year-Old Male With Post-Traumatic Stress Disorder

TAKOTSUBO CARDIOMYOPATHY, also referred to as transient left ventricular ballooning syndrome or stress-induced cardiomyopathy, describes a rapid-onset, yet reversible systolic dysfunction that typically is triggered by an acute, stressful event. The pathophysiology is not completely understood, and similar presentations have been described as a result of the endocrine crisis of pheochromocytoma, 1 Iga K. Gen H. Tomonaga G. et al. Reversible left ventricular wall motion impairment caused by pheochromocytoma—A case report. Jpn Circ J. 1989; 53: 813-818 Crossref PubMed Scopus (42) Google Scholar subarachnoid hemorrhage, 2 Pollick C. Cujec B. Parker S. et al. Left ventricular wall motion abnormalities in subarachnoid hemorrhage: An echocardiographic study. J Am Coll Cardiol. 1988; 12: 600-605 Abstract Full Text PDF PubMed Scopus (192) Google Scholar and Guillain-Barré syndrome. 3 Iga K. Himura Y. Izumi C. et al. Reversible left ventricular dysfunction associated with Guillain-Barre syndrome—An expression of catecholamine cardiotoxicity?. Jpn Circ J. 1995; 59: 236-240 Crossref PubMed Scopus (73) Google Scholar A wide heterogeneity of presentation suggests that multiple overlapping mechanisms such as neurogenic catecholamine-induced myocardial stunning, 4 Wittstein I.S. Thiemann D.R. Lima J.A. et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005; 352: 539-548 Crossref PubMed Scopus (2324) Google Scholar microvascular dysfunction, 5 Bybee K.A. Prasad A. Barsness G.W. et al. Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome. Am J Cardiol. 2004; 94: 343-346 Abstract Full Text Full Text PDF PubMed Scopus (482) Google Scholar and multivessel epicardial spasm 6 Dote K. Sato H. Tateishi H. et al. Myocardial stunning due to simultaneous multivessel coronary spasms: A review of 5 cases. J Cardiol. 1991; 21: 203-214 PubMed Google Scholar , 7 Gianni M. Dentali F. Grandi A.M. et al. Apical ballooning syndrome or takotsubo cardiomyopathy: A systematic review. Eur Heart J. 2006; 27: 1523-1529 Crossref PubMed Scopus (1098) Google Scholar may play a role. Symptoms mimic an ST-segment elevation myocardial infarction. Patients present with ischemic electrocardiographic changes, reduced left ventricular ejection fraction, and a balloon-like contractility pattern that portrays a unique wall-motion abnormality that extends beyond the myocardial territory of a single coronary artery. The classic form presents as transient apical ballooning with basal hypercontractility. In more rare cases of reverse Takotsubo, the opposite is observed—transient dilatation of the basal segments of the heart with hyperkinesis of the apex.

Tako-tsubo cardiomyopathy: is there a preferred time of onset?

The occurrence of major cardiovascular events is not randomly distributed over time, but exhibits chronobiological patterns, i.e., circadian, weekly, or seasonal. No systematic studies on the temporal preference of onset of Tako-tsubo cardiomyopathy (TTC) are known. We performed a computer-assisted search of the literature (from 2000 to January 2010), with the following search terms: transient left ventricular apical ballooning syndrome, takotsubo-like left ventricular dysfunction, ampulla cardiomyopathy, tako-tsubo or takotsubo cardiomyopathy, tako-tsubo, apical ballooning. Criteria for publication inclusion were (a) reporting of original data, (b) inclusion of at least 30 or more cases, (c) adherence to the requested diagnostic criteria for TTC. We focused on studies including in their purposes the "time of onset" of events. Out of the 19 studies found, 7 (4 from Europe, 1 each from Asia, Australia and USA) specifically addressed this aspect. A circadian (morning) and a seasonal (summer) higher frequency of events was found. TTC seems to exhibit a temporal variation of onset, with preferred peaks during morning and summer. Stress and catecholamines, also according to their temporal organization, might play a pivotal role. The demonstration of time frames characterized by highest frequency of occurrence might help to try to ensure maximal protection during particularly vulnerable periods.

Too sympathetic? Role of sympathoexcitation in Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is classically described as sudden and transient left ventricular apical ballooning in the absence of significant coronary artery disease. First described by Dote et al, 1 Dote K. Sato H. Tateishi H. Uchida T. Ishihara M. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases. J Cardiol. 1991; 21: 203-214 PubMed Google Scholar the cardiomyopathy was named “Takotsubo” because the narrow neck and round-bottomed left ventricle resemble a traditional Japanese octopus trap. Since the initial description of the condition, patients with transient left ventricular dysfunction have been identified with both the typical apical ballooning (AB) pattern and an alternative mid-left ventricular ballooning (MB) pattern, the “inverted Takotsubo.” 2 Kurowski V. Kaiser A. von H.K. et al. Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): frequency, mechanisms, and prognosis. Chest. 2007; 132: 809-816 Crossref PubMed Scopus (432) Google Scholar Patients present with symptoms resembling those of acute myocardial infarction, including chest pain, ST-segment elevation, and elevated cardiac enzymes. A high proportion of patients are women who develop symptoms after episodes of high emotion (after receiving bad news or being in a severe argument), and the disorder has captured the public's imagination with names such as “broken heart syndrome.” The interest of the medical profession also has been piqued, with almost 400 hits in PubMed for a search of “Takotsubo AND 2009.” Differential heart rate dynamics in transient left ventricular apical and midventricular ballooningHeart RhythmVol. 7Issue 12PreviewThe aim of the present study was to assess potential differences in cardiac autonomic nervous modulation in patients with transient left ventricular apical ballooning syndrome (AB) and the midventricular variant (MB) of this syndrome. Full-Text PDF To the Editor—Takotsubo Cardiomyopathy: A Role for Magnesium?Heart RhythmVol. 7Issue 12PreviewI read with interest the original research article on the role of sympathoexcitation in Takotsubo cardiomyopathy by Raj.1 Both classic and inverted patterns of stress cardiomyopathy have been reported in association with disorders associated with catecholamine excess, including pheochromocytoma, high-dose epinephrine infusion, and Irukandji syndrome following jellyfish envenomation.2,3 Full-Text PDF