Takotsubo Cardiomyopathy – ABC CARDIOL

ABCIC

Case Report

Single Coronary Artery and Stress Cardiomyopathy: An Association Demonstrated by Multimodality Imaging

Marcus Vinicius Silva Ferreira et al. Julia Pereira Afonso dos Santos Tormin Roberto Nery Dantas Jr Roberto Vitor Almeida Torres … Renan Andreos Cordeiro José de Arimateia Batista Araújo Filho Luiz Francisco Cardoso

Case Report

A 58-years-old female patient was admitted with retrosternal chest pain described as a continuous, oppressive tightness that had started two days earlier, after a tooth extraction procedure performed under ineffective local anesthesia. The patient’s past medical history included diabetes, dyslipidemia, and ovarian cancer, and she was receiving aspirin, rosuvastatin, metformin, dapagliflozin, and semaglutide. Physical examination was unremarkable. The chest pain protocol was initiated, and the initial electrocardiogram showed sinus rhythm with left anterior fascicular block, early repolarization in the inferior leads, and T-wave inversion in aVL, V1, and V2 (). The patient received 5 mg of sublingual isosorbide dinitrate, and blood samples were collected for laboratory testing. High-sensitivity troponin T (hs-cTnT) was 171 ng/L, confirming myocardial injury. An initial diagnosis of non–ST-elevation myocardial infarction (NSTEMI) was made, and the patient underwent coronary angiography (CA) for anatomic assessment ( / Video S1).

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ABC

Case Report

Takotsubo Syndrome in an Adolescent Undergoing Oncological Treatment: A Rare Case Report

Tami Inada et al. Guilherme Santos Marques da Silva Raisa Machado Amaral Edgard Ferreira dos Santos Junior Carlos Eduardo de Barros Branco

Introduction

Takotsubo Syndrome (TTS), or Takotsubo cardiomyopathy, was first described in Japan in 1990 and is characterized by transient and acute dysfunction of the left ventricle, usually with hypokinesia or akinesia of the mid-apical LV segments and hyperkinesia of the basal segments. The resulting morphology, with apical ballooning, resembles an octopus trap (“tako-tsubo”). Despite its symptoms being similar to those of acute coronary syndrome, there is no coronary obstruction, and the ventricular wall motion abnormality usually extends beyond the territory of a single artery.^,

Several factors can precipitate TTS, particularly physical triggers (such as severe infections and surgical interventions) and emotional stress. In oncology patients, the incidence is higher, attributed to treatment-related toxicity, subsequent infectious complications, and physical and psychological overload.^, The literature indicates that oncology patients present higher mortality and more combined major adverse cardiac events when they develop TTS, especially compared to those without a history of cancer.

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ABC

Research Letter

Cardiogenic Shock Due to Inverted-Pattern Takotsubo Syndrome Caused by Pheochromocytoma: Case Report and Literature Review

Pedro Ivo De Marqui Moraes et al. Michell Fayad André Haddad Daniel Bisi de Bôrtoli Valle Luiz Otávio de Oliveira Filho … Mayara da Silva Custódio Dirceu Rodrigues de Almeida

Introduction

Takotsubo syndrome (TTS) is characterized by an acute impairment of myocardial contractility caused by sympathetic hyperstimulation after emotional or physical stress.^, Apical ballooning is the typical and most common pattern, a feature that gave rise to the classic term described by Sato et al. in 1990, due to its similarity to the historical Japanese octopus trap. Atypical patterns include mid-basal, basal, and focal wall motion abnormalities.

Data from multicenter registries reveal that 1 to 3% of patients suspected of having an acute myocardial infarction (AMI) are alternatively diagnosed with TTS,^, and in-hospital mortality rates are comparable to those of patients with AMI and range from 3.2 to 10.6%,^– mainly caused by cardiogenic shock or sudden death from ventricular arrhythmias. In contrast to other cardiomyopathies, the ventricular contractility deficit in TTS is transient, and complete recovery usually occurs within days to weeks.

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ABCIC

Case Report

Late Evolution of Takotsubo Cardiomyopathy Following Transcatheter Aortic Valve Implantation

Merve Akbulut Çakır et al. Emirhan Çakır Çağlar Kaya Kenan Yalta

Introduction

Transcatheter aortic valve implantation (TAVI) is recognized as a first-line treatment for symptomatic patients with advanced aortic stenosis who are at high surgical risk. In inoperable patients with poor prognosis, it carries a risk for complications, such as myocardial infarction due to coronary occlusion, stroke, annular rupture, etc.¹ Takotsubo Cardiomyopathy (TTC) is a syndrome that usually develops in the absence of overt coronary occlusion and signs of alternative diagnosis, including myocarditis. It presents with electrocardiographic changes, increased cardiac biomarkers, and typical echocardiographic findings.^, In this article, we describe a patient with TTC who previously underwent TAVI and subsequent implantable cardiac defibrillator (ICD) implantation.

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ABCHF

Case Report

Tuberculosis and Atrioventricular Block in a Patient with Takotsubo Syndrome: A Case Report

Viviana Karina Sanchez Albarracin

Case Report

An 83-year-old female patient diagnosed with senile dementia and experiencing unintentional weight loss over the past few months was referred to a tertiary hospital due to complaints of typical chest pain. There is no previous history of cardiovascular diseases.

During transport, the patient developed bradycardia, with a heart rate (HR) of 32 beats per minute, and upon arrival at the emergency room, it was observed that she was suffering from complete atrioventricular block () with episodes of non-sustained ventricular tachycardia.

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ABCHF

Case Report

Takotsubo Syndrome and its Relationship with Major Depressive Disorder: Case Report

Wanessa Julia da Silva et al. Gabriel Sembeneli Pedro Petiti Arbex Bueno Rafaela Claro Rodrigues … Fernanda Meirelles Gil Flavia Lima Costa Faldoni Claudia Helena Cury Domingos

Introduction

Takotsubo syndrome (TTS) is a medical condition characterized by reversible regional dysfunction of the left ventricle (LV) and/or right ventricle. TTS is often triggered by situations of acute physical or emotional stress. It presents characteristics similar to an acute coronary syndrome (ACS) event, but without coronary abnormality evidenced by exams such as angiography. Furthermore, upon admission, patients with TTS also manifest substantially lower left ventricular ejection fraction (LVEF) values, when compared to those with ACS. Nonetheless, even with these lower levels, the chances of cardiovascular damage are lower, and the restoration of LVEF is more satisfactory.

Although the pathophysiology of TTS is complex and, in part, unknown, studies suggest that exacerbated sympathetic activation, confirmed by increased levels of plasma catecholamines, and adrenergic drugs may precipitate the condition. It predominantly occurs in postmenopausal women. However, it can affect younger women and men, and it is estimated that 1% to 3% of all patients and 5% to 6% of female patients who undergo coronary angiography due to suspected ACS have TTS. Reproductive and hormonal factors and stressful emotional events are associated with greater occurrence of TTS in women, whereas the physical factor is the most frequent agent in men, as well as in patients undergoing chemotherapy treatment.

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ABCIC

Case Report

Takotsubo Syndrome in a Critical COVID-19 Patient: Electrocardiographic and Echocardiographic Evolution

Cuitláhuac Arroyo-Rodríguez et al. Alejandra Hernández-Parra

Background

By resembling a Japanese traditional octopus trap, i.e. a takotsubo, Hikaru Sato described the first case of “Takotsubo cardiomyopathy” in a patient without coronary stenosis and end-systolic left ventricular apical ballooning on a cardiac left ventriculography.Takotsubo syndrome (TTS) is a clinical syndrome characterized by an acute and transient left ventricular systolic dysfunction related to an emotional or physical stressful event. COVID-19 is a recognized trigger for TTS, with the possible explanations being the enormous emotional stress caused by the pandemic and the entire spectrum of myocardial damage associated with SARS-COV-2.

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ABCIC

Case Report

Takotsubo Syndrome After Percutaneous Mitral Valve Repair With Mitraclip®: A Case Report

Anna Luiza Souza et al. Maurício Lopes Prudente Débora Rodrigues Ana Cecília Campos Nogueira Giulliano Gardenghi

Introduction

Takotsubo syndrome (TTS), also known as stress cardiomyopathy or broken heart syndrome, is a condition whose pathophysiology is not well established, but which results from multiple factors that act synergistically in a setting of stress perception and cardiocirculatory response. It was first described in 1990, and the disproportionate and excessive increase in serum catecholamines is known to play a central role in its pathogenesis by favoring the occurrence of complications. Although rare, TTS deserves attention due to its inherent risk of decompensated heart function.^,

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ABCHF

Review Article

Stress Cardiomyopathy (Takotsubo)

Marcelo Westerlund Montera

Introduction

Takotsubo Cardiomyopathy (CT), also known as stress-induced cardiomyopathy, is a reversible syndrome that usually presents as an acute coronary syndrome, especially in postmenopausal women. The pathophysiology involves multiple factors, including coronary vasospasm, microcirculation dysfunction, catecholaminergic aggression, and sympathetic hyperactivity. The diagnosis of the classic presentation is the presence of a segmental alteration in the form of ballooning or dyskinesia in the antero-septo-apical region of the left ventricle, associated with hyperdynamia of the basal segments, in the absence of obstructive coronary disease that justifies this alteration in contraction. Initially, it was believed that CT was a self-limiting condition with a good prognosis; however, it is currently recognized as a pathology with a high rate of complications and high morbidity and mortality in the short and long term. Even though the first description was made more than 30 years ago, in 1990, by Sato, the etiology and pathophysiology are still not fully defined, and we still do not have an international guideline for standardizing diagnosis and treatment.

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ABCIC

Case Report

Takotsubo Syndrome After Mitral Valve Surgery: Multimedia Presentation of a Rare Diagnosis

Adnaldo da Silveira Maia et al. Germano de Sousa Leão Jhonathan Gouveia da Mota Dante Togeiro Bastos Filgueiras … Verônica Noronha Rodrigues Luiz Minuzzo Mario Issa

Introduction

The Takotsubo Syndrome, also known as “broken heart syndrome”, is characterized by a severe and transitory left ventricular dysfunction, with the presence of alterations in the contraction of the basal, medial, or apical segments of the left ventricular walls. The syndrome can be caused by an emotional or physical trigger, or by a combination of both; however, this is not a mandatory criterion for its diagnosis.

This study describes a case of Takotsubo Syndrome after mitral valve surgery to replace the valve with a mechanical prosthesis.

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ABCHF

Review Article

Takotsubo Cardiomyopathy in Patients with Cancer

Ariane Vieira Scarlatelli Macedo et al. Gustavo Luiz Gouvêa de Almeida Junior Marília Harumi Higuchi dos Santos Rehder

Abstract

Takotsubo cardiomyopathy (TC) in cancer patients has been predominantly noted as a cardiotoxic complication of oncologic therapy or secondary to catecholamine overload in specific tumors such as pheochromocytomas. The underlying pathophysiological mechanisms that lead to TC are not entirely understood. The diagnosis of TC can be challenging and may be neglected during cancer treatment, given the wide range of cardiotoxic effects of antineoplastic therapies. However, TC in oncology exists more often than formerly assumed, and it should be included in the differential diagnosis by physicians dealing with cancer patients. An increased suspicion is crucial for earlier diagnosis and treatment to improve outcomes. In addition to a risk model strategy identifying those cancer patients with the highest risk of having TC, translational studies are awaited. They would clarify the underlying mechanism of TC, disclose targets for prevention and treatment and determine whether re-exposing the patient to the same or equivalent anticancer agents would be secure and feasible.

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ABCIC

Case Report

Inverted Takotsubo Versus Acute Myocarditis: the Importance of Cardiac Resonance for Differential Diagnosis

Carina Massariol Belinassi et al. Stella de Souza Carneiro Débora Pereira Galvêas Negri Davi Muzi Rios … Murilo Jardim de Carvalho José Augusto Murad

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IJCS

Case Report

Takotsubo Syndrome as a Complication of Mild COVID-19: A Case Report

Jéssica Mayara Oséas et al. William Santos de Oliveira Bruna Aparecida Oliveira Jayson Marcus Miranda … Raissa Gabriela Vieira Barros Nestor Rodrigues de Oliveira Neto

Introduction

As the number of cases of coronavirus disease 2019 (COVID-19) has reached tens of millions worldwide, the understanding of its clinical manifestations has grown. These have been described as a range of systemic repercussions resulting from an interplay between direct organ damage and exaggerated host immune response.^, In a descriptive case series study of COVID-19 patients in Wuhan, 44% of patients had either elevated cardiac biomarkers or new changes in electrocardiogram (ECG) and imaging exams, and 34% of all cases had acute heart failure. Systemic diseases with increased adrenergic response may lead to stress cardiomyopathy, or Takotsubo syndrome, which is a rare condition with challenging diagnosis in the course of COVID-19. Herein we present a case of an elderly woman with mild COVID-19 who presented classical features of takotsubo syndrome on the 5th day of illness.

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IJCS

Case Report

Cardiac Manifestations Associated With Coronavirus Disease: A Case Report

Gabriela Ribeiro Prata Leite Barros et al. Raphaela Tereza Brigolin Garofo Bernardo Noya Alves de Abreu Adriano Camargo de Castro Carneiro André Luiz Esteves Mendonça

Abstract

This study presents a 47-year-old female patient, with a history of diabetes, who contracted SARS-CoV-2 and exhibited cardiovascular complications.

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ABC

Research Letter

SARS-CoV-2 and Myocardical Injury with ST-Elevation without Coronary Disease

Carolina Ragonetti et al. Enzo Oku Martinazzo Felipe Montesano Fazionato Guilherme Osório Guimarães Ferreira … Milena Piccolo Santana Camila Hartmann

Introduction

Throughout the SARS-CoV-2 pandemic, there have been reports of infection leading to acute myocardial injury, causing worse clinical outcomes. The manifestations can include troponin elevation, imaging exam abnormalities and electrocardiographic changes. Accordingly, ST-segment elevation (STE) acute myocardial injury has been observed in some patients. However, despite the electrocardiogram (ECG) ischemic changes, complementary exams may not show any obstruction, excluding coronary occlusion as the cause of the injury.

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IJCS

Case Report

Takotsubo Cardiomyopathy and Myocardial Perfusion Image: Unusual Binomial in the Investigation of Acute Coronary Syndrome without Obstructive Lesions

Mathias Silvestre de Brida et al. Raphael Boesche Guimaraes Leonardo Rothlisberger Matheus Patricio

Introduction

Takotsubo cardiomyopathy (TC), also known as broken heart syndrome or stress-induced cardiomyopathy, was primarily described in Japan in 1990, is named after its morphological similarity to the vase used by Asian people to catch octopuses, which has a rounded bottom and a narrow bottleneck. This condition is characterized by transient left ventricular (LV) systolic dysfunction, commonly preceded by physical or emotional stress, mimicking the presentation of acute myocardial infarction. In the present article, we describe a case of TC focusing on its updated approach, highlighting the applicability of myocardial perfusion scintigraphy (MPS) in the acute phase of chest pain and presenting images rarely described in this scenario.

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IJCS

Original Article

The Clinical Course of Takotsubo Syndrome Diagnosed According to the InterTAK Criteria

Nelson Henrique Fantin Fundão et al. Henrique Barbosa Ribeiro Carlos de Magalhães Campos Vinicius Bocchino Seleme … Alexandre de Matos Soeiro Marcelo Luiz Campos Vieira Wilson Mathias Jr Ludhmilla Abraão Hajjar Expedito E. Ribeiro Roberto Kalil Filho

Abstract

Background

There has been an increase in the number of cases of Takotsubo syndrome (TTS) and of scientific publications on the theme over the last years. However, little is known about the status of this disease in Brazilian hospitals.

Objective

To assess mortality and major adverse cardiovascular events (MACE) during hospitalization and follow-up of TTS patients seen in a tertiary hospital in Brazil.

Methods

This was a retrospective, observational study on 48 patients. Clinical data, signs and symptoms, complementary tests, MACE and all-cause mortality were assessed on admission and during follow-up. Kaplan-Meier curves were used for analysis of all-cause mortality and risk for MACE at median follow-up. The 95% confidence interval was also calculated for a significance level of 5%.

Results

Mean age of patients was 71 years (SD±13 years), and most patients were women (n=41; 85.4%). During hospitalization, four patients (8.3%) died and five (10.4%) developed MACE. At median follow-up of 354.5 days (IQR of 81.5-896.5 days), the risk of all-cause mortality and MACE was 11.1% (95% CI= 1.8-20.3%) and 12.7% (95% CI= 3.3-22.3%), respectively.

Conclusion

TTS was associated with high morbidity and mortality rates in a tertiary hospital in Brazil, which were comparable to those observed in acute coronary syndrome. Therefore, the severity of TTS should not be underestimated, and new therapeutic strategies are required. Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0

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ABC

Letter to the Editor

Recurrent Takotsubo Cardiomyopathy: A Puzzle Yet to be Solved

Kenan Yalta et al. Caglar Kaya

Reply

First, we thank the authors for the comments regarding our recent article in Arquivos Brasileiros de Cardiologia entitled “Factors Associated with Recurrence in Takotsubo Syndrome: A Systematic Review”. In the letter, the authors made some interesting additional comments regarding the mechanisms of Takotsubo recurrence related to mechanical triggers related to mid-ventricular gradient that may be related to associated hypertrophic cardiomyopathy (HCM) and a second mechanism related to severe adrenergic discharge.

One question they posed was related to the incidence of HCM and hypertensive heart disease in the data we analyzed. Actually, in the original papers that were revised, the authors did not mention HCM or hypertensive heart disease incidence. Some patients with Takotsubo Syndrome (TS) may present with systolic anterior motion of the mitral valve and ventricular obstruction; it is sometimes difficult to determine whether these features are related to TS or associated to HCM or even their combination and the clinic, electrocardiographic and image follow-up may reveal the diagnosis.^, About the impact of the surgical reconstruction on recurrence, in a brief review of literature we found one article describing a case of ventricular reconstruction in a female who remained with apical aneurism and recurrent embolic events. Therefore, in the case of permanent ventricular outflow obstruction in HCM who has TS, one may consider the indication of the HCM guidelines for surgical intervention.

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ABC

Editorial

Takotsubo Syndrome, Does it Exist as a Specific Disease?

Bruno Caramelli

The name syndrome combines two Greek roots to describe a condition gathering a group of signs and symptoms existing together in patients. It seems that Avicenna first used it in his 1025 publication “The Canon of Medicine”. In genetics, the use of the name syndrome generally assumes that the underlying cause of the disease is known. On the other hand, in medicine, syndrome refers to conditions both with a known and unknown cause.

Historically, associated signs and symptoms found to be of improbable correlation were eventually known to have an underlying cause responsible for all of them. Even after the cause is unraveled, the original word remains, sometimes with the name of the first describer, and this is probably the reason for the existence nowadays of syndromes with identified and unidentified causes.

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IJCS

Brief Communication

Takotsubo Syndrome in the Context of Transmural Acute Myocardial Infarction: Prevalence and How to Differentiate?

João Paulo Soares Costa et al. Luiz Eduardo Fonteles Ritt Rafael Modesto Fernandes Felipe Alvarenga Duarte Campos … Queila Borges Eduardo Sahade Darzé

Introduction

Takotsubo syndrome (TTS) is characterized by transient left ventricular dysfunction culminating in acute cardiac dysfunction. It is frequently preceded by emotional or physical stress.^,

The most common symptoms at presentation are chest pain and dyspnea. Because the presentation of TTS is similar to that of acute coronary syndrome (ACS), the differential diagnosis is difficult, especially from ST-elevation myocardial infarction (STEMI). Absence of coronary artery disease in the affected area must be confirmed to establish the diagnosis of TTS. To facilitate the diagnosis of TTS, the European Society of Cardiology has recently developed the InterTAK diagnostic score, a promising tool that estimates the probability of a TTS event.^,

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ABC

Original Article

Factors Associated with Recurrence in Takotsubo Syndrome: A Systematic Review

Felipe Alverenga Duarte Campos et al. Luiz Eduardo Fonteles Ritt João Paulo Soares Costa Constança Margarida Cruz … Gilson Soares Feitosa-Filho Queila Borges de Oliveira Eduardo Sahade Darzé

Abstract

Background:

Takotsubo syndrome (TTS) is characterized by a temporary systolic dysfunction of the left ventricle (LV) related to a stressful event. However, the factors associated with its recurrence are still not well established.

Objective:

To analyze the main factors associated with TTS recurrence.

Methods:

A systematic review was performed using the PRISMA model. Observational studies, published between January 2008 and October 2017, which presented a recurrence rate of at least 3% and/or 5 or more patients with recurrence, and who met at least 80% of the STROBE criteria were included.

Results:

six articles reached the criteria to compose this systematic review. The recurrence rate ranged from 1 to 3.5% per year (global recurrence rate 3.8%). One study associated higher recurrence rate with the female gender, four reported the time between the first and second episodes, one study associated body mass index (BMI) and hypercontractility of the LV middle anterior wall to a higher recurrence rate. No association between recurrence and electrocardiographic changes were determined. Beta-blockers use was not associated with recurrence rates.

Conclusions:

Female gender, time from the first episode of the syndrome, low BMI and midventricular obstruction were reported as potential predictors of TTS recurrence.

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ABC

Artigo Original

Short and Long-Term Outcome of Stress-Induced Cardiomyopathy: What Can We Expect?

Vânia Filipa Andrade Ribeiro et al. Mariana Vasconcelos Filipa Melão Ester Ferreira … Gracieta Malangatana Maria Júlia Maciel

Background:

Stress-induced/Takotsubo cardiomyopathy (TC) is an increasingly recognized diagnostic entity.

Objective:

This study was aimed to assess the prevalence and clinical predictors of short and long-term outcome of patients (pts) diagnosed with TC.

Methods:

We included all consecutive pts admitted in our department, from November 2006 to August 2011, who met the Mayo Clinic criteria for TC diagnosis.

Results:

We evaluated 37 pts (35 women) with a mean age of 63 ±13 years. TC was precipitated by a stressful emotional event in the majority (57%) and chest pain was the most common symptom (89%). Twelve pts (32%) had ST-segment elevation and 15 pts (41%) had T-wave inversion on the electrocardiogram at admission. Severe left ventricular (LV) dysfunction was found in 16 pts (43%) and the mean troponin I level was 2.6±1.8 ng/mL. The in-hospital complication rate was 30%, with cardiogenic shock being the most common situation. Physical stress, severe LV systolic dysfunction and peak brain natriuretic peptide (BNP) were predictors of acute complications. On the other hand, we found no association between peak troponin I and electrocardiographic presentation. Thirty-five pts were followed for a mean time of 482 ± 512 days, without clinic recurrence.

Conclusion:

In our cohort of pts, TC was associated with a high in-hospital complications rate. Physical stress, LV dysfunction and peak BNP could predict acute adverse outcomes.

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ABC

Case Report

Two-dimensional strain in Takotsubo cardiomyopathy

Carlos Bellini G. Gomes et al. Gustavo J. Veras

This report presents the late follow-up of a case of Takotsubo cardiomyopathy with good clinical outcome and improved left ventricular global systolic function. However, there was persistence of significant regional longitudinal systolic dysfunction evaluated using a new echocardiographic technique (speckle tracking), with corresponding measures of strain (S) and strain rate (SR). We emphasize the importance of this new method to monitoring this cardiomyopathy, since it identifies patients with persistent systolic dysfunction who will possibly benefit from maintenance of clinical therapy

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