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

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Purpose of Review To provide an update on the use of cardiac magnetic resonance imaging in the diagnosis of Takotsubo cardiomyopathy. Recent Findings Long-term prognosis of Takotsubo cardiomyopathy may not be as clear-cut as previously thought. Cardiac magnetic resonance imaging not only allows differentiation between reversible and nonreversible changes but has an emerging role in identifying cellular level changes associated with prognostic indicators such as myocardial energetics using 31P-CMR spectroscopy and detection of myocardial inflammation overlying myocardial oedema, using ultrasmall paramagnetic iron oxide particle uptake in macrophages. Summary Takotsubo cardiomyopathy is a non-ischemic acute heart failure syndrome. It is commonly triggered by emotional or physical stress and is possibly the strongest psychosomatic interaction seen in medicine. While clinically its presentation mimics a myocardial infarction, the acute imaging characteristics are critical in correctly identifying the disease entity.

 The presenting ECG in Takotsubo is subtly different than the presenting ECG of myocardial infarction, by fewer total abnormal leads, lesser total magnitude of STelevation and lesser pathological Q waves. The 4-day evolution of the Takotsubo ECG compared to acute myocardial infarction is characterised by much more widespread and deeper T wave inversion. The mean QTc progressively increases in takotsubo whilst in MI decreases.