Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): A mimic of acute myocardial infarction

Prasad, Abhiram; Lerman, Amir; Rihal, Charanjit S.

doi:10.1016/j.ahj.2007.11.008

Cited by 1,620 publications

(1,610 citation statements)

References 77 publications

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“…Angiotensin‐converting enzyme inhibitors or angiotensin II receptor blockers could have some benefit in term of improved survival at 1 year 3. β‐Blockers showed no effect on survival and recurrence rate,3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38 whereas calcium antagonists could be used if coronary vasospasm has been proven during coronary angiogram or with acetylcholine test 32…”

Section: Discussionmentioning

confidence: 99%

Left Ventricular Thrombi in Takotsubo Syndrome: Incidence, Predictors, and Management: Results From the GEIST (German Italian Stress Cardiomyopathy) Registry

Santoro

Stiermaier

Tarantino

et al. 2017

JAHA

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BackgroundLeft ventricular (LV) thrombi during Takotsubo syndrome represent a potential complication and can be associated with cerebrovascular embolic events. The aim of this study was to evaluate the exact incidence, predictors, and management strategies of LV thrombi in patients with Takotsubo syndrome.Methods and ResultsWe enrolled 541 consecutive patients in a multicenter international registry. Clinical features and echocardiographic data at admission, during hospitalization, and after 3 months were evaluated. Survival rates for long‐term follow‐up (mean 984±908 days) were recorded. Twelve Takotsubo syndrome patients (2.2%) developed LV thrombi (all female presenting with apical ballooning pattern). All patients with LV thrombi were treated with oral anticoagulation therapy; however, 2 (17%) had a stroke before treatment initiation. These patients were characterized by a higher prevalence of ST‐elevation (56% versus 16%; P<0.001) and higher troponin I levels (10.8±18.3 ng/mL versus 3.5±4.3 ng/mL; P=0.001) as compared with those without LV thrombi. At multivariate analysis including age, sex, LV ejection fraction, ST‐elevation at admission, and apical ballooning pattern, troponin I level >10 ng/mL was the only predictor for LV thrombosis (hazard ratio 6.6, confidence interval, 1.01–40.0; P=0.04). After 3 months all LV thrombi disappeared. Oral anticoagulation therapy was interrupted in all patients except 1. At long‐term follow‐up, the survival rate was not different between patients with and without LV thrombi (84% versus 85%; P=0.99).Conclusions LV thrombi have a relatively low incidence among patients with Takotsubo syndrome and were detected in female patients with apical ballooning pattern and increased troponin levels. Oral anticoagulation therapy for 3 months seems reasonable in these high‐risk patients.

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Section: Discussionmentioning

confidence: 99%

Left Ventricular Thrombi in Takotsubo Syndrome: Incidence, Predictors, and Management: Results From the GEIST (German Italian Stress Cardiomyopathy) Registry

Santoro

Stiermaier

Tarantino

et al. 2017

JAHA

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“…Although the pathophysiology remains unclear, the explanation that appears more robust is myocardial stunning mediated by direct catecholamine effect. 1 Other suggested hypotheses are epicardial or microcirculatory vasospasm, LV outflow obstruction, or plaque rupture with spontaneous fibrinolysis. 2 -7 Prior studies have shown the usefulness of cardiac magnetic resonance (CMR) with contrast to differentiate small infarcts from myocarditis or TTC.…”

Section: Introductionmentioning

confidence: 99%

Morphologic Pattern of Late Gadolinium Enhancement in Takotsubo Cardiomyopathy Detected by Early Cardiovascular Magnetic Resonance

Avegliano

Huguet²,

Costabel

et al. 2011

Clinical Cardiology

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Background: Takotsubo cardiomyopathy (TTC) presents clinically as an acute coronary syndrome. It is characterized by transient left ventricular wall dyskinesis-akinesis, without significant epicardial coronary lesions. Late gadolinium enhancement (LGE) sequences on cardiac magnetic resonance (CMR) allow to clarify the pathophysiology in patients with chest pain, elevated troponin, and normal epicardial coronary arteries; in patients with TTC, previous studies have shown absence of LGE. Hypothesis: Early CMR in Takotsubo patients could show a morphological pattern of LGE improving clinical diagnosis. Methods: Between January 2005 and January 2007, 8 consecutive patients with TTC criteria underwent CMR within the first 3 days of admission. Cine, T2-weighted, and LGE images were acquired. Patient follow-up included clinical exam and imaging techniques: echocardiogram on days 3, 7, 30, and 60, and CMR at 3 months. Results: Six patients had experienced a previous stressful situation. No significant lesions were found on coronary angiography, and wall motion improvement was noted at 15 (7-30) days. Median EFs at admission and recovery were 46.5% and 65%, respectively. Dyskinesis was midapical in 6 cases, apical in 1 case, and mid-ventricular in 1 case. Late gadolinium enhancement showed mild hyperenhancement in areas of abnormal wall motion, whereas normal segments had no contrast enhancement. On follow-up CMR, wall motion was normal without late enhancement. Conclusions: Early CMR in TTC demonstrates a special morphological pattern of late gadolinium uptake that might correspond to localized inflammation and edema in the affected area, suggesting diffuse microcirculation damage rather than epicardial vessel involvement.

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“…First, this study duration coincided with the evolution of point‐of‐care cardiac ultrasonography in critical illness, resulting in the higher application and likely greater diagnosis of TTC at the bedside 29. Second, the initial TTC criteria were proposed in 2004 with a subsequent revision in 2008 that potentially resulted in the further unification of clinical definitions and higher awareness in treating physicians 2, 5. The first reported series of TTC in sepsis was in 2005, providing additional awareness 30.…”

Section: Discussionmentioning

confidence: 99%

“…Importantly, this study noted improving mortality in patients with TTC with every subsequent year during the study period. This could be explained by multiple hypothesis: (1) With a greater understanding of sepsis pathophysiology, there has been a shift away from elements of the early goal‐directed therapy, such as blood transfusions and inotropes, that may adversely affect mortality38, 39; (2) greater emphasis on cardiovascular outcomes in sepsis and use of bedside point‐of‐care ultrasonography in critical care11, 12; and (3) evolution in the diagnosis and management of TTC since the unifying criteria were published in 2005 5. Alternately, as with other administrative databases, this could potentially represent potential overdiagnoses resulting in decreased severity of illness of included patients.…”

Section: Discussionmentioning

confidence: 99%

Tako‐Tsubo Cardiomyopathy in Severe Sepsis: Nationwide Trends, Predictors, and Outcomes

Vallabhajosyula

Deshmukh

Kashani

et al. 2018

JAHA

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BackgroundThere are limited data on the presentation of Takotsubo cardiomyopathy (TTC) in severe sepsis.Methods and ResultsThis was a retrospective cohort study using the National Inpatient Sample database (2007–2013) of all adults with severe sepsis. TTC was identified in patients with severe sepsis using previously validated administrative codes. The primary outcome was in‐hospital mortality, and secondary outcomes included resource utilization and discharge disposition. Regression analysis was performed for the entire cohort and a propensity‐matched sample. An exploratory analysis was performed for predictors of TTC incidence and mortality in TTC. During this 7‐year period, in 7.1‐million hospitalizations for severe sepsis, TTC was diagnosed in 10 746 (0.15%) admissions. TTC was noted more commonly in whites, females, and among 65‐ to 79‐year‐old individuals. TTC was independently associated with lower in‐hospital mortality in severe sepsis (odds ratio, 0.58; 95% confidence interval, 0.51–0.65). This association was more prominent in females (odds ratio, 0.51; 95% confidence interval, 0.44–0.59]) compared with males (odds ratio, 0.69; 95% confidence interval, 0.55–0.85]). Presentation in later years of the study period, middle‐age, female sex, and white race were independent predictors for the diagnosis of TTC. Age ≥80 years, black race, greater comorbidity, and multiorgan dysfunction were independently associated with higher in‐hospital mortality among TTC admissions.Conclusions TTC is observed with increasing frequency in severe sepsis and was associated with a significantly lower in‐hospital mortality compared with patients without TTC. Presentation in later years of the study period, middle age, female sex, and white race were independent predictors for the diagnosis of TTC in severe sepsis.

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Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): A mimic of acute myocardial infarction

Cited by 1,620 publications

References 77 publications

Left Ventricular Thrombi in Takotsubo Syndrome: Incidence, Predictors, and Management: Results From the GEIST (German Italian Stress Cardiomyopathy) Registry

Left Ventricular Thrombi in Takotsubo Syndrome: Incidence, Predictors, and Management: Results From the GEIST (German Italian Stress Cardiomyopathy) Registry

Morphologic Pattern of Late Gadolinium Enhancement in Takotsubo Cardiomyopathy Detected by Early Cardiovascular Magnetic Resonance

Tako‐Tsubo Cardiomyopathy in Severe Sepsis: Nationwide Trends, Predictors, and Outcomes

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