Takotsubo cardiomyopathy in the setting of multiple sclerosis: a multifaceted phenomenon with important implications

Abstract

Dear Editor,
 Takotsubo cardiomyopathy (TTC) has been universally regarded as a unique form of reversible myocardial dysfunction associated with a variety of emotional and physical stressors. In their recently published elegant article, Dell’Aquila et al. have reported an interesting case of TTC triggered by an exacerbation of relapsing-remitting multiple sclerosis (MS). However, we would like to comment on this interesting case and its particular implications...

Cardiac myxoma as a potential trigger of takotsubo cardiomyopathy: A brief review on mechanistic and clinical perspectives

“…However, systemic inflammation, rather than serving as a direct trigger, seems to facilitate the impact of neurological stressors on TTC evolution in patients with cardiac myxoma (owing to the modest nature of systemic inflammation in most myxoma patients). Importantly, systemic inflammation in the setting of cardiac myxomas might also be associated with a variety of adverse outcomes including acute HF (1), malignant arrhythmias as well as coronary micovascular dysfunction (as demonstrated with coronary slow flow (CSF) during the course of the associated TTC episode (13).This may also suggest anti-inflammatory strategies in an effort to improve the short-term prognosis ofthe associated TTC episode (17,18).…”

“…Mechanistically, TTC evolution in certain neurological diseases were previously ascribed to the direct involvement of the cardiovascular centre in the brain stem (rostral ventrolateral medulla (RVLM) located in medulla oblongata ( 8)) with consequent adrenergic discharge (17,18). Involvement of the cardiovascular centre was also suggested to be associated with more severe and prolonged adrenergic discharge in patients with TTC potentially associated with adverse events including malignant arrhythmogenesis and coronary ischemic complications (due to coronary microvascular dysfunction as confirmed with a pattern of CSF (19,20)) that might be evaluated with TIMI frame counts on coronary imaging) in the acute setting (17,18). In the long-term, TTC associated with neurological diseases also has a higher risk for future recurrences (17)(18)(19)(20) possibly due to the relapsing nature of the primary neurological pathology.…”

“…Involvement of the cardiovascular centre was also suggested to be associated with more severe and prolonged adrenergic discharge in patients with TTC potentially associated with adverse events including malignant arrhythmogenesis and coronary ischemic complications (due to coronary microvascular dysfunction as confirmed with a pattern of CSF (19,20)) that might be evaluated with TIMI frame counts on coronary imaging) in the acute setting (17,18). In the long-term, TTC associated with neurological diseases also has a higher risk for future recurrences (17)(18)(19)(20) possibly due to the relapsing nature of the primary neurological pathology. Interestingly, atypical takotsubo variants (including reverse and midventricular variants) are more likely to be associated with severe neurological diseases including subarachnoid hemorrhage and multiple sclerosis (MS) characterized by relatively high levels of adrenergic discharge (21)(22)(23).Therefore, it might also be suggested that neurological diseases, as compared with other TTC stressors, might trigger atypical TTC episodes in a more frequent manner.…”

Takotsubo syndrome in association with pheochromocytoma: clinical and practical considerations

“…adrenergic discharge mostly associated with a variety of stressors (1)(2)(3). Occasionally, organic sources of adrenergic discharge (including pheochromocytoma) might also account for this phenomenon and are not considered as exclusion criteria for the diagnosis of TTS (as opposed to previous suggestions) (1,2,4).…”

“…First, TTS episodes in the setting of pheochromocytoma usually emerge in the absence of overt stressors and might have a significant predisposition to certain complications including malignant arrhythmogenesis, heart failure (HF) and coronary ischemic syndromes (associated with coronary microvascular dysfunction characterized by a coronary slow flow (CSF) pattern) (2)(3)(4). Accordingly, TTS episodes due to pheochromocytoma were reported to have significantly higher rates of in-hospital adverse events (mostly in relatively young patients) in a previous analysis on 80 published cases (4).…”