Takotsubo Syndrome and Inflammatory Bowel Diseases: Does a Link Exist?

Abstract

Background: Takotsubo syndrome (TTS) is an acute cardiac dysfunction in the absence of viral causes or obstructive coronary disease completely reversible within 4-8 weeks. Inflammatory bowel diseases (IBD) are a group of diseases caused by the interaction between immune system, genetic, and environmental factors against intestinal mucosa. Both these syndromes are characterized by complex mechanisms involving endothelial dysfunction and affective disorders. Aim: To assess the possibility of an association between IBD and TTS. Methods: First, we present a case of TTS in a patient affected by active stenosing Crohn's disease. Articles in English language were collected from PubMed and Google Scholar databases with the search terms "takotsubo," "IBD," "crohn disease," "ulcerative colitis". Results: Both TTS and IBD show multiple common features: preference for female patients, recurrent course of disease, association with endothelial dysfunction, and affective disorders. Patients affected by IBD could show specific triggers for TTS, such as malabsorption, electrolytes disturbances, and affective disorders. Conclusions: Despite pathophysiological similarities between TTS and IBD in active phase, future studies are needed to confirm this apparently possible association and to assess the presence of a pathophysiological link between these diseases.

Inflammatory Bowel Disease and Takotsubo Syndrome: Cases of Horses or Zebras?

“…To the Editor, I read with great interest the report by Mirijello et al [1], describing the case of an 81-year-old woman with chronic stenosing Crohn's disease (CD) and recurrent takotsubo syndrome (TTS), and providing a review of the literature about inflammatory bowel disease (IBD) and TTS. The exact pathophysiology of TTS is still elusive, but the authors have provided a comprehensive list of the various plausible triggers and pathoetiological mechanisms, which could be instrumental in causing this enigmatic malady.…”

“…The exact pathophysiology of TTS is still elusive, but the authors have provided a comprehensive list of the various plausible triggers and pathoetiological mechanisms, which could be instrumental in causing this enigmatic malady. The authors also draw attention to the many common underpinnings of CD or IBD and TTS [1]. One wonders if it is possible to talk about physical or emotional triggers in such patients with a devastating chronic illness as CD or IBD, or whether it is more suitable to consider a yin and yang conceptualization of a continuous physical/ emotional complementary conglomerate of triggers constantly present, with episodic exacerbations.…”

“…One wonders if it is possible to talk about physical or emotional triggers in such patients with a devastating chronic illness as CD or IBD, or whether it is more suitable to consider a yin and yang conceptualization of a continuous physical/ emotional complementary conglomerate of triggers constantly present, with episodic exacerbations. One also wonders how common is TTS in patients with CD or IBD in general; for example, the presented patient had a most probable occurrence of TTS (i.e., "zebra" episode 3 years earlier (diagnosed erroneously at that time as acute coronary syndrome, i.e, "horse" episode) [1]. In the authors' review of the literature, there is a mention of recurrent TTS in 2 patients with IBD, 1 among 9 patients with CD, and 1 among 4 patients with ulcerative colitis [1]; however, TTS is probably often missed when atypical or mild TTS cases occur [2].…”

“…One also wonders how common is TTS in patients with CD or IBD in general; for example, the presented patient had a most probable occurrence of TTS (i.e., "zebra" episode 3 years earlier (diagnosed erroneously at that time as acute coronary syndrome, i.e, "horse" episode) [1]. In the authors' review of the literature, there is a mention of recurrent TTS in 2 patients with IBD, 1 among 9 patients with CD, and 1 among 4 patients with ulcerative colitis [1]; however, TTS is probably often missed when atypical or mild TTS cases occur [2]. Indeed, a parallel is the frequent (i.e., 28%) detection of TTS, when prospectively sought after, in patients admitted to an intensive care unit for noncardiac physical illnesses, implementing proactively serial echocardiography [3].…”

“…What can be done to enhance our insights about the pathophysiological link between IBD and TTS? First, increase our awareness and index of suspicion that such a link is real and often is manifest by occurrence of definite TTS [1], or "forme fruste" TTS cases [2]. Second, consider employing a currently available technology monitoring the autonomic sympathetic nervous system input to the heart via the stellate ganglia, by recording and analyzing thoracic signals obtained via conventional electrocardiography (ECG) hook-up [4], in patients admitted with exacerbations of IBD.…”