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Introduction and objectives: The coronavirus disease 2019 (COVID-19) spread quickly around the world. Although mainly a respiratory illness, there is growing interest in non-respiratory manifestations, particularly cardiovascular ones. At our center, mobilization of cardiologists with intensive care training was needed. Our aim is to describe patients with severe COVID-19 admitted to a Portuguese intensive care unit (ICU), the cardiovascular impact of the disease and the experience of cardiologists working in a COVID-19 ICU. Methods: Data from adult patients with COVID-19 admitted to the ICU of Centro Hospitalar de Vila Nova de Gaia/Espinho between 16 March 2020 and 21 April 2020 were analyzed retrospectively. Results: Thirty-five patients were admitted. Mean age was 62.6±6.0 years and 23 (65.7%) were male. Dyslipidemia was the most common cardiovascular risk factor (65.7%, n=23), followed by hypertension (57.1%, n=20). Mean ICU stay time was 15.9±10.0 days. Patients had high rates of mechanical ventilation (88.6%, n=31) and vasopressor support (88.6%, n=31). Low rates of new onset left systolic dysfunction were detected (8.5%, n=2). One patient required venoarterial extra-corporeal membrane oxygenation. Mortality was 25% (n=9). Acute myocardial injury and N-terminal pro-B-type natriuretic peptide (NT-proBNP) elevation was detected in 62.9% (n=22). Patients that died had higher NT-proBNP compared to those discharged alive (p

The current coronavirus disease 2019 (COVID-19) presents an ongoing medical challenge with multiple organs involvement, including the cardiovascular system. Takotsubo syndrome (TTS) has been described in the context of COVID-19 in two different scenarios: as a direct complication of the infection, and as an indirect outcome secondary to psychological burden of quarantine and social isolation (i.e., stress induced cardiomyopathy). Confirming the diagnosis of TTS in COVID-19 may be challenging due to the limited use of coronary angiography consistent with the recommended guidelines aimed to minimize contact with infected individuals. The use of natriuretic peptide as a diagnostic and prognostic marker in this context may not be reliable since this peptide is already elevated in severe cases of COVID-19 regardless of TTS diagnosis. A relatively high incidence of complications has been reported in these cases, probably related to the severity of the underlying infectious disease. Although quarantine-induced stress cardiomyopathy is a reasonable outcome of the powerful stress during the current pandemic, conflicting results have been reported, and further studies are encouraged to determine the true incidence., GRAPHICAL ABSTRACT Image, graphical abstract

Takotsubo cardiomyopathy (TC) is an acute cardiac condition triggered by emotional or physical stress. General anesthesia and sympathetic activation are possible triggers for TC. However, little is known about the role of sympathovagal activity in TC. In our report, we present a female patient, aged 62, who underwent thyroidectomy and at the end of the surgery developed cardiac complications. The patient had no chest pain, but had ST depression and negative T waves on the electrocardiogram (ECG). Cardiospecific enzyme troponin was elevated. Cardiac catheterization revealed unobstructed coronary arteries. Echo-cardiography revealed the enlargement of the left ventricle and ejection fraction of 40%. The patient was diagnosed with TC and dual antiplatelet therapy was introduced, a beta blocker and ACE inhibitor.It is possible that TC in perioperative period after thyroidectomy in this patient occured due to both sympathetic and parasympathetic activation. Probably, extraction of large thyroid induced vagal stimulation which resulted in hypotension and bradicardia. The patient was subsequently treated with adrenaline and atropine. In this case, sympathetic and parasympathetic activation in different intervals could result in the development of this condition.

Background We investigate if renin‐angiotensin and endothelin‐1 response pathways follow the same pattern of recovery as left ventricular ejection fraction in patients with takotsubo cardiomyopathy. Methods and Results Ninety patients with takotsubo cardiomyopathy (n=30 in each of “acute,” “convalescent” [3–5 months] and “recovered” [>1 year] groups) who were on minimal or no medication and were free of any significant cardiac/metabolic comorbidities, and 30 controls were studied. Serum concentrations of renin, angiotensin‐converting enzyme, angiotensin II, big endothelin‐1, endothelin‐1 were measured using commercially available ELISA, and B‐type natriuretic peptide was measured using an immunoassay. Mean left ventricular ejection fraction was P =0.03 versus controls). Angiotensin converting enzyme levels are significantly depressed during the acute phase compared with convalescent ( P =0.004), recovered takotsubo cardiomyopathy ( P =0.02) or controls ( P =0.03). Angiotensin II is increased in patients with takotsubo cardiomyopathy ( P P =0.03 versus controls). Big endothelin‐1 levels are unchanged, but endothelin‐1 is significantly lower after takotsubo cardiomyopathy compared with controls ( P =0.03). Conclusions Despite “normalization” of the left ventricular ejection fraction, there is long‐term maladaptive activation of renin‐angiotensin system in patients with takotsubo cardiomyopathy. Registration URL: https://www.clinicaltrials.gov ; Unique identifiers: NCT02897739, NCT02989454.

Aims The risk of life‐threatening ventricular arrhythmias (LTVA) has been reported to be lower in Takotsubo syndrome (TS) compared with ST‐elevation myocardial infarction (STEMI). However, the extent to which these differences relate to the fact that most patients with TS are women (who have a lower risk of LTVA) and a relatively larger proportion of patients with STEMI are men is incompletely understood. We aimed to investigate the risk of LTVA or death in sex‐matched and age‐matched patients with TS, anterior STEMI, and non‐anterior STEMI. Methods and results We systematically reviewed the charts of all patients with TS who were treated at Sahlgrenska University Hospital (Gothenburg, Sweden) between 2008 and 2019. A total of 155 patients with confirmed TS (according to the European Society of Cardiology diagnostic criteria for TS) were sex‐matched and age‐matched 1:1:1 to patients with anterior and non‐anterior STEMI. Baseline characteristics and in‐hospital outcomes were recorded directly from the patient charts for all patients, and all admission electrocardiographs were analysed. The primary outcome was the composite of death or LTVA [defined as sustained ventricular tachycardia (>30 s) or ventricular fibrillation] within 72 h. The risk of LTVA or death within 72 h after admission was considerably lower in TS (2.6%) vs. anterior STEMI (14%; P = 0.002) and non‐anterior STEMI (9.0%; P = 0.02), despite similar or greater risks of acute heart failure, and similar risks of cardiogenic shock. Compared with STEMI, TS was associated with a lower risk of sustained and non‐sustained ventricular tachycardia and ventricular fibrillation. Conclusions In a predominantly female age‐matched and sex‐matched cohort of patients with TS, anterior STEMI, and non‐anterior STEMI, the adjusted risk of in‐hospital LTVA or death was considerably lower in TS compared with STEMI, despite similar or greater risk of acute heart failure and similar risk of cardiogenic shock.

A discinesia ou acinesia da câmara cardíaca ventricular esquerda de característica aguda e transitória, acometendo principalmente mulheres pós-menopausadas e/ou submetidas a estresse físico ou emocional e é conhecida como Síndrome de Takotsubo. Relata-se aqui o caso de uma mulher de 48 anos que sofreu queda em um poço de 12 metros de profundidade e nos primeiros dias de hospitalização, em eletrocardiograma, observou-se inversão de onda T, o ecocardiograma mostrou contratilidade segmentar alterada de ventrículo esquerdo, além de elevação dos níveis de marcadores cardíacos. No nono dia de internação, a paciente recebeu alta devido a melhora de seu quadro geral e a normalização da função cardíaca vista em ecocardiograma. A Síndrome do Balonamento Apical, como também é conhecida, mimetiza infarto agudo do miocárdio (IAM) e para descartar a presença de doenças coronarianas agudas, realizou-se cateterismo, que mostrou ausência de lesão obstrutiva coronariana.

Takotsubo cardiomyopathy (TC) is associated with significant short-term morbidity and mortality. Several risk factors for poor outcomes have been identified; however, the prognostic implications of pre-existing comorbidity in TC are poorly delineated. We sought to assess the association of aggregate pre-existing comorbidity with short-term outcomes in TC. We performed a retrospective observational study of adult subjects diagnosed with TC at two academic tertiary care hospitals between 2005 and 2018. Overall burden of medical comorbidity was estimated using the Charlson comorbidity index (CCI). Multivariable logistic regression was used to test for independent association of CCI with 30-day mortality and severe shock at index presentation. Multivariable poisson regression was performed to assess the association of CCI with duration of hospitalization. Five-hundred and thirty-eight subjects were diagnosed with TC during the study period. The median CCI score of all subjects was 2 (IQR 1-4). Among subjects with physical triggers of TC, the median CCI score was 2 (IQR 1-4) compared to a median CCI score of 1 (IQR 0-1) in subjects with non-physical triggers of TC (P

Background In patients suspected of acute coronary syndrome, but where the coronary angiography (CAG) has shown unobstructed coronary arteries differential diagnoses include spontaneous coronary artery dissection and takotsubo cardiomyopathy. This case report presents a patient with spontaneous coronary artery dissection but diagnostic signs suspicious of takotsubo cardiomyopathy. Which leads to a consideration of the co-existence of the diseases. Case summary A 57-year-old woman was acutely admitted to the emergency ward with sudden development of chest discomfort, palpitations, and dyspnoea. At hospitalization, the electrocardiography showed T-wave inversions in I, aVL, and V2, and Troponin I was elevated. Initial echocardiography revealed apical akinesia consistent with takotsubo cardiomyopathy. Initially, a diagnosis of acute coronary syndrome or takotsubo cardiomyopathy was suspected. The patient was further diagnostically assessed with CAG including optical coherence tomography which showed spontaneous coronary artery dissection in the left anterior descending artery. At follow-up 3 months later, CAG showed a fully healed coronary artery, and repeated echocardiography showed normalization of the left ventricular function. Discussion In this case report, initially, acute coronary syndrome was suspected due to electrocardiography with T-wave inversions and elevated cardiac biomarkers. Takotsubo cardiomyopathy was suspected when echocardiography showed apical ballooning, but CAG with optical coherence tomography revealed a spontaneous coronary artery dissection. Interestingly no severe obstructions of coronary arteries were seen, and follow-up echocardiography showed fully regained myocardial function. This leads to the debate as to whether this might be a case of co-existing spontaneous coronary artery dissection and takotsubo cardiomyopathy.

Background SARS-CoV-2 is known to induce a cytokine storm, a hyperinflammatory state driven by up-regulation of interleukin 6 (IL-6) and immunomodulatory chemokines that may result in acute heart failure. Case summary A 65-year-old woman with confirmed SARS-CoV-2 developed shock with multiorgan system failure, including acute biventricular heart failure, 2 weeks after the initial onset of fever, cough, and shortness of breath. The patient experienced myocardial recovery within 48 h after administration of tocilizumab, a humanized monoclonal anti-IL-6 receptor antibody, and multiple supportive vasoactive medications. Discussion The differential diagnosis of acute heart failure in critically ill patients with COVID-19 infection is broad, including sepsis-induced cardiomyopathy, Takotsubo syndrome, viral lymphocytic myocarditis, and acute coronary syndrome. Immunomodulatory treatment with tocilizumab may benefit patients who develop cardiogenic shock associated with SARS-CoV-2-induced cytokine storm.

Myocardial infarction (MI) is defined as myocardial cell death due to prolonged myocardial ischemia. Clinically, troponin rise and/or fall have become the "defining feature of MI" according to the universal definition of MI (UD-MI). Takotsubo syndrome (TS) and TS-related disease conditions also cause troponin elevation with typical rise and/or fall pattern but through a mechanism other than coronary ischemia. By strict application of the clinical diagnostic criteria for type-1 MI, type-2 MI, type-3 MI, and MI with non-obstructive coronary arteries according to the UD-MI including the fourth one published recently, TS and most of the 26 other causes of troponin elevation mentioned in the fourth UD-MI may erroneously be classified as MI. The existing evidence argues for the case that TS by itself is not a MI. Hyper-activation of the autonomic-sympathetic nervous system including local cardiac sympathetic hyper-activation and disruption with nor-epinephrine churn and spillover is the most probable cause of TS. This autonomic neuro-cardiogenic (ANCA) mechanism results in myocardial "cramp" (stunning), the severity and duration of which depend on the degree of the sympathetic-hyperactivation and nor-epinephrine spillover. The myocardial cramp may squeeze the cytosolic free troponin pools causing mild to moderate troponin elevation in TS and TS-related disease conditions. This ANCA syndrome, which has hitherto been enveloped by the UD-MI over more than one decade, may occur in acute, recurrent, and chronic forms. In this critical review, the controversies of UD-MI, evidence for ANCA syndrome, and a hypothetical mechanism for the troponin elevation in ANCA syndrome are provided.

Background:Conflicting results have been described in the scientific literature regarding the relationship between electrocardiographic parameters and complications in patients with Takotsubo syndrome (TTS). Aim of the present study was to investigate whether there is an association between markers of ventricular repolarization and major adverse cardiovascular events (MACE) during hospitalisation. Methods:A retrospective chart review was conducted on a sample of patients with diagnosis of TTS, based on the fulfilment of the revised Mayo Clinic criteria. MACE included acute heart failure, cardiogenic shock, sustained ventricular tachycardia, ventricular fibrillation, and death. The following parameters, assessed on the admission electrocardiogram, were analysed: ST-segment elevation, ST-segment depression, T wave inversion, presence of Q waves, QT interval, QT interval corrected for heart rate, QT-dispersion, Tpeak-Tend (Tpe) interval, Tpe dispersion, Tpe/QT ratio, and QTpeak/QT ratio. Results:Patients with MACE, compared to patients without MACE, showed more commonly anterior ST-segment elevation and had significantly higher values of Tpe/QT ratio. Low ejection fraction and Tpe/QT ratio > 0.27 identified a sub-population of patients more likely to have MACE during hospitalisation. Conclusions:Tpe/QT ratio represents a useful electrocardiographic parameter in the acute phase of TTS.

BACKGROUND: While takotsubo cardiomyopathy (TCM) was initially considered a benign disease, recent studies have demonstrated poor cardiovascular outcomes. It is important to determine the predictors of these outcomes for appropriate risk stratification and to decrease the overall disease burden. Physical stressors (e.g., acute neurologic disorder and lung disorder) and pre-existing heart failure have been associated with worse outcomes. Alcohol abuse has been associated with cardiomyopathy and may also exacerbate pre-existing heart conditions. AIM: We aimed to determine the impact of alcohol abuse on patients with TCM. METHODS: We identified 11,221 patients from the 2009 to 2012 National Inpatient Sample, of which 10,622 had TCM alone and 599 had TCM and alcohol use disorder (AUD). Our outcomes of interest were overall mortality, need for mechanical hemodynamic support (MHS), acute respiratory failure, sudden cardiac arrest, cardiogenic shock, stroke, and atrial fibrillation. All clinical characteristics were defined per the International Classification of Diseases 9th revision codes. Logistic regression was used to estimate the odds ratios of the outcomes in patients with concomitant TCM and AUD, compared to those with TCM without AUD while adjusting for confounders. RESULTS: The mean age of the sample was 60.5 ± 11 for TCM with AUD and 56.0 ± 11 for TCM alone. There was no significant difference between the two groups in the rates of atrial fibrillation (10.4% vs. 8,5%; p = 0.134), cardiogenic shock (5.9% vs. 4.8%; p = 0.3), use of MHS (2.6% vs. 1.7%; p = 0.165), overall in-hospital mortality (4.0% vs. 3.7%; p = 0.691), stroke (1.6% vs. 1.3%; p = 0.593), and sudden cardiac arrest (2.7% vs. 3.5%; p = 0.24). Rates of acute respiratory failure (17.7% vs. 25.2%; p < 0.0001) were significantly higher in patients with TCM with AUD compared to those with TCM alone. After adjusting for significant cofounders, the odds ratio for respiratory failure among patients with concomitant TCM and AUD was 1.36 (95% CI: 1.11–1.66) compared to those with TCM without AUD. CONCLUSION: Pre-existing AUD is associated with an increased risk for respiratory failure in a patient with TCM.

AimWhether Takotsubo syndrome (TTS) should be classified within myocardial infarction with non-obstructive coronary arteries (MINOCAs) is still controversial. The aim of this work was to evaluate the main differences between TTS and non-TTS MINOCAs.Methods and ResultsA cohort study based on two prospective registries: TTS from the RETAKO registry (N:1,015) and patients with non-TTS MINOCAs from contemporary records of acute myocardial infarction from five 5 national centers (N:1,080). Definitions and management recommended by the ESC were used. Survival analysis was based on the Cox regression analysis; propensity score matching (PS) was created to adjust prognostic variables. Takotsubo syndrome were more often women (85.9 vs. 51.9%; p < 0.001) and older (69.4 ± 12.5 vs. 64.5 ± 14.1 years; p < 0.001). Atrial fibrillation (AF) was more frequent in non-TTS MINOCAs (10.4 vs. 14.4%; p = 0.007). Psychiatric disorders were more prevalent in TTS (15.5 vs. 10.2%, p < 0.001). In-hospital mortality and complications were higher in TTS: 3.4 vs. 1.8%, (p = 0.015), and 25.8 vs. 11.5%, (p < 0.001). Global mortality before PS matching was 16.1% in non-TTS MINOCAs and 8.1% in TTS. Median follow-up was 32.4 months; after PS matching, TTS had fewer major adverse cardiovascular events (MACEs): hazard ratio (HR) 0.59; 95% CI 0.42–0.83. There were no differences in global mortality (HR 0.87; CI: 0.64–1.19), but TTS had lower cardiovascular mortality (HR 0.58; CI: 0.35–0.98).ConclusionCompared to the rest of MINOCAs, TTS presents a different patient profile and a more aggressive acute phase. However, its long-term cardiovascular prognosis is better. These results support that TTS should be considered a separate entity with unique characteristics and prognosis.

Introduction and objectives The coronavirus disease 2019 (COVID-19) spread quickly around the world. Although mainly a respiratory illness, there is growing interest in non-respiratory manifestations, particularly cardiovascular ones. At our center, mobilization of cardiologists with intensive care training was needed. Our aim is to describe patients with severe COVID-19 admitted to a Portuguese intensive care unit (ICU), the cardiovascular impact of the disease and the experience of cardiologists working in a COVID-19 ICU. Methods Data from adult patients with COVID-19 admitted to the ICU of Centro Hospitalar de Vila Nova de Gaia/Espinho between 16 March 2020 and 21 April 2020 were analyzed retrospectively. Results Thirty-five patients were admitted. Mean age was 62.6±6.0 years and 23 (65.7%) were male. Dyslipidemia was the most common cardiovascular risk factor (65.7%, n=23), followed by hypertension (57.1%, n=20). Mean ICU stay time was 15.9±10.0 days. Patients had high rates of mechanical ventilation (88.6%, n=31) and vasopressor support (88.6%, n=31). Low rates of new onset left systolic dysfunction were detected (8.5%, n=2). One patient required venoarterial extra-corporeal membrane oxygenation. Mortality was 25% (n=9). Acute myocardial injury and N-terminal pro-B-type natriuretic peptide (NT-proBNP) elevation was detected in 62.9% (n=22). Patients that died had higher NT-proBNP compared to those discharged alive (p

Takotsubo cardiomyopathy is a relatively common yet poorly understood entity that predominantly affects women. This report presents a case of a spinal cord bleeding that triggered an atypical variant of Takotsubo cardiomyopathy and led to cardiogenic shock. (Level of Difficulty: Intermediate.), Graphical abstract, Takotsubo cardiomyopathy is a relatively common yet poorly understood entity that predominantly affects women. This report presents a case of a spinal…

Takotsubo cardiomyopathy (TCM) is a recently emerging syndrome characterized by transient left ventricular wall motion abnormalities unexplained by obstructive coronary artery disease (CAD).1 Emotional or physical stress is usually illustrated in most cases, with catecholamine excess often playing a mechanistic role.1 We present a case of TCM induced by an unusual trigger: elective direct current (DC) cardioversion for atrial flutter (AF).

Takotsubo's syndrome (TTS) is a form of stress cardiomyopathy with a relatively benign long-term course, but may lead to arrhythmias and cardiogenic shock in the acute setting. Despite a recent rise in suspected stress-induced cardiomyopathy, the relationship between the novel coronavirus disease 19 (COVID-19) and TTS is not fully understood. Early recognition of TTS in these patients is important to guide management and treatment. We present 2 cases of TTS arising in the setting of COVID-19 with rapid progression to biventricular heart failure and cardiogenic shock., Highlights • COVID-19 has significant and potentially fatal extrapulmonary manifestations including Takotsubo's syndrome. • Patients with COVID-19 and Takotsubo's syndrome can present as rapid and fatal cardiogenic shock. • A high index of suspicion for cardiovascular involvement should be maintained when treating patients with COVID-19.

Author(s): Flanagan, Kevin; Dezman, Zachary; Dachroeden, Karl; Bontempo, Laura | Abstract: Introduction: Patients with traumatic injuries can be difficult to assess, and their evaluation often evolves in the emergency department (ED). We describe how an ED attending physician member developed a differential diagnosis for this presentation, arrived at a suspected diagnosis, and what test he proposed to prove his hypothesis.Case Presentation: This clinicopathological case presentation details the initial assessment and management of a 73-year-old female who presented to the ED following a motor vehicle collision precipitated by a syncopal episode.Conclusion: The final surprising diagnosis is then revealed.

Dear Editor, We read with much excitement in the article “Takotsubo syndrome and pheochromocytoma: an insidious combination” published by Maffé et al. in your esteemed journal...

Stress-induced cardiomyopathy (SIC) is associated with varying etiologies. We present a case of a 65-year-old female with recurrent SIC secondary to seizures who presented in cardiogenic shock requiring mechanical circulatory support using an Impella CP via the right axillary approach.

Background Takotsubo syndrome (TS) is defined as transient left ventricular dysfunction, which is often related to an emotional or physically stressful event. We describe a case of TS in a lady with pyruvate carboxylase deficiency (PCD). Pyruvate carboxylase deficiency is rare condition with the majority of those affected demonstrating signs of failure to thrive, recurrent seizures, and metabolic acidosis. To our knowledge, this is the first documented case of TS in an individual with PCD. Case summary This 28-year-old female presented to the emergency department after a tonic-clonic seizure. For 4 days prior to the presentation, she had been suffering from cough and pyrexia. On Day 2, she developed abdominal pain associated with tachycardia and hypotension, and an elevated troponin (791 ng/L). The echocardiogram showed a severely impaired left ventricular systolic function, regional wall motion abnormalities (RWMAs), and a visually estimated left ventricular ejection fraction of 25–30%. Eight days following admission her clinical state significantly improved, with a reduction troponin to 60 ng/L. A repeat echocardiogram on Day 9 showed complete resolution of cardiac function with no RWMAs. Following this, she was discharged from hospital the next day with a diagnosis of TS. Discussion This is the first case report of TS in a patient with PCD. In this case, multiple aetiologies of TS such as emotional and physical stress, seizures, and acute infection were considered. This case also highlights that TS should be an important differential diagnosis in patients presenting with cardiac symptoms.

Background Takotsubo cardiomyopathy is a variant of acute coronary syndrome with characteristic acute left ventricular apical ballooning. Uncommonly, there can be associated left ventricular outflow tract (LVOT) obstruction causing cardiogenic shock refractory to inotropic support. The use of afterload-reducing mechanical support such as intra-aortic balloon pump (IABP) counterpulsation is not routinely employed in instances of this kind. Case summary In our case report, we describe a 66-year-old female with acute Takotsubo cardiomyopathy and associated LVOT obstruction which failed to respond to high-dose dobutamine and whose clinical trajectory was worsened by fast atrial fibrillation with rapid ventricular response. Within 24 h of admission, the patient had an IABP placed which rapidly improved her haemodynamics. Two days later, IABP was removed and within 6 days of admission, apical ballooning and LVOT obstruction had fully recovered. Conclusion We recommend early use of mechanical support with IABP counterpulsation to expedite recovery in patients with acute Takotsubo cardiomyopathy with associated LVOT obstruction.

Aims It is well‐accepted that takotsubo syndrome (TS) is characterized by a massive surge of plasma catecholamines despite lack of solid evidence. The objective of this study was to examine the hypothesis of a massive catecholamine elevation in TS by studying plasma‐free catecholamine metabolites in patients participating in the Stockholm myocardial infarction (MI) with normal coronaries 2 (SMINC‐2) study where TS constituted more than one third of the patients. Methods and results The patients included in the SMINC‐2 study were classified, according to cardiac magnetic resonance (CMR) imaging findings (148 patients), which was performed at a median of 3 days after hospital admission. Plasma‐free catecholamine metabolites; metanephrine, normetanephrine, and methoxy‐tyramine were measured on day 2–4 after admission. Catecholamine metabolite levels were available in 125 patients. One hundred and ten (88%) of the 125 patients included in SMINC‐2 study, and 38 (86.4%) of the 44 patients with TS had completely normal plasma metanephrine and normetanephrine levels. All patients had normal plasma methoxy‐tyramine levels. Fourteen (11.2%) of the 125 patients included in SMINC‐2 study, and 5 (11.6%) of the 43 patients with TS had mild elevations (approximately 1.2 times the upper normal limits) of either plasma metanephrine or normetanephrine. One patient with pheochromocytoma‐triggered TS had marked elevation of plasma metanephrine and mild elevation of plasma normetanephrine. There were no significant differences between the number or degree of catecholamine metabolite elevations between the different groups of patients with CMR imaging diagnosis included in SMINC‐2 study. Conclusion There was no evidence of massive catecholamine elevations in the acute and subacute stages of TS apart from one patient with pheochromocytoma‐induced TS. Most of the TS patients had normal catecholamine metabolites indicating that blood‐borne catecholamines do not play a direct role in the pathogenesis of TS.

We present a case of Takotsubo (stress-induced) cardiomyopathy (TCM) in a healthcare worker that occurred during the COVID-19 pandemic. TCM, or broken-heart syndrome, has various presentations. This case sheds light on how stress due to the COVID-19 pandemic may cause cardiac illness in healthcare workers. LEARNING POINTS The various symptoms indicating Takotsubo cardiomyopathy are characterized and defined. Physicians should be aware that stress in healthcare workers may cause heart disease.

Background Myocardial infarction with non-obstructed coronary arteries (MINOCA) syndrome accounts for ∼6–8% of acute coronary syndrome presentations. Historically, MINOCA has been thought of as a benign condition, however, recent evidence suggests that some aetiologies of MINOCA such as cardiomyopathies are associated with significantly higher mortality than other causes such as myocarditis. Therefore, identifying the underlying cause of MINOCA is important in determining patient management and prognosis. Case summary We describe the case of a 58-year-old lady with an acute admission with MINOCA syndrome. Cardiac magnetic resonance (CMR) examination on Day 9 demonstrated hypertrophy of the apical segments of the left ventricle (LV), with diffuse mid-wall hyper-enhancement on late gadolinium enhancement (LGE) images. T2-weighted imaging was suggestive of active inflammation in the hypertrophied segments. A repeat CMR scan was performed 3 months later showed normalization of LV wall thickness, LGE and T2 values in the apical segments. Discussion This case report highlights the benefits of CMR with oedema-weighted imaging in the acute stages of MINOCA syndrome, as well as the importance of serial imaging in this patient cohort. While baseline imaging raised the possibility of apical hypertrophic cardiomyopathy, resolution of apical hypertrophy on follow-up CMR showed that the patient had acute myocarditis, specifically involving the apical segments.

Aims To investigate predictors of the occurrence of subacute ventricular arrhythmias (VAs), defined as any VAs presenting after 48 h from admission in patients with Takotsubo Syndrome (TTS), and to evaluate the related in-hospital mortality. Methods This is a retrospective single-center study enrolling patients admitted between 2012 and 2017 with TTS according to International Takotsubo diagnostic criteria. Data collection included ECG on admission and at 48 h, telemetry monitoring and transthoracic echocardiogram. Results We enrolled 93 patients; during in-hospital stay (mean 14 ± 16 days) subacute VAs occurred in 25% of patients (VAs group). Life-threatening VAs occurred in 6% of patients (3 sustained ventricular tachycardia, 1 torsade de pointes, 1 ventricular fibrillation) and not life-threatening VAs in 19% (6 non-sustained ventricular tachycardia and 12 premature ventricular contractions > 2000 in 24 h). Mortality was higher in the VAs than in the non-VAs group (P = 0.03), without differences in terms of life-threatening and not life-threatening subacute VAs (P = 0.65) and VAs on admission (P = 0.25). Logistic regression identified the following independent predictors of subacute VAs occurrence: VAs on admission {odds ratio [OR] 22.5 (3.9-131.8), P = 0.001]}, New York Heart Association (NYHA) class III-IV on admission [OR 6.7 (1.3- 34.0), P = 0.021] and QTc at 48 h [OR 1.01 (1.00-1.03), P = 0.046]. Conclusion TTS patients with VAs and NYHA class III-IV on admission and higher QTc at 48 h are at increased risk of subacute VAs occurrence, associated with higher in-hospital mortality. Awareness of this potential complication is critical for proper patients management.

Background Takotsubo cardiomyopathy (TTC) has been widely recognized in recent decades and is triggered by either physical or psychological stressors. Case presentation A 70-year-old woman presented to the Emergency Department due to confusion, hypotension, fever, chills, and cough. She had a one-year history of diabetes insipidus. Pituitary function examination at admission revealed decreased thyroid, sex and adrenal hormones. Pituitary MRI displayed findings suggestive of nonhemorrhagic pituitary apoplexy. Electrocardiogram (ECG) revealed T-wave inversion and extended QT interval. Transthoracic echocardiogram (TTE) showed left ventricular apical dysplasia and ballooning, accompanied by reduced left ventricular ejection fraction. Coronary angiography (CAG) revealed no obvious coronary arterial stenosis. The left ventriculogram demonstrated an octopus clathrate appearance. Most ECG and TTE changes recovered 10 days later. Conclusions To the best of our knowledge, this is the first report of newly diagnosed TTC associated with pituitary apoplexy.

Takotsubo cardiomyopathy is a reversible cardiomyopathy with a unique morphological feature of the left ventricle characterized by an apical ballooning appearance known for approximately known 25 years. Catecholamine drive plays an essential role in the pathogenesis and pathophysiology of Takotsubo cardiomyopathy; hence, it is also called stress cardiomyopathy. Physical stress could also have an impact and leads to a greater variety of characteristics in Takotsubo cardiomyopathy. Supportive and symptomatic medication remains the mainstay therapy with priority to improving the function of the left ventricle for several days and full recovery in 3-4 weeks. Due to its similarity with myocardial infarction, Takotsubo cardiomyopathy requires careful diagnosis and management for the best possible outcome.

The coronavirus disease-2019 (COVID-19) is a global pandemic caused by the novel severe acute respiratory-syndrome coronavirus-2 that is resulting in substantial morbidity and mortality across the globe ([1][1]). Emerging data suggest that patients presenting with COVID-19 requiring hospitalization

Aneurysmal subarachnoid hemorrhage is a life-threatening event that can cause permanent disability. This life-threatening event can be further complicated by subsequent cardiac and pulmonary disability. The presence of a neurogenic cardiomyopathy and pulmonary edema increases the morbidity and mortality of patients who suffer from aneurysmal subarachnoid hemorrhage. In this paper, we discuss a 39-year-old woman who presented to the emergency department (ED) with a chief complaint of a pounding headache with associated nausea and vomiting for the past three days. She had a past medical history significant only for migraines. During her stay in the ED, she began to exhibit signs of altered consciousness, hemoptysis, and respiratory compromise. Neuroimaging showed evidence of subarachnoid hemorrhage. The exact source of her subarachnoid hemorrhage could not be located with neuroimaging or angiography. Her clinical course was complicated by pulmonary edema and neurogenic stunned myocardium, and is still ongoing.

Key Clinical Message Takotsubo syndrome is classically characterized by apical ballooning and left ventricle akinesis associated with an underlying catecholamine surge. In patients with suspected Takotsubo syndrome, clinicians should be vigilant for acute coronary syndrome and arrhythmias. Ventricular standstill with underlying Takotsubo syndrome should be managed with a dual‐chambered pacemaker to improve patient outcome.

Takotsubo syndrome is a recently recognized acute cardiac disease entity with a clinical presentation resembling that of an acute coronary syndrome. The typical takotsubo syndrome patient has a unique circumferential left (bi-) ventricular contraction abnormality profile that extends beyond a coronary artery supply territory and appears to follow the anatomical cardiac sympathetic innervation. The syndrome predominantly affects postmenopausal women and is often preceded by emotional or physical stress. Patients with predisposing factors such as malignancy and other chronic comorbidities are more prone to suffer from takotsubo syndrome. The pathogenesis of takotsubo syndrome is elusive. Several pathophysiological mechanisms involving myocardial ischemia (multivessel coronary artery spasm, microvascular dysfunction, aborted myocardial infarction), left ventricular outlet tract obstruction, blood-borne catecholamine myocardial toxicity, epinephrine-induced switch in signal trafficking, and autonomic nervous system dysfunction have been proposed. The syndrome is usually reversible; nevertheless, during the acute stage, a substantial number of patients develop severe complications such as arrhythmias, heart failure including pulmonary edema and cardiogenic shock, thromboembolism, cardiac arrest, and rupture. Treatment of precipitating factors, predisposing diseases, and complications is fundamental during the acute stage of the disease. The epidemiology, pathogenesis, and management of takotsubo syndrome are reviewed in this paper.

BACKGROUND: The increased prevalence of psychiatric illness among patients with takotsubo cardiomyopathy (TC) has been previously described. OBJECTIVES: We sought to assess the effect of pre-existing psychiatric illness on clinical outcomes following the diagnosis of TC. METHODS: Adults diagnosed with TC at Vanderbilt University Medical Center between 1999 and 2015 were included in the study. Medical records were retrospectively reviewed to identify any pre-existing mood, anxiety, or schizophrenia-spectrum illness before TC presentation. Multivariable logistic regression was used to test for independent association of pre-existing psychiatric illness with 30-day mortality and recurrent TC; Cox proportional hazard analysis was used to evaluate for association with long-term mortality. RESULTS: Among 306 patients diagnosed with TC during the study period, 114 (37%) had a pre-existing psychiatric illness. In all, 43 (14%) and 88 (29%) patients died within 30 days of index diagnosis and as of last medical record review, respectively. Of the 269 who survived their index hospitalization, 19 (7%) had a confirmed recurrent episode of TC. In multivariable analyses, pre-existing psychiatric illness was not associated with increased 30-day (P = 0.320) or long-term (P = 0.621) mortality. Pre-existing psychiatric illness was associated with higher risk of recurrent TC (odds ratio = 7.44, 95% CI: 2.30–24.01, P < 0.001). CONCLUSIONS: Pre-existing psychiatric illness was associated with an increased risk of recurrent TC. No significant association was noted between pre-existing psychiatric illness and survival.

ResumenObjetivoIdentificar drogas de abuso, sustancias químicas o venenos de origen animal asociados a cardiopatía de takotsubo.MétodoRevisión estructurada en Pubmed/Medline, para la que se utilizaron los términos: Takotsubo cardiomyopathy, Tako-tsubo cardiomyopathy, stress cardiomyopathy, transient-left-ventricular ballooning syndrome, ampulla cardiomyopathy, apical ballooning syndrome, OR broken heart syndrome; together with “drugs abuse”, “chemistry substance.” “iatrogenic”, “drug-induced” OR “induced by”. Se seleccionaron artículos publicados entre el 01/01/1990 y 31/10/2015, en inglés, francés o español, con acceso a texto completo. Se incluyeron los artículos con reportes de drogas de abuso, sustancias químicas o venenos de origen animal, como posibles desencadenantes de la miocardiopatía. Adicionalmente, se incluyeron las referencias de los artículos seleccionados, valoradas como relevantes.ResultadoSe recuperaron 852 artículos diferentes y se seleccionaron 23, más 4 referencias relevantes, en las cuales se identificaron 38 casos de miocardiopatía de takotsubo, posiblemente asociados al uso o exposición a drogas de abuso, sustancias químicas o venenos de animales, especialmente, monóxido de carbono (n=13; 34,2%), cocaína o crack (n=5, 13,2%), abstinencia al alcohol (n=5; 13,2%), venenos de origen animal (n=5; 13,2%) y anfetaminas (n=4; 10,5%). En total se identificaron 14 sustancias diferentes como posibles desencadenantes de la miocardiopatía en mención.ConclusiónLa miocardiopatía de takotsubo podría ser desencadenada por el uso o la exposición a 14 drogas de abuso, sustancias químicas o venenos de origen animal, las cuales, en la mayoría de los casos, generan sobreestimulación simpática. Por ello se recomienda considerar este tipo de situación en pacientes que presenten este tipo de miocardiopatía, especialmente en quienes no se identifique un desencadenante físico o emocional.AbstractMotivationTo identify drugs of abuse, chemical substances or animal poisons associated to takotsubo cardiomyopathy.MethodsStructured review of Pubmed/Medline, where the following search terms were used: Takotsubo cardiomyopathy, Tako-tsubo cardiomyopathy, stress cardiomyopathy, transient-left-ventricular ballooning syndrome, ampulla cardiomyopathy, apical ballooning syndrome, OR broken heart syndrome; together with “drugs abuse”, “chemistry substance.” “iatrogenic”, “drug-induced” OR “induced by”. Articles in English, French or Spanish published between January 1st 1990 and October 31st 2015 and with access to the full text were selected. Articles reporting drugs of abuse, chemical substances or animal poisons as possible triggers of this cardiomyopathy were included. Additionally, references of those selected articles were included, valued as relevant.Results852 different articles were found, 23 were selected as well as 4 relevant references, where 38 takotsubo cardiomyopathy were identified, possibly associated to the use or exposure to drugs of abuse, chemical substances or animal poisons, especially carbon monoxide (n=13; 34.2%), cocaine or crack (n=5, 13.2%), alcohol withdrawal (n=5; 13.2%), animal poison (n=5; 13.2%) and amphetamines (n=4; 10.5%). Overall 14 different substances were identified as possible triggers of this cardiomyopathy.ConclusionTakotsubo cardiomyopathy could be triggered by the use or exposure to 14 drugs of abuse, chemical substances or animal poisons, which in most cases generate a sympathetic overstimulation. Thus it is recommended to consider this type of situation in patients presenting this kind of cardiomyopathy, especially in those where a physical or emotional trigger cannot be identified.

Graphical abstract, Highlights • McConnell's sign is not always demonstrated during a massive PE. • The pattern seen on echocardiography is another manifestation of right heart strain. • TAPSE and S′ were unable to assess systolic function of the right ventricle. • Similarities arise between this case and takotsubo syndrome of the right ventricle.

Thromboembolic events are a common complication in Takotsubo syndrome (TTS). However, their long-term incidence compared with acute coronary syndrome (ACS) is lacking. In-hospital and long-term incidence of thromboembolic events of 138 consecutive patients with TTS were compared with 138 sex- and age-matched patients with ACS. Predictors of events were analyzed. The incidence of thromboembolic events in TTS was 2-fold higher than ACS (21% vs 9%; P < .01) over a mean follow-up of 5 years. Although the left ventricular ejection fraction (LVEF) at event was significantly lower in TTS compared with ACS (38% [9%] vs 54% [11%]; P < .01), the follow-up LVEF was comparable. Patients with TTS suffering from thromboembolic events were more often treated with anticoagulation compared with ACS (44.8% vs 8.3%, P = .03). However, more patients presenting with ACS (100% vs 48.3%; P < .01) were discharged on aspirin. Only elevated C-reactive protein was a predictor of thromboembolic events using multivariate analysis (hazard ratio 1.1, 95% confidence interval, 1.0-1.2; P < .01). In conclusion, the risk of thromboembolic events in TTS was significantly higher than the risk of thromboembolic events in ACS over a mean follow-up of 5 years.

To determine the prevalence, clinical characteristics, in-hospital course and determinants of major adverse events in a cohort of Caucasian patients with Takotsubo syndrome (TTS) and right ventricular involvement (RVi), regardless of left ventricular variant forms.The study population consisted of 424 patients (mean age 69.1±11.5years; female 92.2%) with a diagnosis of TTS divided into two groups according to the presence or absence of RVi. RVi patients (n=57; 13.4%) showed a higher prevalence of comorbidities, especially respiratory diseases (p=0.011), and a higher Charlson comorbidity index (CCI; p=0.006) than non-RVi patients. In-hospital major adverse events (acute heart failure, cardiogenic shock and death) occurred more frequently in RVi patients (p0.001). Heart rate and CCI, along with the echocardiographic parameters of wall motion score index, E/e' ratio, tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (sPAP) were associated with adverse in-hospital outcome. At multivariate analysis, CCI (HR: 1.871; 95% CI: 1.202-2.912; p=0.006), sPAP (HR: 1.059; 95% CI: 1.016-1.104; p=0.007) and TAPSE (HR: 0.728; 95% CI: 0.619-0.855; p0.001) were independent correlates of the composite outcome in patients with RVi.Patients with RVi are characterized by distinct clinical profile and should undergo closely clinical and echocardiographic monitoring. The presence of echocardiographic signs of right ventricular failure along with substantial comorbidities burden identify a cohort at higher risk of in-hospital major adverse cardiovascular events.

Background Spontaneous coronary artery dissection (SCAD) is an under-recognized acute cardiac disease entity. It is often missed, or misdiagnosed as coronary spasm, coronary atherosclerotic lesion, or thrombotic coronary occlusion. During the last years, SCAD also has been reported to be ‘misdiagnosed as takotsubo syndrome (TS)’ in patients with features consistent with both conditions. Spontaneous coronary artery dissection may present as an acute coronary syndrome and sometimes as sudden cardiac death. Case summary We report on the case of a 67-year-old woman who presented with features of ST-elevation myocardial infarction treated with fibrinolysis. The patient showed to have obtuse-marginal SCAD, which was misdiagnosed as fibrinolysis caused lysis of a coronary thrombus. The patient had moreover all other features of TS. Discussion This case report teaches important information about SCAD. The association between SCAD and TS are discussed.

Takotsubo syndrome (TTS) is an acute cardiac condition independent of epicardial coronary obstruction that mimics acute coronary syndrome and is characterized by acute heart failure with reversible ventricular motion abnormalities. This consensus paper is the result of a multinational effort aiming to summarize the current state of the art on TTS. Experts in the field provide a thorough and detailed review of this syndrome. Several novel and unique sections are emphasized in this document, including the current state of the art on genetics of takotsubo syndrome, microRNAs (miRs), racial differences, role of cardiac spectroscopy and intracoronary imaging, as well as mechanical circulatory support. In part 1 of this two-part manuscript, we discuss how TTS came to be known, several patterns and forms it can take in patients, epidemiology and pathophysiology of the syndrome, and clinical presentation.

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Background Takotsubo cardiomyopathy (TC), also known as stress-induced cardiomyopathy, has been increasingly described in relation to psychiatric illness. Methods We performed a literature review to identify the key findings related to psychiatric illness in TC that may be relevant to the practice of mental health and other health care providers. Results The association of psychiatric illness with TC in addition to the spectrum of psychiatric illness found in TC, the role of exacerbation or treatment of psychiatric illness in triggering TC, different modes of presentation, prognostic implications, and long-term management of psychiatric illness in TC are discussed. Additionally, we review the limitations of the pre-existing literature and suggest areas of future research. Conclusions There is a strong association between pre-existing psychiatric illness, particularly anxiety and mood spectrum disorders, and TC. Acute exacerbation of psychiatric illness, rapid uptitration or overdose of certain psychotropic agents, and electroconvulsive therapy may trigger TC. Further studies are needed to better evaluate the prognostic significance and long-term management of psychiatric illness in TC.

Background and objectives: Takotsubo cardiomyopathy, also known as broken heart syndrome is a stress-induced cardiomyopathy, which can be interpreted as an acute coronary syndrome as it progresses with suggestive electrocardiographic changes. The purpose of this article is to show the importance of proper monitoring during surgery, as well as the presence of an interdisciplinary team to diagnose the syndrome. Case report: Male patient, 66 years old, with diagnosis of gastric carcinoma, scheduled for diagnostic laparoscopy and possible gastrectomy. In the intraoperative period during laparoscopy, the patient always remained hemodynamically stable, but after conversion to open surgery he presented with ST segment elevation in DII. ECG during surgery was performed and confirmed ST-segment elevation in the inferior wall. The cardiology team was contacted and indicated the emergency catheterization. As the surgery had not yet begun irreversible steps, we opted for the laparotomy closure, and the patient was immediately taken to the hemodynamic room where catheterization was performed showing no coronary injury. The patient was taken to the hospital room where an echocardiogram was performed and showed slight to moderate systolic dysfunction, with akinesia of the mid-apical segments, suggestive of apical ballooning of the left ventricle. Faced with such echocardiographic finding and in the absence of coronary injury, the patient was diagnosed with intraoperative Takotsubo syndrome. Conclusion: Because the patient was properly monitored, the early detection of ST-segment elevation was possible. The presence of an interdisciplinary team favored the syndrome early diagnosis, so the patient was again submitted to safely intervention, with the necessary security measures taken for an uneventful new surgical intervention. Resumo: Justificativa e objetivos: A cardiomiopatia de takotsubo, também conhecida como síndrome do coração partido, é uma cardiomiopatia induzida por estresse que pode ser interpretada como uma síndrome coronária aguda, pois cursa com alterações eletrocardiográficas sugestivas. O objetivo do presente artigo é mostrar a importância de uma monitoração adequada no intraoperatório, assim como a presença de uma equipe interdisciplinar para o diagnóstico da síndrome. Relato de caso: Doente masculino, 66 anos, com o diagnóstico de carcinoma gástrico, proposto para laparoscopia diagnóstica e possível gastrectomia. No intraoperatório durante a laparoscopia manteve sempre estabilidade hemodinâmica, porém após a conversão para cirurgia aberta apresentou elevação do segmento ST em DII e foi feito um ECG no intraoperatório que confirmou supradesnivelamento do segmento ST em parede inferior. Foi contactada a equipe de cardiologia, que indicou cateterismo de urgência. Como a cirurgia ainda não havia iniciado passos irreversíveis, optou-se pelo encerramento da laparotomia e o doente foi levado imediatamente para a sala de hemodinâmica. Foi feito cateterismo que não evidenciou lesão nas coronárias. O doente foi levado para o internamento, onde foi feito um ecocardiograma que mostrava disfunção sistólica ligeira a moderada, com acinésia dos segmentos médio-apicais, imagem sugestiva de balonamento apical do ventrículo esquerdo. Diante de tal achado ecocardiográfico e na ausência de lesões coronárias, foi diagnosticada síndrome de takotsubo intraoperatória. Conclusão: Devido ao fato de o doente estar monitorado de uma forma adequada foi possível a detecção precoce do supradesnivelamento do segmento ST. A presença de uma equipe interdisciplinar favoreceu o diagnóstico precoce da síndrome. Dessa forma o doente foi novamente intervencionado de forma segura e foram tomadas as devidas medidas de segurança, para que a nova intervenção cirúrgica transcorresse sem intercorrências. Keywords: Takotsubo, Acute coronary syndrome, General anesthesia, Angina, Acute myocardial infarction, Cardiogenic shock, Palavras-chave: Takotsubo, Síndrome coronária aguda, Anestesia geral, Angina, Infarto agudo do miocárdio, Choque cardiogênico

ResumoJustificativa e objetivosA cardiomiopatia de takotsubo, também conhecida como síndrome do coração partido, é uma cardiomiopatia induzida por estresse que pode ser interpretada como uma síndrome coronária aguda, pois cursa com alterações eletrocardiográficas sugestivas. O objetivo do presente artigo é mostrar a importância de uma monitoração adequada no intraoperatório, assim como a presença de uma equipe interdisciplinar para o diagnóstico da síndrome.Relato de casoDoente masculino, 66 anos, com o diagnóstico de carcinoma gástrico, proposto para laparoscopia diagnóstica e possível gastrectomia. No intraoperatório durante a laparoscopia manteve sempre estabilidade hemodinâmica, porém após a conversão para cirurgia aberta apresentou elevação do segmento ST em DII e foi feito um ECG no intraoperatório que confirmou supradesnivelamento do segmento ST em parede inferior. Foi contactada a equipe de cardiologia, que indicou cateterismo de urgência. Como a cirurgia ainda não havia iniciado passos irreversíveis, optou‐se pelo encerramento da laparotomia e o doente foi levado imediatamente para a sala de hemodinâmica. Foi feito cateterismo que não evidenciou lesão nas coronárias. O doente foi levado para o internamento, onde foi feito um ecocardiograma que mostrava disfunção sistólica ligeira a moderada, com acinésia dos segmentos médio‐apicais, imagem sugestiva de balonamento apical do ventrículo esquerdo. Diante de tal achado ecocardiográfico e na ausência de lesões coronárias, foi diagnosticada síndrome de takotsubo intraoperatória.ConclusãoDevido ao fato de o doente estar monitorado de uma forma adequada foi possível a detecção precoce do supradesnivelamento do segmento ST. A presença de uma equipe interdisciplinar favoreceu o diagnóstico precoce da síndrome. Dessa forma o doente foi novamente intervencionado de forma segura e foram tomadas as devidas medidas de segurança, para que a nova intervenção cirúrgica transcorresse sem intercorrências.AbstractBackground and objectivesTakotsubo cardiomyopathy, also known as broken heart syndrome is a stress‐induced cardiomyopathy, which can be interpreted as an acute coronary syndrome as it progresses with suggestive electrocardiographic changes. The purpose of this article is to show the importance of proper monitoring during surgery, as well as the presence of an interdisciplinary team to diagnose the syndrome.Case reportMale patient, 66 years old, with diagnosis of gastric carcinoma, scheduled for diagnostic laparoscopy and possible gastrectomy. In the intraoperative period during laparoscopy, the patient always remained hemodynamically stable, but after conversion to open surgery he presented with ST segment elevation in DII. ECG during surgery was performed and confirmed ST‐segment elevation in the inferior wall. The cardiology team was contacted and indicated the emergency catheterization. As the surgery had not yet begun irreversible steps, we opted for the laparotomy closure, and the patient was immediately taken to the hemodynamic room where catheterization was performed showing no coronary injury. The patient was taken to the hospital room where an echocardiogram was performed and showed slight to moderate systolic dysfunction, with akinesia of the mid‐apical segments, suggestive of apical ballooning of the left ventricle. Faced with such echocardiographic finding and in the absence of coronary injury, the patient was diagnosed with intraoperative Takotsubo syndrome.ConclusionBecause the patient was properly monitored, the early detection of ST‐segment elevation was possible. The presence of an interdisciplinary team favored the syndrome early diagnosis, so the patient was again submitted to safely intervention, with the necessary security measures taken for an uneventful new surgical intervention.

Background: In spite of being a major stress factor, acute coronary syndrome (ACS) is still regarded as an exclusion criterion for takotsubo syndrome (TS). The aim of the study is to find out an association between ACS, post-ischemic myocardial stunning (PIMS) and TS. Methods: A series of twenty patients with ACS having an acute coronary culprit lesion on coronary angiography and signs of left ventricular dysfunction, which extended beyond the supply region of the diseased coronary artery were studied. Results: Thirteen (65%) out of the 20 patients were women. Ages ranged from 37 to 85 years old. All patients had signs consistent with PIMS. The extent of the stunned myocardium in all patients went beyond the supply region of the diseased coronary artery. The left ventricular myocardial stunning had also a peculiar ballooning appearance during systole, a clinical picture and course also consistent with TS. In all patients, there was no evidence of any emotional or physical stress factor apart from the ACS event. Conclusions: PIMS induced by ACS had typical feature of TS suggesting that PIMS and TS may be two (among other) different names for the same acute cardiac clinical condition. ACS may trigger rather than exclude TS

Stress-induced cardiomyopathy or takotsubo syndrome is a transient cardiac dysfunction which is precipitated by intense emotional or physical stress. It mimics acute coronary syndrome clinically (chest pain and dyspnea) and has specific echocardiographic findings in the absence of significant coronary stenosis. The underlying pathophysiologic mechanism is mostly due to stress-induced catecholamine release. This syndrome is more commonly seen in females especially in the postmenopausal period. The prognosis of stress-induced cardiomyopathy is usually favorable with a prevalence of in-hospital mortality of less than 2%. Reports of a single episode of stress-induced cardiomyopathy are common in the literature, but recurrence of stress-induced cardiomyopathy is rare. Herein, we present an uncommon case of recurrent stress-induced cardiomyopathy in order to provide an explanation of the pathophysiology of this unique syndrome.

Supplemental Digital Content is available in the text., Background: Takotsubo cardiomyopathy is an increasingly recognized acute heart failure syndrome precipitated by intense emotional stress. Although there is an apparent rapid and spontaneous recovery of left ventricular ejection fraction, the long-term clinical and functional consequences of takotsubo cardiomyopathy are ill-defined. Methods: In an observational case-control study, we recruited 37 patients with prior (>12-month) takotsubo cardiomyopathy, and 37 age-, sex-, and comorbidity-matched control subjects. Patients completed the Minnesota Living with Heart Failure Questionnaire. All participants underwent detailed clinical phenotypic characterization, including serum biomarker analysis, cardiopulmonary exercise testing, echocardiography, and cardiac magnetic resonance including cardiac 31P-spectroscopy. Results: Participants were predominantly middle-age (64±11 years) women (97%). Although takotsubo cardiomyopathy occurred 20 (range 13–39) months before the study, the majority (88%) of patients had persisting symptoms compatible with heart failure (median of 13 [range 0–76] in the Minnesota Living with Heart Failure Questionnaire) and cardiac limitation on exercise testing (reduced peak oxygen consumption, 24±1.3 versus 31±1.3 mL/kg/min, P