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Background: Extensive myocardial edema is a key feature of acute takotsubo syndrome (TTS) and it can be quantitatively assessed by T2 mapping cardiac magnetic resonance (CMR) imaging. Clinical correlates of myocardial edema in TTS are not well characterized., Methods: Sixty patients with acute TTS underwent CMR with T2 mapping within one week of hospitalization. Disease severity was assessed by a validated risk score (GEIST-score)., Results: Mean age of the study population was 71 ± 12 years (92 % females). Mean mid-septal T2 time was 58 ± 6 ms. Higher T2 mapping values were found in patients with left ventricular ejection fraction (LVEF) ≤40 % (60 ± 6 ms vs 56 ± 5 ms; p = 0.006), male sex (66 ± 7 ms vs 58 ± 6 ms; p = 0.010), dyspnea on admission (63 ± 7 ms vs 58 ± 6 ms; p = 0.006), absence of an emotional trigger (60 ± 7 ms vs 57 ± 5 ms; p = 0.039), intermediate-to-severe GEIST-score (63 ± 7 ms vs 58 ± 6 ms; p = 0.045) and in-hospital complications (61 ± 1 ms vs 58 ± 6 ms; p = 0.009). A trend towards higher values was observed in patients who died at follow-up (62 ± 8 ms vs 58 ± 6 ms; p = 0.098). On linear regression analysis, T2 mapping did not correlate with the timing of CMR (Beta -0.182, p = 0.170), whereas after multivariable correction, lack of emotional trigger (Beta 0.262, p = 0.031), decreasing LVEF (Beta -0.254, p = 0.024) and increasing GEIST score (Beta 0.282, p = 0.024) remained independently associated with T2 mapping., Conclusions: In patients with acute TTS undergoing a timely CMR within the first week after admission, T2 mapping was not affected by timing of the examination, was higher in patients displaying high-risk features, and independently associated with the GEIST risk score., Competing Interests: Declaration of competing interest None declared., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Reverse takotsubo cardiomyopathy is a rare variant of a rare disease characterized by basal ballooning and dysfunction of the left ventricle. While it can render patients profoundly unwell and reliant on intensivist care, it is a transient phenomenon, with the worst symptoms subsiding after 2-3 days. At term, a young woman spontaneously entered labor prior to a planned repeat cesarean section. After experiencing physical and psychological distress during labor and a vacuum extraction, she developed cardiogenic shock from reverse takotsubo cardiomyopathy, quickly diagnosed with transthoracic echocardiogram. She required 2 days of intensive care support and made an excellent recovery. This very rare condition should be considered in systemically unwell women in the peripartum as it can be quickly diagnosed, providing patients with the best appropriate care., (© 2024 International Federation of Gynecology and Obstetrics.)

Background: Sex-related differences in Takotsubo syndrome have been described, but no information is available in patients who develop cardiogenic shock., Methods and Results: Of 412 patients with Takotsubo syndrome with cardiogenic shock, 71 (17.2%) were men. Male patients were older (71.1±12.2 versus 65.3±17.1 years, P <0.001), more frequently smokers (47 [66.2%] versus 66 [19.4%], P <0.01), with higher prevalence of neoplasms (6 [8.5%] versus 8 [2.3%], P =0.01), lower left ventricular ejection fraction (31% versus 37%, P <0.001), more frequent invasive mechanical ventilation (30 [42.3%] versus 90 [26.4%], P =<0.01), higher rate of infections (43 [60.6%] versus 148 [43.4%], P =<0.01), and longer in-hospital stay (19±20 days versus 13±15 days, P =0.02). A total of 55 patients (13.3%) died during hospital admission, and 90 patients (21.8%) died at the end of the 5-year follow-up. Male sex was not significantly associated with the in-hospital (odds ratio, 1.31 [95% CI, 0.64-2.68]) or 5-year mortality rate (hazard ratio, 1.66 [95% CI, 0.93-2.94]). In the matched cohort, no significant differences in the short- and long-term mortality rate were found either., Conclusions: Cardiogenic shock due to Takotsubo syndrome has high short- and long-term mortality rates that are similar in men and women.

Takotsubo cardiomyopathy (TTC) is a rare condition associated with transient akinesia of apical segments and hyperkinesia of basal segments of the heart. Although several mechanisms have been proposed to cause direct and indirect myocardial damage owing to catecholamine excess, the underlying pathophysiology remains unknown. An 18-year-old female was referred to our otorhinolaryngology outpatient clinic for a septorhinoplasty. Apart from the fear of surgery, the patient had no other health issues. After the administration of local anesthesia (lidocaine and epinephrine mix), tachycardia storms occurred and soon ended with cardiac collapse. Further evaluation revealed TTC. TTC should be considered, especially in cases of treatment-resistant hemodynamic problems after cardiac resuscitation, and nurses can play a crucial role during the preanesthetic period in helping the patient cope with the stress factors related to the upcoming surgery., Competing Interests: Declaration of Competing Interest None to report., (Copyright © 2024 The American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.)

Takotsubo syndrome (TS) is a temporary form of left ventricular (LV) dysfunction characterized by a distinct pattern of LV impairment, often triggered by a physical or emotional stressful event. Historically, TS was considered a benign condition due to its prompt restoration of myocardial function and generally excellent outcomes. However, recent studies have shown that complications similar to those seen after myocardial infarction can occur, necessitating careful monitoring of these patients. Among noninvasive imaging techniques, cardiovascular magnetic resonance (CMR) is becoming increasingly important in evaluating patients with TS. CMR offers a unique ability to noninvasively assess myocardial tissue characteristics, allowing for detecting the typical features of TS, such as specific wall motion abnormalities and myocardial edema. Beyond its well-established diagnostic utility in the clinical management of TS, CMR has also proven valuable in prognosis and risk stratification for these patients. Advances in CMR, including myocardial strain and parametric mapping have expanded its role in the diagnosis, prognosis, and follow-up of these patients. This review aims to provide a comprehensive overview of the potential applications of CMR in the diagnostic and prognostic evaluation of TS patients. It explores the emerging use of novel CMR imaging biomarkers that may enhance diagnosis, improve prognostic accuracy, and contribute to the overall management of these patients., (© 2024 Wiley Periodicals LLC.)

Background: Differentiating Takotsubo cardiomyopathy (TTC) from acute coronary syndrome involving the left anterior descending coronary artery (LAD-ACS) is difficult due to left ventricular apical wall motion abnormality pattern in both and typically requires an invasive coronary angiography (ICA) study for diagnostic confirmation., Objectives: To identify differences in the regional wall motion abnormality (RWMA) pattern using a comprehensive comparative analysis of the transthoracic echocardiographic (TTE) findings in patients with TTC versus LAD-ACS., Methods: This was a retrospective, randomized, blinded comparison study including a derivation cohort of 105 patients with TTC (N=52) or LAD-ACS (N=53) with concomitant TTE and ICA identified from our institutional database. A comprehensive echocardiographic wall motion analysis was performed (unblinded) to search for subtle differences in RWMA patterns by marking the exact locations of the end-systolic hinge points (HP) - defined as the intersection between the normal and abnormal regional myocardial thickening - in all apical views. The HP location relative to mitral annulus in each apical view was compared for symmetry and the apical 2-chamber (A2C) view was identified as having the most consistent, quantitative difference between TTC and LAD-ACS. This A2C quantitative model was then prospectively studied in a randomized, blinded, validation cohort of 30 subjects with either TTC or LAD-ACS by eight echocardiographic readers with all levels of clinical experience., Results: In the unblinded derivation cohort, the A2C view showed that the ratio (1.02) and the absolute distance between the anterior HP (3.57 cm) and the inferior HP (3.53 cm) in TTC was significantly different than the ratio (0.761) and the absolute differences between the AHP (4.5 cm) and the IHP (5.93 cm) in LAD-ACS. An AHP: IHP of 0.96 for men and 0.84 for women was able to correctly categorize 84.8% of male and 91.7% of female patients. When applied to the validation cohort, the model showed fairly accurate results with a 74% prediction rate in diagnosing TTC in female patients., Conclusion: We propose a relatively simple 2-D TTE diagnostic tool emphasizing subtle differences in the RWMA pattern in the A2C view alone as a semi-quantitative imaging parameter to help differentiate TTC from LAD-ACS., Competing Interests: Declaration of competing interest There are no conflicts of interest to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Takotsubo Syndrome (TS) is a heart disease caused by extreme exposure of the body to physical or psychological stress. In the context of COVID-19, the virus can be a significant source of stress, with particular attention being paid to the cytokine storm as a cause of damage to the body. New research shows that the production of specific cytokines is linked to the activation of immune checkpoint proteins such as PD-1, PD-L1, and CTLA-4 on T cells. Although initially beneficial in combating infections, it can suppress defense and aid in disease progression. Therefore, checkpoint inhibitor therapy has been highlighted beyond oncological therapies, given its effectiveness in strengthening the immune system. However, this treatment can lead to excessive immune responses, inflammation, and stress on the heart, which can cause Takotsubo Syndrome in patients. Several studies investigate the direct link between this therapy and cardiac injuries in these patients, which can trigger TS. From this perspective, we must delve deeper into this treatment and consider its effects on the prognosis against SARS-CoV-2 infection., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Paroxysmal sympathetic hyperactivity (PSH) is a relatively common syndrome typically observed following traumatic brain injury (TBI). It manifests through a combination of non-specific symptoms that collectively define its presentation. Linked to sympathetic hyperactivity, takotsubo syndrome is a cardiomyopathy marked by left ventricular dysfunction and may coincide with PSH. While various factors can lead to the simultaneous occurrence of these syndromes, a notably rare scenario involves their manifestation after brain tumor removal. The nonspecific nature of PSH symptoms and of the cardiac dysfunction in takotsubo syndrome pose challenges in accurately diagnosing these conditions in an intensive care unit (ICU) setting. They often overlap with more prevalent diagnoses like sepsis, pulmonary embolism, and acute heart failure. Thus, it is crucial for clinicians dealing with these patients to be aware that symptoms indicating sympathetic activity surge and left heart failure might prompt consideration of takotsubo syndrome and PSH. This study presents the case of an 8-year-old girl who developed takotsubo syndrome associated with sympathetic hyperactivity following the surgical removal of a bulbar tumor. To the best of our knowledge, this is the tenth case of PSH following brain tumor removal in a pediatric patient and the first reported case of occurrence of takotsubo linked to PSH after brain tumor removal. We offer a detailed account of the patient's clinical journey in the ICU, accompanied by a comprehensive review of relevant literature to identify similar cases. The significance of this case study lies in emphasizing the potential occurrence of takotsubo syndrome due to PSH and underscores the importance of early diagnosis and management due to their association with unfavorable clinical outcomes., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Takotsubo syndrome (TS) is characterized by transient myocardial dysfunction with outcomes ranging from favorable to life-threatening. Cardiovascular magnetic resonance (CMR) has emerged as an essential tool in its diagnosis and management and is consistently recommended by current guidelines in the diagnostic work-up. However, the prognostic value of CMR in patients with TS remains undetermined. The aim of this study was to assess the prognostic value of CMR in managing patients with TS., Method: PubMed, MEDLINE via Ovid, Scopus, and the Cochrane Library were searched to identify studies reporting the prognostic role of multiparameteric CMR in patients with TS with a follow-up ≥ 12 months. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE), defined as all-cause mortality, cardiac death, heart failure, sudden cardiac death, recurrence of TS, and cerebrovascular events., Results: Five studies with 564 patients were included for reporting correlation of CMR parameters with MACCE. Primary endpoint occurred in 69 (12%) patients. Among the CMR parameters assessed, myocardial strain parameters (including measurements of the left atrium, left and right ventricle), right ventricle involvement, and a CMR-based radiomics model demonstrated correlations with MACCE. Additionally, one study showed the predictive ability of a CMR score., Conclusion: The current systematic review suggests that CMR may offer prognostic insights in TS patients, underscoring its potential clinical utility for integration into clinical practice. However, scarce data are currently available; hence, further research is needed., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

A 45-years old woman presented for dyspnea and cardiac chest pain. ECG showed deep T-wave inversion while CMR showed normal ejection fraction, hypertrophy and systolic obliteration of the apex suggesting apical HCM. Myocardial oedema was noted at the apex. Complete regression of hypertrophy and myocardial edema was observed after 2 months, and a final diagnosis of subacute Takotsubo was made., (© 2024. The Author(s).)

Since the first description of takotsubo syndrome 30 years ago, only a little is known on the underlying physiopathology leading to peculiar left ventricular function alteration and myocardial damage related to acute emotional or physical stress. In the present case, we used continuous invasive thermodilution to evaluate coronary microvascular function at the acute phase of takotsubo and after recovery. The acute phase of takotsubo was characterized by a reduced coronary output and altered reserved flow with persistently high resistance during hyperaemia. At 6 weeks, we described a complete recovery of microvascular function, concomitant to LVEF recovery., Competing Interests: Disclosure of interest Dr M. Zeitouni has research grants or honorariums from Bayer, BMS Pfizer, la Fédération Française de Cardiologie, Servier, Amgen, AstraZeneca, NovoNordisk. Pr Collet has research grants or honorariums from AstraZeneca, Boston Scientific, Bristol-Myers Squibb, COR2ED, Lead-Up, Medtronic, WebMD. The authors have nothing to disclose., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Takotsubo cardiomyopathy or stress cardiomyopathy (SCM), was first described in 1990 and initially, it was thought to be only associated with short-term complications and mortality with a benign long-term prognosis comparable to a healthy population. However recent investigations have proven otherwise and have shown SCM patients might have comparable long-term morbidity and mortality to ST-elevation myocardial infarction (STEMI) patients. Many emotional, or physical stressors can trigger SCM, and have been able to describe an interplay of neurohormonal and inflammatory mechanisms as the pathophysiology of this disease. Additionally, given the significantly higher prevalence of SCM in post-menopausal women, estrogen levels have been thought to play a role in the pathogenesis of this disease. Furthermore, there is an elusive disparity in prognosis depending upon different triggers. Currently, many questions remain unanswered regarding the long-term management of these patients to reduce morbidity, mortality, and improve quality of life, such as the need for long-term anticoagulation. In this paper, we review the findings of most recent published investigations regarding etiologies, pathophysiology, diagnostic criteria, prognosis, short-term and in more detail, long-term complications of SCM. Finally, we will discuss what future research is needed to learn more about this disease to improve the long-term prognosis, even though as of now, data for long-term management is still lacking., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Ketamine is a dissociative anesthetic with N-methyl-d-aspartate and glutamate receptor antagonist properties. It has been the most popular agent to facilitate emergency department procedures for three decades. Considered a safe and effective option for procedural sedation, ketamine has rapid onset, short effective sedation time, and a low risk profile. Ketamine's sympathomimetic effects could theoretically induce stress-related cardiac dysfunction, including cardiomyopathy. A review of the literature demonstrates one prior report of stress (Takotsubo) cardiomyopathy after ketamine sedation., Case Report: In this case report, we present a case of Takotsubo cardiomyopathy after ketamine sedation for distal radius fracture reduction. The patient presented hemodynamically normal with an unremarkable cardiac ultrasound and progressed to hypoxia from bilateral pulmonary edema, eventually requiring intubation. Inpatient evaluation revealed elevated high sensitivity troponin, non-obstructive coronary arteries on catheterization, and echocardiogram findings of Takotsubo cardiomyopathy. She received operative fixation of her radius fracture by orthopedics and was discharged home on hospital day 9. She had an unremarkable follow up with cardiology but had no echocardiogram to determine full resolution., Conclusion: Although ketamine has robust evidence of safety and efficacy, physicians should be aware of the potential complications of its sympathomimetic effects, from hypertension and tachycardia to overt Takotsubo cardiomyopathy., Competing Interests: Declaration of competing interest The authors have no declarations or statements of interest and this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Takotsubo syndrome is a state of an acute heart failure featuring reversible left ventricular dysfunction. In recent years, the incidence of Takotsubo syndrome has risen 8-fold. In this case series and literature review, we present the rare presentations or complications of Takotsubo syndrome and highlight diagnostic or management strategies. We aim to raise the awareness on the pathologic spectrum of takotsubo syndrome for the clinicians encountering this challenging diagnosis., Competing Interests: Declaration of competing interest The authors declare they have no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Stress cardiomyopathy develops after abrupt sympathetic stimulation, likely from catecholamine-induced myocardial toxicity. The evolution of myocardial strain during and after an episode have not been previously characterized. We aimed to determine whether preexisting contractile abnormalities may explain the observed regional dysfunction during an acute episode and to investigate the persistence of strain abnormalities after clinical recovery. We identified patients who were diagnosed with stress cardiomyopathy and had an echocardiogram performed before their episode, during their episode, and within 1 year after. The diagnosis was confirmed based on the absence of obstructive coronary lesions. Left ventricular (LV) longitudinal strain was calculated using speckle-tracking software and compared between baseline, episode, and follow-up echocardiograms. The LV strain analysis was performed on 23 patients. The LV ejection fraction was 64 ± 8.7% at baseline, 45 ± 12% during the episode, and 5 9 ± 10% after a median follow-up of 46 days. The LV global longitudinal strain was 24 ± 4.7% at baseline, 11 ± 4.9% during the episode, and 19 ± 4.6% after the follow-up. The mean ejection fraction (p <0.01) and global longitudinal strain (p <0.001) remained below baseline levels at follow-up. Longitudinal strain was reduced (<18%) in 80 ± 23% of myocardial segments during an episode and 41 ± 21% of myocardial segments at follow-up. During the acute episode, 35 ± 6% of the abnormal segments were in the base, outside of the region of ballooning. Our findings suggests that stress cardiomyopathy is associated with global rather than regional myocardial injury and that contractile abnormalities persist after clinical improvement. These findings challenge our previous understanding of stress cardiomyopathy and may guide future pathophysiologic understanding of this complex disease., Competing Interests: Declaration of Competing Interest The authors have no competing interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Takotsubo syndrome, was described in Japan in 1990, it is a stress cardiomyopathy, predominantly in women, usually postmenopausal. Cardiac hypokinesia occurs, with involvement of multiple coronary territories. In intensive care unit (ICU), it is considered underdiagnosed. Manifestations of severe dengue fever include cardiovascular involvement, mainly arrhythmias and systolic dysfunction. A case of a 72-year-old man is presented, who was hospitalized in ICU for dengue fever, with plateletopenia (15000 cells/mm3) and dehydration. After fluid management the patient reported respiratory discomfort, auscultating crackling rales. A pulmonary ultrasound was made where bilateral B lines were found with B7 pattern compatible with interstitial syndrome and pulmonary edema. Basal hyperkinesia, medial and apical hypokinesia with an image consistent with apical ballooning were observed in the transthoracic echocardiogram. The electrocardiogram showed complete right bundle branch block. Chagas serology was negative and quantitative troponin I was increased. In the context of severe dengue, a Takotsubo syndrome was diagnosed. The patient evolved favorably. After discharge, a normalization of the cardiac function was stated in ultrasound images. The case is of clinical importance due to the low association of these two diseases and the need to screen for cardiac involvement in severe dengue.

Objectives: Cardiogenic shock (CS) can occur in patients with Takotsubo syndrome (TTS). As TTS has received increasing attention and has been more closely researched, several aspects of the pathogenesis have been identified, particularly that an excessive release of catecholamines plays an important role. Nevertheless, evidence on specific therapy concepts is still lacking. As a result, TTS with severe hemodynamic instability and low cardiac output creates unique challenges, and mechanical circulatory support is needed with as few inotropic drugs as possible., Methods: We present a 77-year-old female patient who underwent minimally invasive surgical mitral valve replacement. After an uneventful course, the patient developed acute heart failure eleven days after surgery. Transthoracic echocardiography (TTE) revealed a new onset of TTS. The patient needed left ventricular venting and full haemodynamic flow. We successfully implanted a microaxial left ventricular assist device (Impella 5.5) using the transaxillary approach. The haemodynamic situation stabilised immediately. The patient was weaned and the Impella 5.5 was explanted after five days., Conclusion: We present the first-in-man implantation of a transaxillary Impella 5.5 in a patient with TTS. The patient benefitted from Impella 5.5 therapy with full haemodynamic support and venting of the left ventricle., (© 2023. The Author(s).)

Currently, there are 2 proposed causes of acute left ventricular ballooning. The first is the most cited hypothesis that ballooning is caused by direct catecholamine toxicity on cardiomyocytes or by microvascular ischemia. We refer to this pathogenesis as Takotsubo syndrome. More recently, a second cause has emerged: that in some patients with underlying hypertrophic cardiomyopathy, left ventricular ballooning is caused by the sudden onset of latent left ventricular outflow tract obstruction. When it becomes severe and unrelenting, severe afterload mismatch and acute supply-demand ischemia appear and result in ballooning. In the context of 2 causes, presentations might overlap and cause confusion. Knowing the pathophysiology of each mechanism and how to determine a correct diagnosis might guide treatment.

Takotsubo cardiomyopathy has an incidence of 1% of acute coronary syndrome in the adult population, and the risk of recurrence is approximately 1.5% per year. However, only a few cases have been reported in children. Having a neurologic disorder and being exposed to the same trigger repeatedly have been associated with an increased risk.

Pregnancy and the post-partum period are known hypercoagulable states. Mid-cavitary variant Takotsubo cardiomyopathy (TCM) is uncommon and seen in only about 14% of all Takotsubo cases. Left ventricular thrombus (LVT) in the setting of mid-cavitary TCM is extremely rare, occurring in approximately 1% of cases. We describe a case of a young female, 1-week post-partum, with an acute LVT in the setting of mid-ventricular TCM, and we discuss the striking images and clinical management of this uncommon presentation., (© 2023 Wiley Periodicals LLC.)

Purpose of Review: Takotsubo cardiomyopathy (TCM) is a heart disease that mimics the symptoms of a myocardial infarction (MI). The exact cause of TCM is unknown, but the main theory is that the syndrome is triggered by an excessive release of catecholamines, a consequence of factors related to stress or severe emotional distress. The aim of this review is to summarize the various scientific journal articles on the nursing differential diagnosis of TCM, on the specific nurse training (particularly the role of the Advanced Practice Nurse, APN), and on the nursing educational support for the patient after hospital discharge., Recent Findings: A literature review was conducted on Medline (via PubMed), Web of Science (WoS), Scopus, and Google Scholar databases. Relevant indexed articles that investigated the elements characterizing TCM in nursing differential diagnosis and the role of the APN were identified., Results: Sixteen studies were included in the review; they highlighted the role of the nurse in identifying and educating patients with TCM. Nurses must have a thorough understanding of the syndrome, the onset symptoms, the unusual characteristics, and the probable etiology of TCM in order to recognize and promptly treat patients affected by this syndrome and have the opportunity to educate them after hospital discharge to reduce the possibility of recurrence., (© 2023. The Author(s).)

Introduction: Left ventricular (LV) dysfunction is estimated to occur in 10%-25% of the general intensive care unit (ICU) population and is frequently seen as regional wall motion abnormalities (RWMAs). Although RWMA is mostly attributed to myocardial ischemia or infarction, some studies have suggested that nonischemic RWMA might also be prevalent. We sought to establish that RWMA can be seen in critically ill patients with normal coronary arteries and to explore reasons for RWMA in this population., Methods: In this retrospective study, data from the hospital angiography register and the ICU register were collated between 2012 and 2019. Patients were identified who underwent angiography in conjunction with their ICU stay and had RWMA on echocardiography. Patients were divided into either those with non-obstructed or those with obstructed coronary arteries. Cardiac magnetic resonance imaging (cMRI) examinations were reviewed if they had been performed on patients with non-obstructed coronaries., Results: We identified 53 patients with RWMA and non-obstructed coronary arteries and 204 patients with RWMA and obstructed coronary arteries. Patients with non-obstructed coronary arteries were more often female, younger, and had fewer cardiovascular risk factors. They less commonly had ST elevation, but more frequently had T-wave inversion or serious arrhythmias. Troponin levels were higher in patients with obstructed coronary arteries, but NT-proBNP was similar between the groups. There were no differences in risk-adjusted 90-day mortality between patients with non-obstructed versus obstructed coronary arteries (OR 1.21, [95% CI 0.56-2.64], p = .628). In those with non-obstructed coronary arteries, follow-up echocardiography was available for 38 patients, of whom 30 showed normalization of cardiac function. Of the 14 patients with non-obstructed coronary arteries on whom cMRI was performed, 7 had a tentative diagnosis of Takotsubo syndrome or myocardial stunning; 4 had a myocardial infarction (preexisting in 3 cases); 1 patient had acute myocarditis; 1 patient had post-myocarditis; and 1 patient was diagnosed with dilated cardiomyopathy., Conclusion: RWMA can be seen to occur in critically ill patients in the absence of coronary artery obstruction. Several conditions can cause regional hypokinesia, and cMRI is useful to evaluate the underlying etiology., (© 2023 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

Background: Takotsubo syndrome mimics an acute myocardial infarction, typically in the aftermath of mental or physical stress., Objectives: The mechanism by which emotional processing in the context of stress leads to significant cardiac injury is poorly understood, so a full exploration of brain structure and function in takotsubo syndrome patients merits investigation., Methods: Twenty-five acute (<5 days) takotsubo patients and 25 control subjects were recruited into this observational cross-sectional study. Surface-based morphometry was carried out on magnetic resonance imaging (MRI) brain scans to extract cortical morphology based on volume, thickness, and surface area with the use of Freesurfer. Cortical morphology general linear models were corrected for age, sex, photoperiod, and total brain volume. Resting-state functional MRI and diffusion tensor tractography images were preprocessed and analyzed with the use of the Functional Magnetic Resonance Imaging of the Brain Diffusion Toolbox and Functional Connectivity Toolbox., Results: There was significantly smaller total white matter and subcortical gray matter volumes in takotsubo (P < 0.001), with smaller total brain surface area but increased total cortical thickness (both P < 0.001). Individual gray matter regions (hippocampus and others) were significantly smaller in takotsubo (P < 0.001); only thalamus and insula were larger (P < 0.001). There was significant hyperfunctional and hypofunctional connectivity in multiple areas, including thalamus-amygdala-insula and basal ganglia (P < 0.05). All structural tractography connections were increased in takotsubo (P < 0.05)., Conclusions: The authors showed smaller gray and white matter volumes driven by smaller cortical surface area, but increased cortical thickness and structural tractography connections with bidirectional changes in functional connectivity linked to emotion, language, reasoning, perception, and autonomic control. These are interventional targets in takotsubo patients' rehabilitation., Competing Interests: Funding Support and Author Disclosures This work was supported by National Health Service Grampian Endowment EA9667/ES868. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: No evidence-based therapy has yet been established for Takotsubo syndrome (TTS). Given the putative harmful effects of catecholamines in patients with TTS, beta-blockers may potentially decrease the intensity of the detrimental cardiac effects in those patients., Objective: The purpose of this study was to assess the impact of beta-blocker therapy on long-term mortality and TTS recurrence., Methods: The cohort study used the national Spanish Registry on TakoTsubo Syndrome (RETAKO). A total of 970 TTS post-discharge survivors, without pheochromocytoma, left ventricular outflow tract obstruction, sustained ventricular arrhythmias, and significant bradyarrhythmias, between January 1, 2003, and July 31, 2018, were assessed. Cox regression analysis and inverse probability weighting (IPW) propensity score analysis were used to evaluate the association between beta-blocker therapy and survival free of TTS recurrence., Results: From 970 TTS patients, 582 (60.0%) received beta-blockers. During a mean follow-up of 2.5±3.3 years, there were 87 deaths (3.6 per 100 patients/year) and 29 TTS recurrences (1.2 per 100 patient/year). There was no significant difference in follow-up mortality or TTS recurrence in unadjusted and adjusted Cox analysis (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.59-1.27, and 0.95, 95% CI 0.57-1.13, respectively). After weighting and adjusting by IPW, differences in one-year survival free of TTS recurrence between patients treated and untreated with beta-blockers were not found (average treatment effect -0.01, 95% CI -0.07 to 0.04; p=0.621)., Conclusions: In this observational nationwide study from Spain, there was no significant association between beta-blocker therapy and follow-up survival free of TTS recurrence., (Copyright © 2023. Publicado por Elsevier España, S.L.U.)

Purpose: The aims of our study were to investigate with cardiovascular magnetic resonance (CMR) the role of Epicardial Fat Volume (EFV) and distribution in patients with Takotsubo cardiomyopathy (TTC). Moreover, we explored EFV in patients with TTC and related this to comorbidities, cardiac biomarkers, and cardiac function., Methods: This retrospective study performed CMR scans in 30 consecutive TTC patients and 20 healthy controls. The absolute amount of EFV was quantified in consecutive short-axis cine stacks through the modified Simpson's rule. In addition, the left atrio-ventricular groove (LV) and right ventricle (RV) Epicardial Fat Thickness (EFT) were measured as well. Besides epicardial fat, LV myocardial strain parameters and T2 mapping measurements were obtained., Results: TTC patients and controls were of comparable age, sex, and body mass index. Compared to healthy controls, patients with TTC demonstrated a significantly increased EFV, epicardial fat mass, and EFV indexed for body 7surface area (p = 0.005; p = 0.003; p = 0.008; respectively). In a multiple regression model including age, sex, BMI, atrial fibrillation, and dyslipidemia, TTC remained an independent association with EFV (p = 0.008). Global T2 mapping and Global longitudinal strain in patients with TTC were correlated with EFV (r = 0.63, p = 0.001, and r = 0.44, p = 0.02, respectively)., Conclusion: Patients with TTC have increased EFV compared to healthy controls, despite a similar body mass index. The amount of epicardial fat was associated with CMR markers of myocardial inflammation and subclinical contractile dysfunction., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE) is a key diagnostic tool in the differential diagnosis between non-ischemic cause of cardiac chest pain. Some patients are not eligible for a gadolinium contrast-enhanced CMR; in this scenario, the diagnosis remains challenging without invasive examination. Our purpose was to derive a machine learning model integrating some non-contrast CMR parameters and demographic factors to identify Takotsubo cardiomyopathy (TTC) in subjects with cardiac chest pain., Material and Methods: Three groups of patients were retrospectively studied: TTC, acute myocarditis, and healthy controls. Global and regional left ventricular longitudinal, circumferential, and radial strain (RS) analysis included were assessed. Reservoir, conduit, and booster bi-atrial functions were evaluated by tissue-tracking. Parametric mapping values were also assessed in all the patients. Five different tree-based ensemble learning algorithms were tested concerning their ability in recognizing TTC in a fully cross-validated framework., Results: The CMR-based machine learning (ML) ensemble model, by using the Extremely Randomized Trees algorithm with Elastic Net feature selection, showed a sensitivity of 92% (95% CI 78-100), specificity of 86% (95% CI 80-92) and area under the ROC of 0.94 (95% CI 0.90-0.99) in diagnosing TTC. Among non-contrast CMR parameters, the Shapley additive explanations analysis revealed that left atrial (LA) strain and strain rate were the top imaging markers in identifying TTC patients., Conclusions: Our study demonstrated that using a tree-based ensemble learning algorithm on non-contrast CMR parameters and demographic factors enables the identification of subjects with TTC with good diagnostic accuracy., Translational Outlook: Our results suggest that non-contrast CMR features can be implemented in a ML model to accurately identify TTC subjects. This model could be a valuable tool for aiding in the diagnosis of subjects with a contraindication to the contrast media. Furthermore, the left atrial conduit strain and strain rate were imaging markers that had a strong impact on TTC identification. Further prospective and longitudinal studies are needed to validate these findings and assess predictive performance in different cohorts, such as those with different ethnicities, and social backgrounds and undergoing different treatments., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Introduction: Takotsubo syndrome (TTS) is characterized by transient left ventricular dysfunction and associated with considerable morbidity and mortality. We sought to evaluate the association between change in cardiac mechanics after diagnosis of TTS with 1-year incidence of major adverse cardiovascular events (MACE)., Methods: We retrospectively identified 85 patients with apical TTS based on ICD 9/10 codes and chart adjudication, who had a follow-up echocardiogram within 6 months of diagnosis. Echocardiograms were analyzed for left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), GLS ratio, global circumferential strain (GCS), and global radial strain (GRS). Multivariable logistic regression was performed to identify parameters associated with MACE (all-cause mortality, heart failure, stroke, and coronary artery disease [CAD] requiring percutaneous coronary intervention [PCI]) at 1 year. Event-free survival was assessed in patients with GLS (≤-18% vs. >18%) and LVEF (≥53% vs. <53%)., Results: Within 1 year of diagnosis, MACE occurred in 15 (18%) patients. Between baseline and follow-up echocardiogram (median 15 [range 1-151] days), there were significant differences in change in LVEF and GLS in patients with versus without incident MACE. In multivariate analysis, change in LVEF (odds ratio [OR] = .93 [.87, .98], p = .013) and change in GLS (OR = 1.32 [1.04, 1.67], p = .022) were independently associated with MACE; however, the association with change in GLS was attenuated (odds ratio [OR] = 1.13 [.94, 1.36], p = .21) after adjustment for baseline and change in LVEF. Among patients with normalized LVEF at follow-up, there were five (14.7%) MACE; whereas, there were no events among patients with normalized GLS., Conclusions: In patients with apical TTS, recovery in GLS and LVEF at follow-up was associated with significantly lower MACE at 1 year. Normalization of GLS at follow-up was better able to discriminate event-free survival than normalization of LVEF., (© 2023 Wiley Periodicals LLC.)

There is increasing evidence that Takotsubo cardiomyopathy behaves more like a highly variable and dangerous syndrome than an isolated cardiomyopathy. In this case report, we describe a case of Takotsubo cardiomyopathy complicated by complete heart block. We discuss the potential mechanisms for its etiology and examine the need for pacemaker placement.

We describe a case of a 57-year-old white woman treated for rheumatoid arthritis (RA) with tofacitinib 10mg daily (started one year ago) and prednisolone 5mg daily. She presented to the emergency department with a tight squeezing chest pain and shortness of breath for 7h and the clinical evaluation revealed regional systolic dysfunction of the left ventricle, mimicking a myocardial infarction, in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. All changes were transient and resolved completely within 4 days. The diagnosis of Takotsubo cardiomyopathy (TKM) was established. This is, as far as we know, the first report of a case of TKM in a RA patient taking tofacitinib. Although the association has not been previously described and the precise cause cannot be identified in this patient, the association with tofacitinib should be considered given the etiopathogenic rationale and the absence of any other identifiable cause., (Copyright © 2021 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.)

Background: During the COVID-19 pandemic, the risk of SARS-CoV-2 infection, the public health measures of social distancing, the freedom limitations, quarantine, and the enforced homeworking under the lockdown period, as well as medical causes including COVID-19 infection per se, may have caused major emotional distress, especially in the most vulnerable patients. We aimed to evaluate the variations in the number of admissions due to Takotsubo syndrome (TTS) during the COVID-19 pandemic in the Veneto region. Methods: We retrospectively reviewed and analyzed the number of admissions because of TTS in 13 Divisions of Cardiology located in the Veneto region, the northeastern area of Italy, covering a population of more than 2.5 million inhabitants, during the two major pandemic waves of COVID-19 (the first between 15 March and 30 April 2020 and the second between 15 November and 30 December 2020) that occurred in 2020. Results: In total, 807 acute coronary syndromes were admitted in the 13 enrolling hospitals. Among these, 3.9% had TTS. Compared to the corresponding 2018 and 2019 time periods, we observed a significant increase in the number of TTS cases (+15.6%, p = 0.03 and +12.5%, p = 0.04, comparing 2018 to 2020 and 2019 to 2020, respectively). Geographical distribution of the TTS cases reflected the broad spread of the SARS-CoV-2 infection with a significant direct relationship between TTS incidence and the number of COVID-19 infections according to Pearson’s correlation (r = 0.798, p < 0.001). Conclusions: The higher incidence of TTS during the 2020 COVID-19 pandemic waves, especially in the areas that were hit hardest in terms of morbidity and mortality by the SARS-CoV-2 infection, suggest a strong direct and/or indirect role of COVID-19 in the pathogenesis of TTS.

Introduction: Subarachnoid hemorrhage (SAH) is caused by a ruptured intracranial aneurysm leading to acute extravasation of blood into the subarachnoid space. SAH has an incidence of 6.3 per 100,000 persons per year in Europe and accounts for 5% of all strokes. SAH occurs at a relatively young age and has poor clinical outcomes and high mortality rates. Cardiac syndromes are regularly seen in patients with acute neurologic disease including SAH. These cardiac complications of SAH are associated with increased morbidity and mortality and present in a large variety and severity., Areas Covered: The main goal of this review is to describe the SAH-related cardiac syndromes. Secondly, we will provide an overview of the underlying pathophysiology regarding the development of cardiac syndromes. Thirdly, we will describe the impact of cardiac syndromes on patient outcome., Expert Opinion: Of all neurology patients, SAH patients have the highest risk of developing takotsubo syndrome (TTS), occurring in about 0.8-30% of patients. Both TTS and neurogenic stunned myocardium have many similarities on echocardiographic evaluation. In European Cardiology consensus, SAH is recognized as a primary cause of TTS.

A new onset acute heart failure (HF) with a sudden drop in the left ventricular ejection fraction (LVEF) post orthotopic liver transplant (LT) is a rare but a potentially fatal complication. Because in most of the cases there is no evidence of coronary thrombosis, it can be classified as nonischemic cardiomyopathy. More specifically, clinical presentation of this syndrome shares many features with stress-induced or takotsubo cardiomyopathy. The known factors that predispose these patients to acute HF during or shortly after LT include cirrhotic cardiomyopathy, rapid hemodynamic changes during LT surgery, and the large concentrations of catecholamines, either administered or released endogenously during surgery. The hemodynamic changes during surgery, such as the drop in preload during the anhepatic phase (occasionally requiring massive transfusions and vasopressors) and subsequent increase in preload with acidic and hyperkalemic plasma in the reperfusion phase, lead to rapid electrolyte and hemodynamic shifts. In several cases, intraoperative onset of HF, with or without ventricular arrythmia, could be timed to the reperfusion phase (and occasionally in the anhepatic and pre-anhepatic phases). In other cases, the HF syndrome started hours to days post-surgery. Recovery of cardiac function occurred in the majority of patients during the same admission; however, these patients generally need significantly longer hospitalizations and aggressive supportive care (occasionally requiring mechanical ionotropic and ventilatory support). If recover, the patients have a similar 1-year mortality as those LT patients that did not have this complication. Because no reliable risk stratification currently exists, intraoperative transesophageal echocardiography might be the most dependable way of detecting and addressing this syndrome promptly. Given the mechanism of takotsubo cardiomyopathy, beta-blockade and a preferential use of non-catecholaminergic vasopressors may be a reasonable way to manage this syndrome., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Rates of stress (Takotsubo) cardiomyopathy have increased during the coronavirus pandemic due to social stressors, even in patients who are not infected with the virus. At times, Takotsubo cardiomyopathy (TC) may present as cardiogenic shock. Herein, we present a case during the pandemic of shock from TC secondary to left ventricular outflow tract obstruction (LVOTO), mitral regurgitation (MR), and left ventricular (LV) dysfunction. The contrasting management strategy of LVOTO, MR, and LV failure was cause for clinical challenge, and we highlight the balance of treating these opposing forces., (© 2022 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

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 <40% during the acute phase in all groups, but recovered to 63% in convalescent and 64% in the recovered groups, respectively. Serum renin concentrations remain persistently elevated after a episode of takotsubo cardiomyopathy ( 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 <0.001 versus controls) remaining persistently elevated in the chronically recovered group alone ( 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.

Myocardial injury, diagnosed by troponin elevation, is common in COVID-19 patients, but cardiac involvement with clinical manifestations occurs less frequently. We analyzed the literature on COVID-19 (2020) and systematically reviewed the cases where individual patient data were presented. We searched PubMed and Google Scholar for "COVID," "COVID-19," and "coronavirus" in combination with "myocarditis," "heart failure," "takotsubo," "cardiomyopathy," and "cardiogenic shock." We identified 90 cases of COVID-19 with myocardial involvement, mean age 52.9 ± 18.3 years, 54.5% males. Of them, 55 survived (61.1%), 20 died (22.2%), and in 15 (16.7%) the outcome was unknown at the time of publication. Among patients with known outcome, mortality was 26%. The nadir LVEF was 31.7 ± 13.1% and recovered to 50.1 ± 16.0%. Pericardial effusion was a common finding, reported in 21 (23.3%) of patients, including moderate size effusion in 8.9% and large in 7.8%. The effusion caused tamponade in 11 (12.2%) of patients. Out of 83 patients who experienced a decrease in LVEF, 30 could be classified as takotsubo syndrome. The takotsubo patients were older than those with myocarditis, and with relatively high proportion of males. About one third of the cases was complicated by cardiogenic shock. Myocardial involvement in COVID-19 patients most often presents as a new, rapid decrease in LVEF, although normal LVEF or takotsubo-like wall motion pattern does not rule out myocarditis. Moderate and large pericardial effusion is common, and cardiac tamponade occurs in 12.2% of patients. Cardiogenic shock develops in one third of the patients. Mortality appears to be high at 26%., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Aims: Cardiac energetic impairment is a major finding in takotsubo patients. We investigate specific metabolic adaptations to direct future therapies., Methods and Results: An isoprenaline-injection female rat model (vs. sham) was studied at Day 3; recovery assessed at Day 7. Substrate uptake, metabolism, inflammation, and remodelling were investigated by 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography, metabolomics, quantitative PCR, and western blot (WB). Isolated cardiomyocytes were patch-clamped during stress protocols for redox states of NAD(P)H/FAD or [Ca2+]c, [Ca2+]m, and sarcomere length. Mitochondrial respiration was assessed by seahorse/Clark electrode (glycolytic and β-oxidation substrates). Cardiac 18F-FDG metabolic rate was increased in takotsubo (P = 0.006), as was the expression of GLUT4-RNA/GLUT1/HK2-RNA and HK activity (all P < 0.05), with concomitant accumulation of glucose- and fructose-6-phosphates (P > 0.0001). Both lactate and pyruvate were lower (P < 0.05) despite increases in LDH-RNA and PDH (P < 0.05 both). β-Oxidation enzymes CPT1b-RNA and 3-ketoacyl-CoA thiolase were increased (P < 0.01) but malonyl-CoA (CPT-1 regulator) was upregulated (P = 0.01) with decreased fatty acids and acyl-carnitines levels (P = 0.0001-0.02). Krebs cycle intermediates α-ketoglutarate and succinyl-carnitine were reduced (P < 0.05) as was cellular ATP reporter dihydroorotate (P = 0.003). Mitochondrial Ca2+ uptake during high workload was impaired on Day 3 (P < 0.0001), inducing the oxidation of NAD(P)H and FAD (P = 0.03) but resolved by Day 7. There were no differences in mitochondrial respiratory function, sarcomere shortening, or [Ca2+] transients of isolated cardiomyocytes, implying preserved integrity of both mitochondria and cardiomyocyte. Inflammation and remodelling were upregulated-increased CD68-RNA, collagen RNA/protein, and skeletal actin RNA (all P < 0.05)., Conclusion: Dysregulation of glucose and lipid metabolic pathways with decreases in final glycolytic and β-oxidation metabolites and reduced availability of Krebs intermediates characterizes takotsubo myocardium. The energetic deficit accompanies defective Ca2+ handling, inflammation, and upregulation of remodelling pathways, with the preservation of sarcomeric and mitochondrial integrity., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Male sex in takotsubo syndrome (TTS) has a low incidence and it is still not well characterized., Objectives: The aim of the present study is to describe TTS sex differences., Methods: TTS patients enrolled in the international multicenter GEIST (GErman Italian Spanish Takotsubo) registry were analyzed. Comparisons between sexes were performed within the overall cohort and using an adjusted analysis with 1:1 propensity score matching for age, comorbidities, and kind of trigger., Results: In total, 286 (11%) of 2,492 TTS patients were men. Male patients were younger (age 69 ± 13 years vs 71 ± 11 years; P = 0.005), with higher prevalence of comorbid conditions (diabetes mellitus 25% vs 19%; P = 0.01; pulmonary diseases 21% vs 15%; P = 0.006; malignancies 25% vs 13%; P < 0.001) and physical trigger (55 vs 32% P < 0.01). Propensity-score matching yielded 207 patients from each group. After 1:1 propensity matching, male patients had higher rates of cardiogenic shock and in-hospital mortality (16% vs 6% and 8% vs 3%, respectively; both P < 0.05). Long-term mortality rate was 4.3% per patient-year (men 10%, women 3.8%). Survival analysis showed higher mortality rate in men during the acute phase in both cohorts (overall: P < 0.001; matched: P = 0.001); mortality rate after 60 days was higher in men in the overall (P = 0.002) but not in the matched cohort (P = 0.541). Within the overall population, male sex remained independently associated with both in-hospital (OR: 2.26; 95% CI: 1.16-4.40) and long-term mortality (HR: 1.83; 95% CI: 1.32-2.52)., Conclusions: Male TTS is featured by a distinct high-risk phenotype requiring close in-hospital monitoring and long-term follow-up., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

While the most recent evidence suggests a lack of benefit, antithrombotic therapy is still extensively prescribed in patients with Takotsubo syndrome (TTS). The objective of this study was to determine whether patients with TTS benefit from anti-aggregation, in terms of either short-term or long-term outcomes. A systematic review and meta-analysis was conducted. A comprehensive search of the literature included MEDLINE, Cochrane Library, Clinicaltrials.gov, EU Clinical Trial Register, References, and contact with the authors. Methodological quality assessment and data extraction were systematically performed. The review adhered to the PRISMA framework guidelines. A total of 86 citations were identified, six being eligible for inclusion, for a total of 1997 patients. One of them considered both short-term and long-term outcomes. One reported outcomes during the index event, while the remaining four focused on potential long-term benefits. They were all retrospective cohort studies.Based on our data, the long-term use of antiplatelet therapy (AT) led to a significantly higher incidence of the composite outcome (OR: 1.54; 95% CI 1.09-2.17; p = 0.014) and overall mortality (OR 1.72; 95% CI 1.07-2.77; p = 0.027). The analysis did not show a statistically significant difference in TTS recurrences, stroke/TIA, and MI or CAD worsening with AT compared with no anti-aggregation. The AT in this settings did not show any clear benefit in improving the long-term outcomes, and it may be even detrimental and it may be detrimental. These results warrant further future research and the design of adequately powered randomized controlled trials focusing on the impact of aspirin on the outcomes in patients presenting with TTS., (© 2021. The Author(s).)

The novel coronavirus disease 2019 (COVID-19) is associated with several cardiovascular manifestations including myocardial injury, myocarditis, arrhythmia, and pulmonary embolism. Rare cases of stress-induced cardiomyopathy, or takotsubo syndrome have also been reported during the acute infection, and secondary to stress following lockdown and self-isolation. Diagnosis in the setting of the acute infection is challenging since conventional imaging modalities such as transthoracic echocardiography and coronary angiography should be restricted to minimize physician-patient contact until the patients is tested negative for COVID-19. The use of point of care hand-held ultrasound is appropriate for this purpose. The overall course of the disease seems to be similar to takotsubo in the general population. Physicians should be familiar with the clinical presentation, possible complications, and management of takotsubo during COVID-19 outbreak. Here, we review the special considerations in the diagnosis and management of takotsubo syndrome during the current pandemic.

Takotsubo syndrome is an acute reversible heart failure syndrome, most frequently seen in postmenopausal women and precipitated generally by significant emotional stress or physical illness. A sudden sympathetic activation seems to play a key role in the pathophysiology, but growing evidence is emerging about the role of inflammation in the subacute and chronic phases. An incidence of life-threatening complications occurring in the acute phase and at long-term follow-up has been demonstrated, comparable with the acute coronary syndrome. Multimodality imaging could be useful to stratify in-hospital and long-term prognosis. The efficacy of specific medical treatments in long-term follow-up should be investigated., (Copyright © 2021 Elsevier Inc. All rights reserved.)