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ABSTRACTBACKGROUND 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.

La miocardiopatía por estrés, o takotsubo, se da en respuesta a un evento estresante que causa dilatación aguda del ventrículo izquierdo, disfunción ventricular, elevación de biomarcadores de daño miocárdico y cambios electrocardiográficos sin evidencia de lesiones coronarias significativas. Típicamente se presenta en mujeres posmenopáusicas y es de carácter reversible en la mayoría de los casos. Se reporta una serie de doce pacientes de sexo femenino, en la séptima década de la vida, con miocardiopatía por estrés, que se presentaron en un periodo de nueve años. La principal causa de consulta fue dolor torácico y el desencadenante más común fue de tipo emocional. De estas, el 25% tenía antecedentes médicos cardiológicos y los medicamentos más usados antes del evento fueron el ácido acetilsalicílico, los betabloqueadores y los inhibidores de la enzima convertidora de angiotensina. En todos los casos se documentó deterioro inicial de la función ventricular, que se recuperó en un periodo variable.

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.

Takotsubo syndrome, initially described in the 1990s by Sato, has been increasingly recognized around the world. Pathophysiology is directed towards central role of catecholamine surge , but other aspects like microvascular endothelial dysfunction and vasospasm have also been described. Dyspnea and chest pain are most common manifestations, but syncope can also be seen. Right ventricular involvement is not uncommon, and left ventricular outflow tract obstruction is a frequent complication. EKG can differentiate between Takotsubo syndrome and myocardial infarction, but coronary angiography should always be performed. Although treatment has been angiotensin converting enzyme inhibitors and betablockers, recent evidence from nonrandomized studies shows no benefit on betablockers regarding outcomes. [ABSTRACT FROM AUTHOR]

Introduction: The link between chemotherapy and Takotsubo cardiomyopathy has become increasingly recognized in recent years, although causality remains to be established and the mechanism of action is not yet fully understood. Case Report: Here we present the case of a patient with Multiple Myeloma, that after of cytotoxic treatment with cyclophosphamide and thalidomide, developed coronary acute syndrome. She went onto have coronary angiography that demonstrated unobstructed coronary arteries and Apical ballooning, consistent with Takotsubo C a r d i o m y o p a t h y. C o n c l u s i o n : Ta k o t s u b o cardiomyopathy may represent a form of cardiac dysfunction within the spectrum of chemotherapyinduced cardiac toxicity that differs from the more common cumulative-dosing toxicity. Given the increasing amount of case report, and the presence of recurrence after the re administration from the same chemotherapy agent; must be properly identified and avoid its use in high risk patient. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Résumé Depuis sa première description au Japon en 1990, la cardiomyopathie de Takotsubo (de stress) est actuellement mondialement reconnue. La maladie est caractérisée par un dysfonctionnement ventriculaire gauche systolique et diastolique transitoire avec anomalies de la cinétique ventriculaire gauche. Elle affecte principalement les femmes ménopausées, le plus souvent précédée d'un stress émotif ou physique. Pendant la phase aiguë, la présentation clinique, les résultats électrocardiographiques et le profil enzymatique myocardique sont souvent semblables à ceux d'un syndrome coronaire aigu. Bien que la cause de la cardiomyopathie de Takotsubo demeure inconnue, le rôle de l'axe cerveau-cœur dans la pathogénie de la maladie a été décrit. Le rôle potentiel de l'excès de catécholamine dans sa pathogénie a été longtemps discuté et l'utilisation des bêtabloquants a été proposée comme stratégie thérapeutique. Actuellement le traitement n'est pas codifié, il s'adapte en fonction de la symptomatologie clinique. Il semble difficile de résumer tous les facteurs capables de déclencher la cardiomyopathie, nous décrivons un cas de Takotsubo après implantation de pacemaker (PM) et faire un point sur cette cardiopathie. Abstract Since its first description in Japan in 1990, Takotsubo (stress) cardiomyopathy has gained worldwide recognition. The disease is characterized by transient systolic and diastolic left ventricular dysfunction with a variety of wall-motion abnormalities. She predominantly affects elderly women and she is often preceded by an emotional or physical trigger. In the acute phase, the clinical presentation, electrocardiographic findings and biomarker profiles are often similar to those of an acute coronary syndrome. Although, the cause of Takotsubo cardiomyopathy remains unknown, the role of the brain–heart axis in the pathogenesis of the disease has been described. The potential role of catecholamine excess in the pathogenesis of Takotsubo cardiomyopathy has been long debated, and as such beta-blockers have been proposed as a therapeutic strategy. Currently, the treatment is not codified and it adapts according to clinical symptomatology. It seems difficult to summarize all the factors to provoque the cardiomyopathy, we describe a case of Takotsubo after a pacemaker (PM) implantation and to give a recent progress on this heart disease. [ABSTRACT FROM AUTHOR]

Stress cardiomyopathy is an acute reversible heart failure syndrome initially believed to represent a benign condition due to its self-limiting clinical course, but now recognized to be associated with a non-negligible rate of serious complications such as ventricular arrhythmias, systemic thromboembolism, and cardiogenic shock. Due to an increased awareness and recognition, the incidence of stress cardiomyopathy has been rising (15-30 cases per 100,000 per year), although the true incidence is unknown as the condition is likely underdiagnosed. Stress cardiomyopathy represents a form of neurocardiogenic myocardial stunning, and while the link between the brain and the heart is established, the exact pathophysiological mechanisms remain unclear. We herein review the proposed risk factors and triggers for the syndrome and discuss a practical approach to diagnosis and treatment of the patients with stress cardiomyopathy, highlighting potential challenges and unresolved questions. [ABSTRACT FROM AUTHOR]

Spontaneous coronary artery dissection (SCAD) and takotsubo syndrome (TS) are two cardiovascular syndromes with predilection for women. Both conditions may be preceded by an emotional stress or, for the affected individual, an unusual severe physical exercise. "Restitution ad integrum" occurs in most cases suffering from SCAD or TS with complete angiographic resolution of the dissected vessel and left ventricular dysfunction respectively. Recently, many cases, which were initially diagnosed as TS because of typical left ventricular ballooning pattern showed to have SCAD, have been reported; these cases were deemed to be "SCAD misdiagnosed as TS". The left ventricular wall motion abnormality has been attributed to the ischemia caused by SCAD-affected coronary vessel especially in the left anterior descending artery (LAD) with "wrap-around course". However, the left ventricular ballooning pattern have occurred in patients with SCAD in non-long-wrap-around LAD and SCAD in other coronary branches where coronary ischemia on its own cannot explain the left ventricular ballooning. In this review, sufficient data supporting the evidence for the possibility of coexistence of SCAD and TS is provided. Misdiagnosis of the association of the two conditions may result in mismanagement of the patient with undesirable consequences. Furthermore, the causal links between SCAD and TS is discussed. [ABSTRACT FROM AUTHOR]

Stress (Takotsubo) cardiomyopathy (SC) is a cardiomyopathy characterised by transient myocardial dysfunction, commonly triggered by a surge in catecholamine. Electrocardiographic features may mimic other conditions, such as myocardial infarction. We presented two cases of SC and reviewed the electrocardiographic features of this disease entity. [ABSTRACT FROM AUTHOR]

Background and purpose: Takotsubo cardiomyopathy (TCM), first reported by Japanese doctors, has gained an overall acknowledgment as an independent malady of international attention. It resembles the presentation of an acute myocardial infarction but lacks ischemic myocardial tissue. The objective of this article is to review the physiology, diagnostics, treatment, and complications of TCM and report a case study of a patient who developed TCM. Methods: Observation through direct patient care allowed for data collection of this unique medical phenomenon. Supporting information was obtained via investigation of scholarly articles on TCM over the past 10 years. Conclusions: Although TCM is usually transient, it is important to quickly differentiate TCM from other more serious medical conditions, such as myocardial infarction, pulmonary embolism, and pheochromocytoma. Typical diagnostic workup includes electrocardiography, cardiac biomarkers, and echocardiography or coronary angiography. Complications include cardiogenic shock, left ventricular wall rupture, and life-threatening arrhythmias. Implications for practice: The advanced practice nurse (APN) is instrumental in differentiating between TCM versus acute myocardial infarction, heart failure, pulmonary edema, dynamic outflow obstruction, and cardiogenic shock. Because of these possible acute and critical presentations, prompt recognition and intervention for patients with TCM are priorities for nurse practitioners. [ABSTRACT FROM AUTHOR]

Background: Takotsubo syndrome (TTS) is a heart failure syndrome which is usually reversible. Factors associated with degree of recovery of left ventricular systolic function in TTS are poorly understood.Materials and Methods: We conducted a retrospective analysis of 90 TTS patients treated at our institution from 2006 to 2014. Patients were grouped based on recovery of left ventricular ejection fraction (LVEF) on follow-up transthoracic echocardiogram as left ventricular ejection fraction <50% (partial group) or preserved ejection fraction ≥50% (full group). Patient baseline characteristics, comorbidities, biomarkers, electrocardiography, and echocardiogram were collected. We also compared adverse events that occurred during hospitalization.Results: In comparison to full recovery group patients (n=63), partial recovery patients (n=27) were older (76.9±13 vs. 70.6±13years; P=0.02) and had a higher prevalence of comorbid hypothyroidism (26% vs. 8%; P=0.02). A greater number of patients from the partial group were also taking levothyroxine replacement (22% vs. 3%; P=0.003). We found no significant between-group differences in type of triggering event or cardiac biomarker levels. QT interval was longer in the partial group (540.6±71msec vs. 460.7±35msec; P=0.01). Follow-up LVEF was 37.9±8% in the partial group and 58.0±4% in the full group (P<0.001). There were no statistically significant differences in length of stay or adverse events.Conclusion: Takotsubo patients with partial myocardial recovery were older, presented with longer QT intervals, and were more likely to have comorbid hypothyroidism. [ABSTRACT FROM AUTHOR]

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<0.001; increased VE/Vco2 slope, 31±1 versus 26±1, P=0.002). Despite normal left ventricular ejection fraction and serum biomarkers, patients with prior takotsubo cardiomyopathy had impaired cardiac deformation indices (reduced apical circumferential strain, -16±1.0 versus -23±1.5%, P<0.001; global longitudinal strain, -17±1 versus -20±1%, P=0.006), increased native T1 mapping values (1264±10 versus 1184±10 ms, P<0.001), and impaired cardiac energetic status (phosphocreatine/γ-adenosine triphosphate ratio, 1.3±0.1 versus 1.9±0.1, P<0.001).Conclusions: In contrast to previous perceptions, takotsubo cardiomyopathy has long-lasting clinical consequences, including demonstrable symptomatic and functional impairment associated with persistent subclinical cardiac dysfunction. Taken together our findings demonstrate that after takotsubo cardiomyopathy, patients develop a persistent, long-term heart failure phenotype.Clinical Trial Registration: URL: https://clinicaltrials.gov. Unique identifier: NCT02989454. [ABSTRACT FROM AUTHOR]

Unraveling the mechanisms underlying Takotsubo (TTS) leads to question the current inclusion of the condition within the spectrum of cardiomyopathies. Indeed, the clinical presentation and pathophysiology of TTS clearly differ from cardiomyopathies, i.e. diseases of heart muscle unexplained by abnormal loading conditions or coronary artery disease, which cannot recover spontaneously and may cause sudden death often in minimally symptomatic individuals or result in a gradual deterioration in ventricular function and end-stage heart failure. Furthermore, the term ‘cardiomyopathy’ can no longer be applied when functional or morphologic abnormalities of the coronary arteries leading to acute myocardial ischemia are deemed responsible for left ventricular (LV) systolic dysfunction. After 27 years of investigation, time has come to recognize that patients with TTS do suffer from severe myocardial ischemia and fulfill all criteria of acute coronary syndromes, i.e. acute chest pain, typical electrocardiographic changes, cardiac troponin rise, as well as LV wall motion abnormalities. Accordingly, we propose that TTS should be labeled as an acute ‘syndrome’ to be included more appropriately within the spectrum of ischemic heart disease. With regard to the term ‘stress’, it may imply that the catecholamine surge is essential to produce the typical transient myocardial injury. Thus, the terminology ‘Takotsubo (stress) syndrome’ would more accurately reflect recent advances in the pathophysiology. [ABSTRACT FROM AUTHOR]

Heart failure (HF) is a complex clinical syndrome with multiple interactions between the failing myocardium and cerebral (dys-)functions. Bi-directional feedback interactions between the heart and the brain are inherent in the pathophysiology of HF: (i) the impaired cardiac function affects cerebral structure and functional capacity, and (ii) neuronal signals impact on the cardiovascular continuum. These interactions contribute to the symptomatic presentation of HF patients and affect many co-morbidities of HF. Moreover, neuro-cardiac feedback signals significantly promote aggravation and further progression of HF and are causal in the poor prognosis of HF. The diversity and complexity of heart and brain interactions make it difficult to develop a comprehensive overview. In this paper a systematic approach is proposed to develop a comprehensive atlas of related conditions, signals and disease mechanisms of the interactions between the heart and the brain in HF. The proposed taxonomy is based on pathophysiological principles. Impaired perfusion of the brain may represent one major category, with acute (cardio-embolic) or chronic (haemodynamic failure) low perfusion being sub-categories with mostly different consequences (i.e. ischaemic stroke or cognitive impairment, respectively). Further categories include impairment of higher cortical function (mood, cognition), of brain stem function (sympathetic over-activation, neuro-cardiac reflexes). Treatment-related interactions could be categorized as medical, interventional and device-related interactions. Also interactions due to specific diseases are categorized. A methodical approach to categorize the interdependency of heart and brain may help to integrate individual research areas into an overall picture. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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.

BackgroundThe CHA2DS2‐VASc score predicts stroke in patients with atrial fibrillation and has been reported to have a prognostic role even in acute coronary syndrome patients. The Takotsubo syndrome is a condition that mimics acute coronary syndrome and may present several complications including stroke. We sought to assess the ability of CHA2DS2‐VASc score to predict adverse events in Takotsubo syndrome patients. Methods and ResultsOverall, 371 Takotsubo syndrome patients were enrolled in a prospective registry. Patients were divided into 3 groups according to the CHA2DS2‐VASc score: Group A (≤1), B (2–3), and C (≥4). The median CHA2DS2‐VASc score was 3 (interquartile range: 2–4). Overall, 9%, 42%, and 49% were included in Group A, B, and C, respectively. Follow‐up length was 26±20 months. The mortality rate was 6%, 7%, and 17% in Group A, B, and C, respectively (P=0.011). The stroke rate was 3% and not different among the 3 groups. Estimated major adverse cardiac and cerebrovascular events (the composite of death, myocardial infarction, and stroke) rates in the 3 groups were 6%, 9%, and 17% in Group A, B, and C, respectively (P=0.033). The CHA2DS2‐VASc score resulted as a predictor of major adverse cardiac and cerebrovascular events (odds ratio 2.1, 95% confidence interval, 1.2–3.6; P=0.01) and all‐cause mortality (odds ratio 1.5, 95% confidence interval, 1.2–1.9; P=0.001). ConclusionsIn Takotsubo syndrome, the CHA2DS2‐VASc score allows prediction of cardiovascular events and mortality at long‐term follow‐up.

We describe a case of a 57-year-old white woman treated for rheumatoid arthritis (RA) with tofacitinib 10 mg daily (started one year ago) and prednisolone 5 mg daily. She presented to the emergency department with a tight squeezing chest pain and shortness of breath for 7 h 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. [ABSTRACT FROM AUTHOR]

Acute stress-induced (takotsubo) cardiomyopathy has a dramatic clinical presentation, mimicking an acute myocardial infarction and is triggered by intense emotional or physical stress. In this paper, we review the current state of knowledge of the mechanistic physiology underlying the left ventricular ballooning. The pathophysiology of the recovery from this acute heart failure syndrome is presented. The short-term and long-term outlook puts this new syndrome on a different perspective compared with recently held views. Current knowledge on susceptibility and predisposition already define distinctive characteristics of patients with takotsubo compared with myocardial infarction. Gaps in knowledge and future directions of research are identified in order to best direct efforts for identifying specific therapies for this condition, in the acute setting, to mitigate postacute symptoms or to prevent recurrences, none of which exist. [ABSTRACT FROM AUTHOR]

Basal septal hypertrophy is a rare and unique anatomical finding associated with hypertrophic cardiomyopathy (HCM). It is also described as a sigmoid hypertrophy and is linked with aging and chronic hypertension. Takotsubo cardiomyopathy is a transient cardiomyopathy that occurs during periods of high physical or emotional stress. Its occurrence with HCM is relatively common; however, this presentation occurs more often with the classic asymmetrical septal hypertrophy or the apical variant. This case demonstrates its coexistence with isolated sigmoid hypertrophy in an elderly, hypertensive female with severe ischemic bowel disease. [ABSTRACT FROM AUTHOR]

Predominant causes for newly diagnosed postpartum heart failure are preeclampsia and peripartum cardiomyopathy. Being an anatomical variant of Takotsubo syndrome (TTS) reverse TTS in this period is rare. We present a 36 year old patient, who had delivered triplets by cesarean section. Because of postpartum bleeding she was administered sulprostone. Later she was transferred to the Intensive Care Unit with sudden development of dyspnea, tachypnea and tachycardia. Clinical symptoms, laboratory findings and chest radiograph showed signs of acute heart failure. Transthoracic echocardiography (TTE) revealed reverse TTS with moderately reduced left ventricular ejection fraction (LVEF 39%). The patient stabilized with loop diuretic, angiotensine-converting enzyme inhibitors and beta-blockade. Breast-feeding was discouraged and bromocriptine administered. Left ventricular function normalized (LVEF 60%) within four weeks. TTS should be considered in patients with early postpartum development of heart failure. Rapid cardiac recompensation after the start of adequate therapy and complete resolution of clinical symptoms and TTE findings are typical for postpartum TTS. [ABSTRACT FROM AUTHOR]

Context Pheochromocytoma and paraganglioma are rare neuroendocrine tumors which overproduce catecholamines and arise from the adrenal gland or extra-adrenal chromaffin cells of the sympathetic and parasympathetic ganglia (1). Excessive catecholamine-induced stimulation of cardiac myocytes leads to damage which manifests in several forms ranging from Takotsubo to dilated cardiomyopathy. Diagnosis of pheochromocytoma-related cardiomyopathies is often delayed due to the atypical presentation associated with many cases. Objective Limited data exists on the presentation and outcomes of the various forms of pheochromocytoma-induced cardiomyopathies. We performed a literature review to assess the association of pheochromocytoma and cardiomyopathy to aide in further understanding this clinical entity. Design 163 cases from 150 articles published between 1991 and November 2016 were included from a PubMed search. Results There were 163 occurrences of pheochromocytoma and cardiomyopathy (63 dilated cardiomyopathy, 38 Takotsubo cardiomyopathy, 30 inverted Takotsubo cardiomyopathy, 10 HOCM, 8 myocarditis, and 14 unspecified cardiomyopathy). Many patients lacked classic signs or symptoms of pheochromocytoma with hypertension as a presenting symptom in 65% and the triad of headache, palpitations, and diaphoresis only in 4%. Resection of the pheochromocytoma led to improvement of the cardiomyopathy in 96% while lack of resection was associated with death or cardiac transplantation in 44%. Conclusion Pheochromocytoma should be considered in the evaluation of non-ischemic, non-valvular cardiomyopathy even in the absence of symptoms of catecholamine excess. Our study highlights the importance of early suspicion and diagnosis of pheochromocytoma in cases of idiopathic heart failure as early resection may prevent progression to irreversible myocardial remodeling and death. [ABSTRACT FROM AUTHOR]

Introduction Takotsubo syndrome ( TTS), also known as Takotsubo cardiomyopathy or stress-induced cardiomyopathy, has been described following a variety of surgeries and disease states. The relationship between intra-operative anesthesia management and the development of this syndrome has never been fully elucidated. Objectives The primary objective of this study was to determine the relationship of multiple intra-operative factors on the pathogenesis of TTS. Methods A single-center retrospective review of all liver transplants performed at Mayo Clinic Florida from January 2005 to December 2014. Patients developing left ventricular dilation and a concomitant decrease in ejection fraction, a negative cardiac catheterization, or stress test within 30 days of transplantation were identified. Cases were matched 2:1 to controls with respect to MELD, age, sex, and indication for transplantation. Our evaluation included liver graft characteristics, intra-operative medications, and intra-operative hemodynamic measurements. Results We identified 24 cases of TTS from a pool of 1752 transplants, for an incidence of 1.4%. No statistically significant differences in intra-operative measures between the two groups were identified (all P ≥ .08). Conclusion Our exploratory, single-center retrospective review evaluating 46 intra-operative characteristics found no association with the development of TTS. [ABSTRACT FROM AUTHOR]

Background Takotsubo syndrome (TT) and myocardial infarction (MI) share numerous similarities in clinical presentation, ECG modifications and biomarker elevation. We sought to determine whether the ratio of high-sensitivity cardiac troponin T (hs-TnT) to the myocardial fraction of creatine kinase (CKMB) could be a potent discriminator between TT and MI patients. Methods We separately present analysis of data from retrospective files and prospectively recruited patients presenting with TT (35 retrospective and 42 prospective), NSTEMI (48 retrospective and 75 prospective) and STEMI (20 retrospective and 39 prospective). We compared ratios of hs-TnT to CKMB on admission to the hospital between TT, NSTEMI and STEMI patients. Receiver operating characteristic (ROC) curves were analysed to determine optimal cut-off values. Results On admission, hs-TnT/CKMB ratio was significantly higher in TT patients than in NSTEMI and STEMI patients in both the retrospective phase (median and interquartile range, TT 0.024 [0.018–0.047] vs NSTEMI 0.009 [0.006–0.022], p < 0.0001; TT vs STEMI 0.011 [0.006–0.016], p = 0.0002) and the prospective cohort (median and interquartile range, TT 0.032 [0.018–0.040] vs NSTEMI 0.009 [0.006–0.015], p < 0.0001; TT vs STEMI 0.009 [0.005–0.017], p < 0.0001). A cut-off hs-TnT/CKMB ratio of 0.015 distinguished TT from MI with a sensitivity of 85.7% and a specificity of 67.6% (AUC 0.796; 95%CI: 0.71–0.89) in the retrospective phase. In the prospective phase, a ratio of 0.017 distinguished TT from MI with a sensitivity of 83.3% and a specificity of 78.1% (AUC 0.88; 95%CI: 0.83–0.94). Conclusion hs-TnT/CKMB ratio is a novel, readily available parameter that could be used alongside clinical risk scores, other biomarkers and ECG findings to discriminate between TT and MI. [ABSTRACT FROM AUTHOR]

Broken heart syndrome, also known as takotsubo cardiomyopathy, is a syndrome characterized by a transient regional systolic dysfunction of the left ventricle associated to a psychological stress. We herein describe a case of a 23-year-old female habitual marijuana user who was resuscitated after cardiac arrest and then diagnosed with midventricular stress cardiomyopathy complicated by subendocardial hemorrhage. We discuss this unique pathological finding, the incidence of arrhythmias in this syndrome, and the possible relation with chronic cannabis and tobacco use. Unfortunately, the patient did not survive, but had she survived, the management of the patient for secondary prevention would have been challenging considering the risk of recurrence with this disease. [ABSTRACT FROM AUTHOR]

Genetic and acquired motor-neuron-disorders (MNDs) may undergo acute deterioration resulting in various emergency situations. This literature review aims at summarising and discussing current knowledge about emergencies in MNDs. Emergencies that have been reported in MND patients include: respiratory, bulbar, cardiac, septic, epileptic, psychiatric, pain-related, and traumatic emergencies. Emergencies due to respiratory insufficiency have the strongest impact on morbidity and mortality in MNDs. To optimise the management of emergencies in MNDs, it is recommended to discuss these topics with the patient prior to their occurrence. After informed consent, patients may indicate their decision by signing an advance directive as to how such emergencies should be managed in case they arise. Generally, treatment of emergencies in MNDs is not at variance from treatment of similar emergencies due to other causes, but some peculiarities need to be pointed out. It is concluded that patients with MNDs may experience various emergencies during the disease course. Management of these conditions should be discussed with the patient prior to their appearance. Management of these emergencies follows general guidelines, which widely vary between countries, and depend on the availability of a patient's advance directive. [ABSTRACT FROM AUTHOR]

Background: Takostsubo (stress) cardiomyopathy (TC) is a clinical syndrome featuring transient left ventricular dysfunction and wall-motion abnormalities, usually following emotional or physical stress. The diagnosis of TC depends on fulfillment of multiple clinical criteria. Although the pathogenesis has not been firmly established, myocardial cathecholamine toxicity is thought to represent a primary mechanism. The vast majority of patients with TC survive. However, a rare cause of death in TC is myocardial rupture. All documented cases of rupture have followed known, recently diagnosed or suspected TC. However, in this report we propose that an initial diagnosis of TC with myocardial rupture can be made by autopsy when supported by a compelling clinical history and appropriate histologic changes in the myocardium. Case presentation: An 82 year-old female underwent elective craniotomy for a recently discovered craniopharyngioma. The surgery was uneventful; the initial postoperative course featured diabetes insipidus and delirium. With no prior warning, on the third postoperative day she was found unresponsive in bed. Two prolonged cardiopulmonary resuscitations were successful, however, during a third arrest maneuvers were stopped at the request of the family. An autopsy was conducted which revealed hemopericardium due to cardiac rupture. Coronary artery atherosclerosis, valve disease, and renal and extra-renal pheochromocytoma were absent. Microscopy of the myocardium showed a recent, localized, transmural myocardial infarction and diffuse changes (all four ventricles) typical of cathecholamine cardiomyopathy. The findings were considered compatible with TC with secondary myocardial rupture. Conclusion: An initial diagnosis of TC with myocardial rupture can be reasonably made by autopsy in the context of an appropriate clinical history and the presence of the characteristic microscopic features of cathecholamine excess in the myocardium. [ABSTRACT FROM AUTHOR]

Background Takotsubo syndrome (TS) may be triggered by numerous physical stress factors including exogenous Norepinephrine administration. The aim of this study is to report on the clinical features and outcome of serotonin-norepinephrine reuptake inhibitor (SNRI)-, selective NRI (S-NRI)-, and exogenously administered norepinephrine-induced TS in a largest possible cohort of published cases. Methods A computer assisted search of the electronic data base Pubmed was performed from 1990 to August 2016. All cases deemed to have SNRI-, S-NRI-, and norepinephrine-induced TS were retrieved. Results Twenty two cases of SNRI-, S-NRI-, and norepinephrine-induced TS were retrieved from the literature. At presentation, the 22 patients with TS were 11 to 82 years of age (mean age 49.9 ± 20 years). Seventeen of 21 (81%) of the patients were women. The most common presenting symptom was chest pain, which occurred in 59% of cases. The TS localization pattern was apical in 68%, mid-ventricular in 13.6%, basal in 13.6% and global in 4.5% of cases. Complications occurred in 7 of 22 (32%) with more complications in exogenously administered norepinephrine-induced TS (4 of 6, 66.7%) than SNRI-, and S-NRI-induced TS (3 of 16, 18, 8%) ( p = 0.054). All 4 male patients in the study developed complications. One patient (exogenous norepinephrine-induced TS) died during hospitalization. Conclusion The SNRI-, and S-NRI-induced TS have clinical features, complications and course comparable to that of all-TS population cohorts, whereas the exogenously administered norepinephrine-induced TS has a more dramatic clinical presentation and complication rates, which resembles that of exogenously administered epinephrine-induced TS. [ABSTRACT FROM AUTHOR]

Background: Takotsubo syndrome (TTS) is characterized by a transient left and/or right ventricular dysfunction as a consequence of a distinctive pattern of regional wall motion abnormalities. However, a systematic evaluation of the left atrial (LA) function in patients with TTS is lacking. The aim of the present study was therefore to comprehensively assess LA performance indexes and function in patients with TTS. Methods: We compared LA function assessed by volumetric indexes derived from fractional volume changes in cardiovascular magnetic resonance (CMR) between 125 TTS patients and 125 patients with anterior ST-segment elevation myocardial infarction (STEMI). Furthermore, recovery of LA performance was evaluated in a subgroup of 20 TTS patients with follow-up CMR data. Results: Patients with TTS demonstrated a significantly lower total LA emptying fraction (EF) [44% (interquartile range (IQR) 34-53%) versus 51% (IQR 42-56%); p < 0.01], passive LA-EF [21% (IQR 14-30%) versus 24% (IQR 20-29%); p = 0.03] and active LA-EF [29% (IQR 20-38%) versus 35% (28-42%); p < 0.01] compared to patients with anterior STEMI. Among the 20 TTS patients with serial CMR data, the total LA-EF significantly improved from 42% (IQR 29-48%) at the acute stage to 51% (IQR 46-59%) at follow-up (p < 0.01). Similarly, active LA-EF (p < 0.01) and passive LA-EF (p = 0.02) improved significantly as well. Conclusion: Compared to anterior STEMI, TTS patients demonstrated a significantly decreased LA function during the acute/subacute phase of the disease. However, impairment of LA performance seems to be transient in TTS with recovery during follow-up. [ABSTRACT FROM AUTHOR]

Takotsubo syndrome (TS), an increasingly recognized acute cardiac disease entity, is characterized by a unique pattern of circumferential and typically regional left ventricular wall motion abnormality resulting in a conspicuous transient ballooning of the left ventricle during systole. The mechanism of the disease remains elusive. However, the sudden onset of acute myocardial stunning in a systematic pattern extending beyond a coronary artery territory; the history of a preceding emotional or physical stress factor in two thirds of cases; the signs of sympathetic denervation at the regions of left ventricular dysfunction on sympathetic scintigraphy; the finding of myocardial edema and other signs consistent with (catecholamine-induced) myocarditis shown by cardiac magnetic resonance imaging; and the contraction band necrosis on histopathological examination all argue strongly for the involvement of the cardiac sympathetic nervous system in the pathogenesis of TS. In this narrative review, extensive evidence in support of local cardiac sympathetic nerve hyperactivation, disruption and norepinephrine spillover causing TS in predisposed patients is provided. [ABSTRACT FROM AUTHOR]

Introduction: Takotsubo cardiomyopathy (TC) is an acquired cardiomyopathy affecting mostly postmenopausal women mimicking an acute coronary syndrome (ACS). TC clinical presentation involves chest pain, elevated cardiac enzymes, wall motion abnormalities and electrocardiographic changes, all of which share striking similarities to ACS. Areas covered: Differential diagnosis between TC and ACS can be complex since there are no reliable and widely-accepted electrocardiographic criteria and, at the moment, only coronary angiography can rule out one of the two diagnoses with good certainty. The present review will discuss the pros and cons of the ECG in TC, focusing on how the signal changes through the acute phase, the hospitalization, and after discharge. Specific information will be provided for each component of the ECG trace, and potential pitfalls will be highlighted, in order get to the core of this important unmet clinical issue. Expert commentary: There are at least several reasons why the ECG is still not considered a useful tool in differential diagnosis between TC and ACS. These include recent awareness of the syndrome, lack of evidence-based therapy, and, more importantly, a wide range of ECG features according to race, patient characteristics, wall motion abnormalities, triggers, and time from symptoms onset. [ABSTRACT FROM AUTHOR]

Tachyarrhythmias have been well-defined in patients with Takotsubo cardiomyopathy (TTCM) and are estimated to occur in almost 13.5% of patients. However, limited data are available on bradyarrhythmias in patients with TTCM. The pathophysiology, clinical implications, and manage-ment are not well defined in this subgroup. We describe a 53-year-old woman presenting with complete heart block with TTCM and a 73-year-old woman presenting with syncope with complete heart block with TTCM. Both had persistent conduction delays despite recovery of ventricular function and eventually required permanent pacemaker implantation. The dependency on pacing was up to 90% in both patients at a 6-month follow-up., (Copyright© 2023 Tehran University of Medical Sciences. Published by Tehran University of Medical Sciences.)

Takotsubo syndrome (TTS) is a nonischemic cardiomyopathy with transient apical ballooning of the left ventricle and reduced ejection fraction that can be caused by severe emotional or physical stress, with diverse clinical presentations. This case describes a patient who went into cardiac arrest at a casino after winning the lottery. She was found to have Takotsubo cardiomyopathy, in the setting of uncontrolled hyperthyroidism. This is a very unique case of TTS presenting with cardiac arrest, and is also an uncommon example of TTS triggered by a positive rather than negative emotional life event., Competing Interests: Conflict of interest No conflicts of interest to disclose., (© 2023 Greater Baltimore Medical Center.)

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).)

Although Takotsubo cardiomyopathy (TCM) knowledge is increasing, the exact pathophysiology remains unclear. TCM represents 1%-2% of all troponin positive acute coronary syndromes, affects predominantly postmenopausal women, and is commonly preceded by exposure to severe physical or emotional stress. Transient wall motion abnormalities mimicking ST-elevation myocardial infarction is expected as well as increase of troponin levels and echocardiography alterations. This case report is about a patient that as far as we know is the first case that shows the use of myocardial perfusion imaging in the acute phase of TCM. In general, the TCM Mayo Clinic diagnostic criteria have been very helpful in the clinical setting. In this specific case, however, the presence of reduced myocardial perfusion in the acute phase combined with increased troponin levels seemed to be in contradiction with the exclusion of obstructive coronary artery disease. [ABSTRACT FROM AUTHOR]