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Takotsubo cardiomyopathy

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Abstract

Takotsubo cardiomyopathy (TC) is characterized by transient left ventricular apical wall motion abnormalities, chest pain with electrocardiographic changes, and modest myocardial enzymatic release mimicking acute coronary syndrome, but without significant coronary artery disease. TC is an increasingly recognized type of acquired cardiomyopathy occurring commonly after a recent stressful event, in particular emotional stress, and is relatively common in middle-aged and older women. The pathogenetic mechanism remains unknown. Catecholamine surge related to emotional distress seems to play a major role in the pathogenesis of this cardiomyopathy, rendering TC a type of neurocardiological disorder that manifests as acute but reversible heart failure. Clinicians should consider this syndrome in the differential diagnosis of patients presenting with clinical findings suggestive of acute coronary syndrome, especially in postmenopausal women with a recent history of acute emotional or physical stress.

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References

  1. Sato H, Tateishi H, Uchida T (1990) Takotsubo-like left ventricular dysfunction due to multivessel coronary spasm. Clinical aspect of myocardial injury: from ischemia to heart failure. Kagakuhyoronsha Press, Tokyo

    Google Scholar 

  2. Bybee KA, Prasad A, Barsness GW, Lerman A, Jaffe AS, Murphy JG, Wright RS, Rihal CS (2004) Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome. Am J Cardiol 94(3):343–346

    Article  PubMed  Google Scholar 

  3. Sharkey SW, Lesser JR, Zenovich AG, Maron MS, Lindberg J, Longe TF, Maron BJ (2005) Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation 111(4):472–479. doi:10.1161/01.cir.0000153801.51470.eb

    Article  PubMed  Google Scholar 

  4. Tsuchihashi K, Ueshima K, Uchida T, Oh-mura N, Kimura K, Owa M, Yoshiyama M, Miyazaki S, Haze K, Ogawa H, Honda T, Hase M, Kai R-i, Morii I (2001) Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. J Am Coll Cardiol 38(1):11–18

    Article  CAS  PubMed  Google Scholar 

  5. Desmet WJR, Adriaenssens BFM, Dens JAY (2003) Apical ballooning of the left ventricle: first series in white patients. Heart 89(9):1027–1031. doi:10.1136/heart.89.9.1027

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  6. Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E (2006) Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J 27(13):1523–1529. doi:10.1093/eurheartj/ehl032

    Article  PubMed  Google Scholar 

  7. Nef HM, Mollmann H, Elsasser A (2007) Tako-tsubo cardiomyopathy (apical ballooning). Heart 93(10):1309–1315. doi:10.1136/hrt.2006.101675

    Article  PubMed Central  PubMed  Google Scholar 

  8. Bybee KA, Kara T, Prasad A, Lerman A, Barsness GW, Wright RS, Rihal CS (2004) Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med 141(11):858–865

    Article  PubMed  Google Scholar 

  9. Elesber AA, Prasad A, Lennon RJ, Wright RS, Lerman A, Rihal CS (2007) Four-year recurrence rate and prognosis of the apical ballooning syndrome. J Am Coll Cardiol 50(5):448–452. doi:10.1016/j.jacc.2007.03.050

    Article  PubMed  Google Scholar 

  10. Sharkey SW, Windenburg DC, Lesser JR, Maron MS, Hauser RG, Lesser JN, Haas TS, Hodges JS, Maron BJ (2010) Natural history and expansive clinical profile of stress (tako-tsubo) cardiomyopathy. J Am Coll Cardiol 55(4):333–341. doi:10.1016/j.jacc.2009.08.057

    Article  PubMed  Google Scholar 

  11. Kurowski V, Kaiser A, von Hof K, Killermann DP, Mayer Bn, Hartmann F, Schunkert H, Radke PW (2007) Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): frequency, mechanisms, and prognosis. Chest 132(3):809–816

    Article  PubMed  Google Scholar 

  12. Kurisu S, Sato H, Kawagoe T, Ishihara M, Shimatani Y, Nishioka K, Kono Y, Umemura T, Nakamura S (2002) Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction. Am Heart J 143(3):448–455

    Article  PubMed  Google Scholar 

  13. Wittstein IS, Thiemann DR, Lima JAC, Baughman KL, Schulman SP, Gerstenblith G, Wu KC, Rade JJ, Bivalacqua TJ, Champion HC (2005) Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 352(6):539–548. doi:10.1056/NEJMoa043046

    Article  CAS  PubMed  Google Scholar 

  14. Hinojosa-Laborde C, Chapa I, Lange D, Haywood JR (1999) Gender differences in sympathetic nervous system regulation. Clin Exp Pharmacol Physiol 26(2):122–126. doi:10.1046/j.1440-1681.1999.02995.x

    Article  CAS  PubMed  Google Scholar 

  15. Sader MA, Celermajer DS (2002) Endothelial function, vascular reactivity and gender differences in the cardiovascular system. Cardiovasc Res 53(3):597–604. doi:10.1016/s0008-6363(01)00473-4

    Article  CAS  PubMed  Google Scholar 

  16. Lambert G, Naredi S, Eden E, Rydenhag B, Friberg P (2002) Monoamine metabolism and sympathetic nervous activation following subarachnoid haemorrhage: influence of gender and hydrocephalus. Brain Res Bull 58(1):77–82

    Article  CAS  PubMed  Google Scholar 

  17. Taddei S, Virdis A, Ghiadoni L, Mattei P, Sudano I, Bernini G, Pinto S, Salvetti A (1996) Menopause is associated with endothelial dysfunction in women. Hypertension 28(4):576–582. doi:10.1161/01.hyp.28.4.576

    Article  CAS  PubMed  Google Scholar 

  18. Hayward CS, Kelly RP, Collins P (2000) The roles of gender, the menopause and hormone replacement on cardiovascular function. Cardiovasc Res 46(1):28–49. doi:10.1016/s0008-6363(00)00005-5

    Article  CAS  PubMed  Google Scholar 

  19. Bybee KA, Motiei A, Syed IS, Kara T, Prasad A, Lennon RJ, Murphy JG, Hammill SC, Rihal CS, Wright RS (2007) Electrocardiography cannot reliably differentiate transient left ventricular apical ballooning syndrome from anterior ST-segment elevation myocardial infarction. J Electrocardiol 40(1):38.e1–38.e6

    Article  Google Scholar 

  20. Prasad A, Lerman A, Rihal CS (2008) Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J 155(3):408–417

    Article  PubMed  Google Scholar 

  21. Eitel I, von Knobelsdorff-Brenkenhoff F, Bernhardt P, Carbone I, Muellerleile K, Aldrovandi A, Francone M, Desch S, Gutberlet M, Strohm O, Schuler G, Schulz-Menger J, Thiele H, Friedrich MG (2011) Clinical characteristics and cardiovascular magnetic resonance findings in stress (takotsubo) cardiomyopathy. JAMA 306(3):277–286. doi:10.1001/jama.2011.992

    Article  CAS  PubMed  Google Scholar 

  22. Eitel I, Behrendt F, Schindler K, Kivelitz D, Gutberlet M, Schuler G, Thiele H (2008) Differential diagnosis of suspected apical ballooning syndrome using contrast-enhanced magnetic resonance imaging. Eur Heart J 29(21):2651–2659. doi:10.1093/eurheartj/ehn433

    Article  PubMed  Google Scholar 

  23. Haghi D, Fluechter S, Suselbeck T, Kaden JJ, Borggrefe M, Papavassiliu T (2007) Cardiovascular magnetic resonance findings in typical versus atypical forms of the acute apical ballooning syndrome (Takotsubo cardiomyopathy). Int J Cardiol 120(2):205–211

    Article  PubMed  Google Scholar 

  24. Mahrholdt H, Wagner A, Judd RM, Sechtem U, Kim RJ (2005) Delayed enhancement cardiovascular magnetic resonance assessment of non-ischaemic cardiomyopathies. Eur Heart J 26(15):1461–1474. doi:10.1093/eurheartj/ehi258

    Article  PubMed  Google Scholar 

  25. Aretz HT, Billingham ME, Edwards WD, Factor SM, Fallon JT, Fenoglio JJ Jr, Olsen EG, Schoen FJ (1987) Myocarditis. A histopathologic definition and classification. Am J Cardiovasc Pathol 1(1):3–14

    CAS  PubMed  Google Scholar 

  26. Akashi YJ, Nakazawa K, Sakakibara M, Miyake F, Musha H, Sasaka K (2004) 123I-MIBG myocardial scintigraphy in patients with ‘’ takotsubo ‘’ cardiomyopathy. J Nucl Med 45(7):1121–1127

    PubMed  Google Scholar 

  27. Kume T, Kawamoto T, Okura H, Toyota E, Neishi Y, Watanabe N, Hayashida A, Okahashi N, Yoshimura Y, Saito K, Nezuo S, Yamada R, Yoshida K (2008) Local release of catecholamines from the hearts of patients with tako-tsubo-like left ventricular dysfunction. Circ J 72(1):106–108

    Article  CAS  PubMed  Google Scholar 

  28. Movahed A, Reeves WC, Mehta PM, Gilliland MG, Mozingo SL, Jolly SR (1994) Norepinephrine-induced left ventricular dysfunction in anesthetized and conscious, sedated dogs. Int J Cardiol 45(1):23–33

    Article  CAS  PubMed  Google Scholar 

  29. Frustaci A, Loperfido F, Gentiloni N, Caldarulo M, Morgante E, Russo MA (1991) Catecholamine-induced cardiomyopathy in multiple endocrine neoplasia. A histologic, ultrastructural, and biochemical study. Chest 99(2):382–385

    Article  CAS  PubMed  Google Scholar 

  30. Kono T, Morita H, Kuroiwa T, Onaka H, Takatsuka H, Fujiwara A (1994) Left ventricular wall motion abnormalities in patients with subarachnoid hemorrhage: neurogenic stunned myocardium. J Am Coll Cardiol 24(3):636–640. doi:10.1016/0735-1097(94)90008-6

    Article  CAS  PubMed  Google Scholar 

  31. Takizawa M, Kobayakawa N, Uozumi H, Yonemura S, Kodama T, Fukusima K, Takeuchi H, Kaneko Y, Kaneko T, Fujita K, Honma Y, Aoyagi T (2007) A case of transient left ventricular ballooning with pheochromocytoma, supporting pathogenetic role of catecholamines in stress-induced cardiomyopathy or takotsubo cardiomyopathy. Int J Cardiol 114(1):E15–E17

    Article  PubMed  Google Scholar 

  32. Ueyama T (1018) (2004) Emotional stress-induced Tako-tsubo cardiomyopathy: animal model and molecular mechanism. Ann N Y Acad Sci 1:437–444. doi:10.1196/annals.1296.054

    Google Scholar 

  33. Obunai K, Misra D, Van Tosh A, Bergmann SR (2005) Metabolic evidence of myocardial stunning in takotsubo cardiomyopathy: a positron emission tomography study. J Nucl Cardiol 12(6):742–744. doi:10.1016/j.nuclcard.2005.06.087

    Article  PubMed  Google Scholar 

  34. Bybee KA, Murphy J, Prasad A, Wright RS, Lerman A, Rihal CS, Chareonthaitawee P (2006) Acute impairment of regional myocardial glucose uptake in the apical ballooning (takotsubo) syndrome. J Nucl Cardiol 13(2):244–250. doi:10.1016/j.nuclcard.2006.01.016

    Article  PubMed  Google Scholar 

  35. Huang MT, Lee CF, Dobson GP (1997) Epinephrine enhances glycogen turnover and depresses glucose uptake in vivo in rat heart. FASEB J 11(12):973–980

    CAS  PubMed  Google Scholar 

  36. Kume T, Akasaka T, Kawamoto T, Yoshitani H, Watanabe N, Neishi Y, Wada N, Yoshida K (2005) Assessment of coronary microcirculation in patients with takotsubo-like left ventricular dysfunction. Circ J 69(8):934–939

    Article  PubMed  Google Scholar 

  37. Elesber A, Lerman A, Bybee KA, Murphy JG, Barsness G, Singh M, Rihal CS, Prasad A (2006) Myocardial perfusion in apical ballooning syndrome correlate of myocardial injury. Am Heart J 152(3):469.e9–469.e13

    Article  Google Scholar 

  38. Kulandavelu S, Hare JM (2012) Alterations in beta3-adrenergic cardiac innervation and nitric oxide signaling in heart failure. J Am Coll Cardiol 59(22):1988–1990. doi:10.1016/j.jacc.2012.01.058

    Article  CAS  PubMed  Google Scholar 

  39. Gauthier C, Langin D, Balligand J-L (2000) Beta3-adrenoceptors in the cardiovascular system. Trends Pharmacol Sci 21(11):426–431

    Article  CAS  PubMed  Google Scholar 

  40. Heubach JF, Rau T, Eschenhagen T, Ravens U, Kaumann AJ (2002) Physiological antagonism between ventricular β1-adrenoceptors and α1-adrenoceptors but no evidence for β2- and β3-adrenoceptor function in murine heart. Br J Pharmacol 136(2):217–229. doi:10.1038/sj.bjp.0704700

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  41. Niu X, Watts VL, Cingolani OH, Sivakumaran V, Leyton-Mange JS, Ellis CL, Miller KL, Vandegaer K, Bedja D, Gabrielson KL, Paolocci N, Kass DA, Barouch LA (2012) Cardioprotective effect of beta-3 adrenergic receptor agonism: role of neuronal nitric oxide synthase. J Am Coll Cardiol 59(22):1979–1987

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  42. Moens AL, Yang R, Watts VL, Barouch LA (2010) Beta 3-adrenoreceptor regulation of nitric oxide in the cardiovascular system. J Mol Cell Cardiol 48(6):1088–1095. doi:10.1016/j.yjmcc.2010.02.011

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  43. Haghi D, Roehm S, Hamm K, Harder N, Suselbeck T, Borggrefe M, Papavassiliu T (2010) Takotsubo Cardiomyopathy is not due to plaque rupture: an intravascular ultrasound study. Clin Cardiol 33(5):307–310. doi:10.1002/clc.20747

    Article  PubMed  Google Scholar 

  44. Abe Y, Kondo M, Matsuoka R, Araki M, Dohyama K, Tanio H (2003) Assessment of clinical features in transient left ventricular apical ballooning. J Am Coll Cardiol 41(5):737–742. doi:10.1016/S0735-1097(02)02925-X

    Article  PubMed  Google Scholar 

  45. Ito K, Sugihara H, Kawasaki T, Yuba T, Doue T, Tanabe T, Adachi Y, Katoh S, Azuma A, Nakagawa M (2001) Assessment of ampulla (Takotsubo) cardiomyopathy with coronary angiography, two-dimensional echocardiography and 99mTc-tetrofosmin myocardial single photon emission computed tomography. Ann Nucl Med 15(4):351–355

    Article  CAS  PubMed  Google Scholar 

  46. Kurisu S, Inoue I, Kawagoe T, Ishihara M, Shimatani Y, Nishioka K, Umemura T, Nakamura S, Yoshida M, Sato H (2003) Myocardial perfusion and fatty acid metabolism in patients with tako-tsubo-like left ventricular dysfunction. J Am Coll Cardiol 41(5):743–748. doi:10.1016/S0735-1097(02)02924-8

    Article  CAS  PubMed  Google Scholar 

  47. Galiuto L, De Caterina AR, Porfidia A, Paraggio L, Barchetta S, Locorotondo G, Rebuzzi AG, Crea F (2010) Reversible coronary microvascular dysfunction: a common pathogenetic mechanism in Apical Ballooning or Tako-Tsubo Syndrome. Eur Heart J 31(11):1319–1327. doi:10.1093/eurheartj/ehq039

    Article  PubMed  Google Scholar 

  48. Meimoun P, Malaquin D, Sayah S, Benali T, Luycx-Bore A, Levy F, Zemir H, Tribouilloy C (2008) The coronary flow reserve is transiently impaired in tako-tsubo cardiomyopathy: a prospective study using serial Doppler transthoracic echocardiography. J Am Soc Echocardiogr 21(1):72–77

    Article  PubMed  Google Scholar 

  49. Meimoun P, Malaquin D, Benali T, Tribouilloy C (2008) Assessment of coronary flow reserve by transthoracic Doppler echocardiography in left apical ballooning syndrome. Eur J Echocardiogr 9(1):78–79. doi:10.1016/j.euje.2007.01.002

    PubMed  Google Scholar 

  50. Lacy CR, Contracta RJ, Robbins ML, Tannenbaum AK, Moreyra AE, Chelton S, Kostis JB (1995) Coronary vasoconstriction induced by mental stress (simulated public speaking). Am J Cardiol 75(7):503–505

    Article  CAS  PubMed  Google Scholar 

  51. Martin EA, Prasad A, Rihal CS, Lerman LO, Lerman A (2010) Endothelial function and vascular response to mental stress are impaired in patients with apical ballooning syndrome. J Am Coll Cardiol 56(22):1840–1846. doi:10.1016/j.jacc.2010.03.107

    Article  PubMed Central  PubMed  Google Scholar 

  52. Hizume T, Morikawa K, Takaki A, Abe K, Sunagawa K, Amano M, Kaibuchi K, Kubo C, Shimokawa H (2006) Sustained elevation of serum cortisol level causes sensitization of coronary vasoconstricting responses in pigs in vivo. Circ Res 99(7):767–775. doi:10.1161/01.RES.0000244093.69985.2f

    Article  CAS  PubMed  Google Scholar 

  53. Chilian WM (1990) Adrenergic vasomotion in the coronary microcirculation. Basic Res Cardiol 85(Suppl 1):111–120

    PubMed  Google Scholar 

  54. Akashi YJ, Goldstein DS, Barbaro G, Ueyama T (2008) Takotsubo cardiomyopathy: a new form of acute, reversible heart failure. Circulation 118(25):2754–2762. doi:10.1161/circulationaha.108.767012

    Article  PubMed  Google Scholar 

  55. Kaski JC (2006) Cardiac syndrome X in women: the role of oestrogen deficiency. Heart 92(suppl 3):iii5–iii9. doi:10.1136/hrt.2005.070318

    CAS  PubMed Central  PubMed  Google Scholar 

  56. Mori H, Ishikawa S, Kojima S, Hayashi J, Watanabe Y, Hoffman JIE, Okino H (1993) Increased responsiveness of left ventricular apical myocardium to adrenergic stimuli. Cardiovasc Res 27(2):192–198. doi:10.1093/cvr/27.2.192

    Article  CAS  PubMed  Google Scholar 

  57. Pierpont GL, DeMaster EG, Cohn JN (1984) Regional differences in adrenergic function within the left ventricle. Am J Physiol Heart Circ Physiol 246(6):H824–H829

    CAS  Google Scholar 

  58. Kawano H, Okada R, Yano K (2003) Histological study on the distribution of autonomic nerves in the human heart. Heart Vessels 18(1):32–39. doi:10.1007/s003800300005

    Article  PubMed  Google Scholar 

  59. Hernandez-Pampaloni M, Keng FYJ, Kudo T, Sayre JS, Schelbert HR (2001) Abnormal longitudinal, base-to-apex myocardial perfusion gradient by quantitative blood flow measurements in patients with coronary risk factors. Circulation 104(5):527–532. doi:10.1161/hc3001.093503

    Article  CAS  PubMed  Google Scholar 

  60. Broadley AJ, Korszun A, Abdelaal E, Moskvina V, Jones CJ, Nash GB, Ray C, Deanfield J, Frenneaux MP (2005) Inhibition of cortisol production with metyrapone prevents mental stress-induced endothelial dysfunction and baroreflex impairment. J Am Coll Cardiol 46(2):344–350. doi:10.1016/j.jacc.2005.03.068

    Article  CAS  PubMed  Google Scholar 

  61. Dimsdale JE (2008) Psychological stress and cardiovascular disease. J Am Coll Cardiol 51(13):1237–1246. doi:10.1016/j.jacc.2007.12.024

    Article  PubMed Central  PubMed  Google Scholar 

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Kono, T., Sabbah, H.N. Takotsubo cardiomyopathy. Heart Fail Rev 19, 585–593 (2014). https://doi.org/10.1007/s10741-013-9404-9

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