Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): A mimic of acute myocardial infarction

The transient left ventricular apical ballooning syndrome, also known as takotsubo cardiomyopathy, is characterized by transient wall-motion abnormalities involving the left ventricular apex and mid-ventricle in the absence of obstructive epicardial coronary disease. In this paper, we review case series that report on patients with the transient left ventricular apical ballooning syndrome to better characterize patients presenting with the syndrome. We identified 7 case series that reported on at least 5 consecutive patients with the transient left ventricular apical ballooning syndrome. The syndrome more often affects postmenopausal women (82% to 100%) (mean age, 62 to 75 years). Patients commonly present with ST-segment elevation in the precordial leads, chest pain, relatively minor elevation of cardiac enzyme and biomarker levels, and transient apical systolic left ventricular dysfunction despite the absence of obstructive epicardial coronary disease. An episode of emotional or physiologic stress frequently precedes presentation with the syndrome. The in-hospital mortality rate seems to be low, as does the risk for recurrence.

Systematic Review: Transient Left Ventricular Apical Ballooning: A Syndrome That Mimics ST-Segment Elevation Myocardial Infarction

Aims To clarify the major features of the apical ballooning syndrome, we performed a systematic review of the existing literature.

Methods and results Review of all relevant case series using the MEDLINE and EMBASE databases resulted in the identification of 14 studies. These studies suggest that the apical ballooning syndrome accounts for ∼2.0% of ST-segment elevation infarcts, with most cases described in post-menopausal women. The most common clinical presentations are chest pain and dyspnoea, reported in 67.8 and 17.8% of the patients, respectively. Cardiogenic shock (4.2% of the patients) and ventricular fibrillation (1.5%) were not infrequent. ST-segment elevation was reported in 81.6% of the patients, T wave abnormalities in 64.3%, and Q waves in 31.8%. Cardiac biomarkers were usually mildly elevated, as reported in 86.2% of the patients. Typically, patients had left ventricular (LV) dysfunction on admission, with mean ejection fraction ranging from 20 to 49%. However, over a period of days to weeks, all patients experienced dramatic improvement in LV function. The onset of symptoms was often preceded by emotional (26.8%) or physical stress (37.8%). Norepinephrine concentration was elevated in 74.3% of the patients. Prognosis was generally excellent, with full recovery in most patients. In-hospital mortality was 1.1%. Only 3.5% of the patients experienced a recurrence.

Conculsion Clinicians should consider this syndrome in the differential diagnosis of patients presenting with chest pain, especially in post-menopausal women with a recent history of emotional or physical stress.

http://www.fortbildung.usz.ch/pdf/fb-Programme_alte-Versionen/ws06-07/kliwiko_01-11-06b.pdf

Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review.

Background— A clinical entity characterized by acute but rapidly reversible left ventricular (LV) systolic dysfunction and triggered by psychological stress is emerging, with reports largely confined to Japan. Methods and Results— Over a 32-month period, 22 consecutive patients with this novel cardiomyopathy were prospectively identified within a community-based practice in the Minneapolis–St. Paul, Minn, area. All patients were women aged 32 to 89 years old (mean 65±13 years); 21 (96%) were ≥50 years of age. The syndrome is characterized by (1) acute substernal chest pain with ST-segment elevation and/or T-wave inversion; (2) absence of significant coronary arterial narrowing by angiography; (3) systolic dysfunction (ejection fraction 29±9%), with abnormal wall motion of the mid and distal LV, ie, “apical ballooning”; and (4) profound psychological stress (eg, death of relatives, domestic abuse, arguments, catastrophic medical diagnoses, devastating financial or gambling losses) immediately preceding and...

Acute and Reversible Cardiomyopathy Provoked by Stress in Women From the United States

Takotsubo syndrome (TTS) is a poorly recognized heart disease that was initially regarded as a benign condition. Recently, it has been shown that TTS may be associated with severe clinical complications including death and that its prevalence is probably underestimated. Since current guidelines on TTS are lacking, it appears timely and important to provide an expert consensus statement on TTS. The clinical expert consensus document part I summarizes the current state of knowledge on clinical presentation and characteristics of TTS and agrees on controversies surrounding TTS such as nomenclature, different TTS types, role of coronary artery disease, and etiology. This consensus also proposes new diagnostic criteria based on current knowledge to improve diagnostic accuracy.

International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology

Assessment of clinical features in transient left ventricular apical ballooning

[Usefulness of technetium-99m tetrofosmin single-photon emission computed tomography for short-term risk stratification in patients with acute chest pain in the emergency room].

Noninvasive assessment of coronary microvascular dysfunction using Tc-99m tetrofosmin SPECT in patients with acute myocardial infarction

[Effect of collateral circulation on myocardial protection in patients with acute myocardial infarction: comparison of technetium-99m-tetrofosmin myocardial single photon emission computed tomography and coronary angiography].

Ryota Matsuoka

Papers

Assessment of clinical features in transient left ventricular apical ballooning

[Usefulness of technetium-99m tetrofosmin single-photon emission computed tomography for short-term risk stratification in patients with acute chest pain in the emergency room].

Noninvasive assessment of coronary microvascular dysfunction using Tc-99m tetrofosmin SPECT in patients with acute myocardial infarction

[Effect of collateral circulation on myocardial protection in patients with acute myocardial infarction: comparison of technetium-99m-tetrofosmin myocardial single photon emission computed tomography and coronary angiography].