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

The clinical expert consensus statement on takotsubo syndrome (TTS) part II focuses on the diagnostic workup, outcome, and management. The recommendations are based on interpretation of the limited clinical trial data currently available and experience of international TTS experts. It summarizes the diagnostic approach, which may facilitate correct and timely diagnosis. Furthermore, the document covers areas where controversies still exist in risk stratification and management of TTS. Based on available data the document provides recommendations on optimal care of such patients for practising physicians.

https://www.zora.uzh.ch/id/eprint/162489/1/ehy077.pdf

International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management

Stress Cardiomyopathy Diagnosis and Treatment: JACC State-of-the-Art Review

Aims The aim of our study is to assess the incidence and clinical significance of right ventricular (RV) involvement in Takotsubo cardiomyopathy (TTC).

Methods and results Between February 2002 and December 2005, 47 patients with TTC underwent cardiovascular magnetic resonance (CMR) at our institutions. 13 patients with delayed initial CMR were excluded. In the remaining 34 patients (32 women), RV wall motion abnormalities (WMAs) were present in nine (26%). Left ventricular ejection fraction (LVEF) was significantly lower in patients with RV involvement (40 ± 6 vs. 48 ± 10%, P  = 0.04). The most frequently affected RV segments were the apico-lateral (89%), the antero-lateral (67%), and the inferior segment (67%). All RV WMA improved or disappeared in eight of nine patients who underwent a follow-up CMR study. Pleural effusion was more common in patients with RV involvement (67 vs. 8%, P  < 0.001) and was predictive of RV dysfunction (sensitivity 67% and specificity 92%). Significant or bilateral pleural effusions were seen exclusively in patients with RV involvement.

Conclusion RV involvement is common in TTC and seems to be associated with a more severe impairment in LV systolic function. It may be suspected by the presence of pleural effusion.

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Right ventricular involvement in Takotsubo cardiomyopathy

Clinical expression of phaeochromocytoma may involve numerous cardiovascular manifestations, but usually presents as sustained or paroxysmal hypertension associated with other signs and symptoms of catecholamine excess. Most of the life-threatening cardiovascular manifestations of phaeochromocytoma, such as hypertensive emergencies, result from a rapid and massive release of catecholamines from the tumour. More rarely, patients with phaeochromocytoma present with low blood pressure or even shock that may then precede multisystem crisis. Sinus tachycardia, with palpitations as the presenting symptom, is the most prevalent abnormality of cardiac rhythm in phaeochromocytoma, but tumours can also be associated with more serious ventricular arrhythmias or conduction disturbances. Reversible dilated or hypertrophic cardiomyopathy are well established cardiac manifestations of phaeochromocytoma, with more recent attention to an increasing number of cases with Takotsubo cardiomyopathy. This review provides an update on the cause, clinical presentation and treatment of the cardiovascular manifestations of phaeochromocytoma. As the cardiovascular complications of phaeochromocytoma can be life-threatening, all patients who present with manifestations that even remotely suggest excessive catecholamine secretion should be screened for the disease.

Cardiovascular manifestations of phaeochromocytoma

Summary Background: Left ventricular (LV) thrombus is a known complication of tako-tsubo cardiomyopathy (TC). However, current literature almost exclusively consists of isolated case reports. The aim of this study was to determine the incidence and clinical significance of LV thrombus formation in TC. Methods and Results: Over a 33-month period 52 patients with TC were assembled into a database at our institution. A retrospective database search was performed to identify patients with LV thrombus among these patients. LV thrombus, by echocardiography, was discovered in four patients[(8%); 95% confidence interval 3–19%]. Thrombus was present at the time of diagnosis in three patients. In one patient thrombus was absent initially and developed later. The LV apex was the site of thrombus formation in two patients, but the true apex was spared in the other two. All four patients had elevated serum levels of C-reactive protein (CRP). Two patients also had thrombocytosis. Treatment with low molecular weight heparin (LMWH) led to resolution of thrombus in all cases. Conclusions: Our findings suggest that LV thrombus is a noteworthy complication in TC. It can occur both at initial presentation or at anytime later during the disease course. Elevated CRP levels and thrombocytosis may indicate a higher risk of thrombus formation.

Incidence and clinical significance of left ventricular thrombus in tako-tsubo cardiomyopathy assessed with echocardiography

Takotsubo cardiomyopathy (TTC) consists of an acute onset of transient akinesia of the apical and mid portions of the left ventricle, without significant coronary artery stenosis. TTC is often accompanied by chest pain, dynamic reversible ST-T segment abnormalities, and increased cardiac enzymes disproportionate to the extent of akinesia.1

Until now, it was believed that wall motion abnormalities (WMA) in this syndrome invariably affect the left ventricular (LV) apex. However, we present a syndrome mimicking classic TTC without involvement of the LV apex.

We retrospectively evaluated consecutive patients admitted with an acute coronary syndrome between January 2004 and December 2004. Patients who met the following criteria were selected: firstly, reversible akinesia/dyskinesia beyond a single major coronary artery vascular distribution on left ventriculography sparing the LV apex; secondly, no coronary artery diameter stenosis > 50% on angiography; thirdly, increased cardiac enzymes; and lastly, available results of a gadolinium enhanced cardiovascular magnetic resonance (CMR) scan. Laboratory tests, serial ECGs, and echocardiography were performed according to standard protocol for management of acute coronary syndromes at our …

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Variant form of the acute apical ballooning syndrome (takotsubo cardiomyopathy): observations on a novel entity.

Tako-Tsubo cardiomyopathy (TTC) predominantly affects elderly people with a high prevalence of cardiovascular risk factors. Therefore, one would expect to encounter incidental coronary artery disease in a significant number of cases. In fact, the prevalence of mild coronary artery disease (CAD), by angiography, has been reported to be in the range of 30%-60%. Similarly, more severe stenotic lesions in at least one coronary vessel were incidentally found in 10%-35% of patients with the disease. Using intravascular ultrasound in a series of 10 patients with TTC, coronary atherosclerosis was demonstrable in all patients, although five patients had normal coronary angiograms. Therefore, TTC and CAD are not mutually exclusive disease entities. The incidental finding of coronary lesions, even if significant, should not automatically lead to a dismissal of the diagnosis of TTC. Rather, a case-by-case approach using additional imaging modalities should be endorsed.

T. Suselbeck

Papers

Incidence and clinical significance of left ventricular thrombus in tako-tsubo cardiomyopathy assessed with echocardiography

Variant form of the acute apical ballooning syndrome (takotsubo cardiomyopathy): observations on a novel entity.

Coincidence of coronary artery disease and Tako-Tsubo cardiomyopathy.

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