Síndrome de tako-tsubo en una adolescente. Presentación de caso

El síndrome de tako-tsubo es una miocardiopatía aguda por estrés, caracterizada por una anormalidad regional del movimiento de la pared del ventrículo izquierdo, con un patrón circunferencial peculiar que resulta en un abultamiento notorio del ventrículo izquierdo durante la sístole. En Cuba, el síndrome de tako-tsubo ha sido publicado en pacientes adultos, pero se considera una entidad rara en niños, razón por la cual se decidió hacer este reporte. Se presenta el caso de una adolescente de 16 años, con antecedentes de haber dado a luz hacía 44 días al momento del ingreso, que fue recibida en el Servicio de Emergencias en estado grave, con disnea, dolor precordial y manifestaciones de choque, por lo que fue derivada inmediatamente a la Unidad de Cuidados Intensivos Pediátricos. Los antecedentes de haber tenido un factor desencadenante de estrés como el parto por cesárea, el electrocardiograma con signos de isquemia miocárdica y el ecocardiograma típico, con discinesia de segmentos apicales del ventrículo izquierdo, permitieron hacer el diagnóstico de síndrome de tako-tsubo y dirigir el tratamiento en ese sentido. Este síndrome es infrecuente en la edad pediátrica, por tanto, puede presentarse como una forma grave y no ser reconocido, trayendo implicaciones pronósticas.

Takotsubo syndrome is an acute stress cardiomyopathy, characterized by a regional abnormality of left ventricular wall motion, with a peculiar circumferential pattern that results in marked left ventricular bulging during systole. In Cuba, takotsubo syndrome has been published in adult patients, but it is considered a rare entity in children, so it was decided to make this report. The case of a 16-years-old adolescent, with a history of having given birth 44 days before at the time of admission, who was received at the Emergency Department in serious condition, with dyspnea, precordial pain, and manifestations of shock, for what she was immediately referred to the Pediatric Intensive Care Unit it is presented. The history of having had a stress trigger such as delivery by cesarean section, the electrocardiogram with signs of myocardial ischemia, and the typical echocardiogram, with dyskinesia of the apical segments of the left ventricle, allowed the diagnosis of takotsubo syndrome and direct treatment in that sense. This syndrome is rare in the pediatric age, therefore, it can present as a severe form and not be recognized, bringing prognostic implications.

Recurrent takotsubo syndrome: case report and literature review

Introduction: Takotsubo syndrome is a cardiomyopathy that can lead to severe myocardial involvement. It is characterized by the presence of signs and symptoms suggestive of ventricular dysfunction associated with an adrenergic discharge during a stressful event. This case report presents a literature review, as well as a comparison with other similar cases. Case presentation. A 56-year-old female with a previous episode of Takotsubo was admitted to the emergency department due to symptoms of acute coronary syndrome and a history of Takotsubo syndrome. Her electrocardiogram showed T-wave inversion in leads V1-V4 and a raise in troponins. Percutaneous coronary angiography revealed no coronary lesions, and an echocardiogram revealed segmental alterations compatible with Takotsubo syndrome, requiring medical therapy with beta-blockers and angiotensin-converting enzyme (ACE) inhibitors, with subsequent improvement in ventricular function. Conclusions. Recurrence in Takotsubo cardiomyopathy is a rare complication that should be suspected. The risk factors associated with recurrence are not known. Although therapy with ACE inhibitors and beta-blockers seems to have an impact on the recovery of ventricular function in patients with this condition, further studies are necessary to establish the best pharmacological treatment.

Introducción. La miocardiopatía de Takotsubo (MT) es una afección cardiaca que puede generar compromiso miocárdico severo y se caracteriza por la presencia de signos y síntomas sugestivos de disfunción ventricular que se asocian a una descarga adrenérgica durante un evento estresor. En este reporte de caso se realizó una revisión de la literatura y se hizo una comparación con otros casos similares al presentado. Presentación del caso. Mujer de 56 años, quien asistió al servicio de urgencias por síntomas sugestivos de un síndrome coronario agudo. A la paciente, que tenía antecedente de MT, se le realizó un electrocardiograma que mostró inversión de la onda T en las derivaciones V1-V4 y elevación de troponinas, una angiografía coronaria que evidenció arterias epicárdicas sin lesiones y un ecocardiograma que reveló alteraciones segmentarias compatibles con MT, por lo que se estableció manejo con betabloqueadores e inhibidores de la enzima convertidora de angiotensina (IECA), con lo cual se logró mejoría de la función ventricular. Conclusiones. La MT es una afección poco frecuente de la cual no se conocen los factores de riesgo asociados a su recurrencia. Aunque la terapia con IECA y betabloqueadores parece tener un impacto en la recuperación de la función ventricular en pacientes con esta condición, se requieren estudios adicionales para establecer el mejor manejo farmacológico.

Soporte circulatorio con ECMO venoarterial en paciente con cardiomiopatía de Takotsubo biventricular / Circulatory support with venoarterial ECMO in a patient with biventricular Takotsubo cardiomyopathy

Resumen La cardiomiopatía de Takotsubo es una entidad caracterizada por disfunción ventricular aguda y transitoria, la cual está generalmente relacionada a un evento desencadenante (estrés emocional o físico) y que, por lo general, se presenta con disfunción sistólica regional del ventrículo izquierdo, aunque hasta en un 30% puede ser biventricular. Según su severidad, en algunos casos puede condicionar choque cardiogénico refractario a manejo con inotrópicos y vasopresores, por lo que para estos casos deben considerarse los dispositivos de asistencia circulatoria. Presentamos el caso de una paciente joven a quien se realizó cambio valvular pulmonar con prótesis biológica, la cual siete semanas posteriores a la cirugía acudió al servicio de urgencias con derrame pericárdico y fisiología de tamponade secundario a síndrome pospericardiotomía. Por tal motivo se le practicó ventana pericárdica, sin embargo durante el transquirúrgico presentó cardiomiopatía de Takotsubo biventricular que le condicionó choque cardiogénico con insuficiencia mitral y tricúspidea severas y refractariedad a tratamiento médico, así como a balón intraaórtico de contrapulsación (BIAC), por lo cual requirió soporte circulatorio con ECMO venoarterial durante 5 días.

Abstract Takotsubo cardiomyopathy is an entity characterized by acute and transient ventricular dysfunction, which is usually related to a triggering event (emotional or physical stress), and usually presents with regional systolic dysfunction of the left ventricle, however up to 30% may be biventricular. Depending on its severity in some cases the disease can condition refractory cardiogenic shock to management with inotropics and vasopressors, so for these cases circulatory assistance devices should be considered. We present the case of a young patient who had pulmonary valve change with biological prosthesis, which seven weeks after surgery went to the emergency department with pericardial effusion and tamponade physiology secondary to postpericardiotomy syndrome. For this reason pericardial window was practiced, however during the procedure she presented biventricular Takotsubo cardiomyopathy which conditioned cardiogenic shock with severe mitral and tricuspid regurgitation, and refractivity to medical treatment as well as intraaortic balloon pump, requiring circulatory support with venoarterial ECMO for 5 days.

El síndrome de Takotsubo con taponamiento cardíaco como complicación inusual / Takotsubo syndrome with cardiac tamponade as an unusual complication

Introducción: La miocardiopatía por estrés o síndrome de Takotsubo está asociado a la reducción de la fracción de eyección, niveles elevados de enzimas cardiacas y signos de isquemia en el electrocardiograma. Sin embargo, en pocas ocasiones trascurre con complicaciones tan importantes como el taponamiento cardiaco, deterioro significativo de la contractilidad y la posibilidad de trombos dentro de la cavidad ventricular. Estas son subestimadas a pesar de poner en riesgo la vida del paciente. Objetivo: Describir el caso de una paciente con miocardiopatía por estrés con taponamiento cardiaco como una complicación inusual. Caso clínico: Paciente en la novena década de la vida con antecedente de hipertensión arterial sistémica primaria y enfermedad pulmonar obstructiva crónica. Presentó dolor precordial con trastornos de la contractilidad de patrón usual correspondiente a la cardiomiopatía de Takotsubo en la que se descartaron otros diagnósticos diferenciales. Conclusiones: El caso presentado de miocardiopatía de Takotsubo asociado a una complicación cardiovascular tan importante e inusual como el taponamiento cardiaco, aporta información sobre esta enfermedad infrecuente en nuestro medio(AU)

Introduction: Stress cardiomyopathy or Takotsubo syndrome is associated with reduced ejection fraction, elevated levels of cardiac enzymes and signs of ischemia on the electrocardiogram. However, it rarely occurs with complications as important as cardiac tamponade, significant deterioration of contractility and the possibility of thrombi within the ventricular cavity. These are underestimated despite putting the patient's life at risk. Objective: To describe the case of a patient with stress cardiomyopathy with cardiac tamponade as an unusual complication. Clinical case report: A case of a female patient in her nineties is reported due to her history of primary systemic arterial hypertension and chronic obstructive pulmonary disease. She had chest pain with contractility disorders of the usual pattern corresponding to Takotsubo cardiomyopathy in which other differential diagnoses were ruled out. Conclusions: This case of Takotsubo cardiomyopathy associated with a cardiovascular complication as important and unusual as cardiac tamponade, provides information on this rare disease in our setting(AU)

Dor torácica na emergência: quando pensar em síndrome de Takotsubo? / Emergency chest pain: when to think about Takotsubo syndrome?

A síndrome de Takotsubo é uma cardiomiopatia induzida por estresse, caracterizada por disfunção transitória do ventrículo esquerdo. Essa disfunção pode ser confundida com infarto agudo miocárdio na sala de emergência por ter características clínicas semelhantes ­ principalmente a dor torácica. A fisiopatologia ainda não é bem definida, mas está associada à deficiência de estrogênio e ao aumento de catecolaminas que estimulam o acoplamento dos receptores beta-2 do coração, o que resulta em atividade inotrópica negativa, levando à disfunção contrátil do ventrículo esquerdo. As enzimas cardíacas alteradas dificultam ainda mais o diagnóstico da síndrome de Takotsubo. O exame padrão-ouro, que diferencia a síndrome de Takotsubo do infarto agudo do miocárdio, é a angiografia coronariana. Uma das opções na emergência é o ecocardiograma na beira do leito. Além disso, os critérios de Mayo devem ser usados para diagnosticar a síndrome de Takotsubo. É importante, para o profissional que trabalha no pronto-socorro, ter a síndrome de Takotsubo como diagnóstico diferencial na dor torácica.

Takotsubo syndrome is a stress-induced cardiomyopathy characterized by a transient left ventricular dysfunction. This dysfunction can be confused with acute myocardial infarction in the emergency room as it has similar clinical characteristics, especially chest pain. Its pathophysiology is not yet well defined, but is associated with estrogen deficiency and increased catecholamines that stimulate the coupling of cardiac beta-2 receptors, resulting in negative inotropic activity and leading to contractile dysfunction of the left ventricle. Altered cardiac enzymes make the diagnosis of Takotsubo syndrome even more difficult. The gold standard exam that will differentiate Takotsubo syndrome from acute myocardial infarction is coronary angiography. One of the options in the emergency room is bedside echocardiography. In addition, Mayo criteria should be used to diagnose Takotsubo syndrome. Professionals working in the emergency room shall have Takotsubo syndrome as a differential diagnosis in chest pain.

Registro Multicêntrico de Takotsubo (REMUTA) - Aspectos Clínicos, Desfechos Intra-Hospitalares e Mortalidade a Longo Prazo / Takotsubo Multicenter Registry (REMUTA) - Clinical Aspects, In-Hospital Outcomes, and Long-Term Mortality

Resumo Fundamento A síndrome de takotsubo (takotsubo) é uma forma de cardiomiopatia adquirida. Dados nacionais sobre essa condição são escassos. O Registro REMUTA é o primeiro a incluir dados multicêntricos dessa condição no nosso país. Objetivo Descrever as características clínicas, prognóstico, tratamento intra-hospitalar e mortalidade hospitalar e em 1 ano de seguimento. Métodos Estudo observacional, retrospectivo, tipo registro. Incluídos pacientes internados com diagnóstico de takotsubo ou que desenvolveram esta condição durante internação por outra causa. Os desfechos avaliados incluíram fator desencadeador, análise dos exames, uso de medicações, complicações e óbito intra-hospitalar e em 1 ano de seguimento. O nível de significância adotado foi de 5%. Resultados Foram incluídos 169 pacientes, em 12 centros no Estado do Rio de Janeiro. A idade média foi de 70,9 ± 14,1 anos e 90,5% eram do sexo feminino; 63% dos casos foram de takotsubo primário e 37% secundário. Troponina I foi positiva em 92,5% dos pacientes e a mediana de BNP foi de 395 (176,5; 1725). Supradesnivelamento do segmento ST esteve presente em 28% dos pacientes. A fração de ejeção do ventrículo esquerdo teve mediana de 40 (35; 48)%. Observamos taxa de 25,7% de ventilação mecânica invasiva e 17,4% de choque. Suporte circulatório mecânico foi utilizado em 7,7%. A mortalidade intra-hospitalar foi de 10,6% e a mortalidade ao final de 1 ano foi de 16,5%. Takotsubo secundário e choque cardiogênico foram preditores independentes de mortalidade. Conclusão Os resultados do REMUTA mostram que takotsubo não se trata de patologia benigna como se pensava, especialmente no grupo de takotsubo secundário que acarreta elevada taxa de complicações e de mortalidade. (Arq Bras Cardiol. 2020; 115(2):207-216)

Abstract Background Takotsubo syndrome (TTS) is an acquired form of cardiomyopathy. National Brazilian data on this condition are scarce. The Takotsubo Multicenter Registry (REMUTA) is the first to include multicenter data on this condition in Brazil. Objective To describe the clinical characteristics, prognosis, in-hospital treatment, in-hospital mortality, and mortality during 1 year of follow-up. Methods This is an observational, retrospective registry study including patients admitted to the hospital with diagnosis of TTS and patients admitted for other reasons who developed this condition. Evaluated outcomes included triggering factor, analysis of exams, use of medications, complications, in-hospital mortality, and mortality during 1 year of follow-up. A significance level of 5% was adopted. Results The registry included 169 patients from 12 centers in the state of Rio de Janeiro, Brazil. Mean age was 70.9 ± 14.1 years, and 90.5% of patients were female; 63% of cases were primary TTS, and 37% were secondary. Troponin I was positive in 92.5% of patients, and median BNP was 395 (176.5; 1725). ST-segment elevation was present in 28% of patients. Median left ventricular ejection fraction was 40 (35; 48)%. We observed invasive mechanical ventilation in 25.7% of cases and shock in 17.4%. Mechanical circulatory support was used in 7.7%. In-hospital mortality was 10.6%, and mortality at 1 year of follow-up was 16.5%. Secondary TTS and cardiogenic shock were independent predictors of mortality. Conclusion The results of the REMUTA show that TTS is not a benign pathology, as was once thought, especially regarding the secondary TTS group, which has a high rate of complications and mortality. (Arq Bras Cardiol. 2020; 115(2):207-216)

Factors Associated with Recurrence in Takotsubo Syndrome: A Systematic Review / Fatores Associados à Recorrência na Síndrome de Takotsubo: Uma Revisão Sistemática

Abstract Background: Takotsubo syndrome (TTS) is characterized by a temporary systolic dysfunction of the left ventricle (LV) related to a stressful event. However, the factors associated with its recurrence are still not well established. Objective: To analyze the main factors associated with TTS recurrence. Methods: A systematic review was performed using the PRISMA model. Observational studies, published between January 2008 and October 2017, which presented a recurrence rate of at least 3% and/or 5 or more patients with recurrence, and who met at least 80% of the STROBE criteria were included. Results: six articles reached the criteria to compose this systematic review. The recurrence rate ranged from 1 to 3.5% per year (global recurrence rate 3.8%). One study associated higher recurrence rate with the female gender, four reported the time between the first and second episodes, one study associated body mass index (BMI) and hypercontractility of the LV middle anterior wall to a higher recurrence rate. No association between recurrence and electrocardiographic changes were determined. Beta-blockers use was not associated with recurrence rates. Conclusions: Female gender, time from the first episode of the syndrome, low BMI and midventricular obstruction were reported as potential predictors of TTS recurrence.

Resumo Fundamento: A síndrome de Takotsubo (STT) é caracterizada por uma disfunção sistólica temporária do ventrículo esquerdo (VE) relacionada a um evento estressante. No entanto, os fatores associados à sua recorrência ainda não estão bem estabelecidos. Objetivo: Analisar os principais fatores associados à recorrência da STT. Métodos: Uma revisão sistemática foi realizada usando o modelo PRISMA. Foram incluídos estudos observacionais, publicados entre janeiro de 2008 e outubro de 2017, que apresentaram uma taxa de recorrência de pelo menos 3% e/ou 5 ou mais pacientes com recidiva e que preencheram pelo menos 80% dos critérios STROBE. Resultados: Seis artigos atenderam aos critérios para esta revisão sistemática. A taxa de recorrência variou de 1 a 3,5% ao ano (taxa de recorrência global 3,8%). Um estudo associou maior taxa de recorrência ao sexo feminino, quatro relataram o tempo entre o primeiro e o segundo episódio, um estudo associou o índice de massa corporal (IMC) e a hipercontratilidade da parede anterior média do VE a uma maior taxa de recorrência. Não foi determinada associação entre recorrência e alterações eletrocardiográficas. O uso de betabloqueadores não foi associado a taxas de recorrência. Conclusões: Sexo feminino, tempo desde o primeiro episódio da síndrome, baixo IMC e obstrução ventricular foram relatados como possíveis preditores de recorrência da STT.

Cardiomiopatía de Tako-tsubo y síndrome de QT largo congénito / Tako-tsubo cardiomyopathy and congenital long QT syndrome

La miocardiopatía de Tako-tsubo (MT) y síndrome de QT largo congénito (SQTLc) son dos entidades que presentan un retardo de la repolarización cardíaca y su asociación ha sido publicada en reportes de casos. Presentamos el caso de una paciente de 55 años, con antecedentes de SQTLc, que ingresó a nuestro hospital por dolor precordial, luego de un evento estresante, diagnosticándose MT. Evolucionó con prolongación del intervalo QT en el electrocardiograma, persistiendo luego de la externación, sin presentar episodios de arritmias ventriculares ni síncope

Takobsubo cardiomyopathy (TC) and congenital long QT syndrome (LQTS) are two entities that present a delay of cardiac repolarization and their association has been published in case reports. We present the case of a 55-year-old female patient with medical history of congenital LQTS, who was admitted to our hospital due to precordial pain after a stressful event and TC was diagnosed. She evolves with QT interval prolongation on the ECG that remains after the externalization, without presenting any episodes of ventricular arrhythmia or syncope

A cardiomiopatia de Tako-tsubo (CT) e a síndrome do QT longo congênito (SQTLc) são duas entidades que apresentam um atraso da repolarização cardíaca e sua associação foi publicada em relatos de casos. Apresentamos o caso de uma paciente de 55 anos de idade com história médica de SQTLc, admitida em nosso hospital devido a dor precordial após um evento estressante, com diagnóstico de CT. Ela evolui com prolongamento do intervalo QT no ECG que permanece após a externalização, sem apresentar nenhum episódios de arritmias ventriculares ou síncope

Características clínicas y complicaciones del síndrome de Takotsubo en un centro de referencia de la seguridad social peruana / Clinical features and complications of Takotsubo syndrome in a peruvian social security referral center

RESUMEN Con el objetivo de describir las características clínicas y complicaciones del síndrome de Takotsubo, se realizó un estudio de serie de casos de pacientes que ingresaron con esta patología al Instituto Nacional Cardiovascular-INCOR en Lima-Perú, entre enero de 2013 a diciembre de 2018. Se incluyeron 26 pacientes, con una edad promedio de 69 años y predominio del sexo femenino (96,2%), además un desencadenante se identificó en 23 casos (88,5%). En el electrocardiograma, el 61,5% tuvo supradesnivel del segmento ST; y en la evolución el 92,3% mostró ondas T negativas y el 38,5% un intervalo QTc >500 ms. Las complicaciones intrahospitalarias fueron choque cardiogénico (11,5%), fibrilación auricular (7,7%) y taquicardia ventricular (7,7%). En esta serie, el síndrome de Takotsubo predominó en mujeres posmenopáusicas, generalmente desencadenado por un factor estresante, con una baja tasa de complicaciones y ausencia de mortalidad intrahospitalaria.

ABSTRACT In order to describe the clinical features and complications of Takotsubo syndrome, a case series study was conducted with patients admitted with this pathology to the National Cardiovascular Institute-INCOR in Lima-Peru between January 2013 and December 2018. Twenty-six patients (26) were included, with an average age of 69 years and female predominance (96.2%); additionally, a trigger was identified in 23 cases (88.5%). In the electrocardiogram, 61.5% had ST segment elevation; and, in the evolution, 92.3% showed negative T waves and 38.5% a QTc interval >500 ms. In-hospital complications were cardiogenic shock (11.5%), atrial fibrillation (7.7%) and ventricular tachycardia (7.7%). In this series, Takotsubo syndrome predominated in postmenopausal women, usually triggered by a stressor, with a low complication rate and no in-hospital mortality.

Infarto agudo de miocardio sin enfermedad coronaria ateroesclerótica obstructiva / Acute myocardial infarction without obstructive atheroesclerotic coronary disease

RESUMEN El infarto de miocardio con arterias coronarias no obstructivas es una nueva definición y manifestación clínica que incluye múltiples condiciones cardiacas. La importancia en su reconocimiento y búsqueda de la etiología radica en el pronóstico a largo plazo, dada la mayor incidencia de eventos cardiovasculares mayores. Por ello, la diferenciación de otras causas clínicas de elevación de biomarcadores cardiacos y el abordaje diagnóstico detallado basado en la historia clínica, junto con otros estudios complementarios, son fundamentales para definir un tratamiento y seguimiento que impacte en la evolución de los pacientes.

SUMMARY Myocardial infarction with non-obstructive coronary arteries is a new definition and clinical manifestation that includes multiple cardiac conditions. The importance in its recognition and search of the etiology lies in the long-term prognosis given the higher incidence of major cardiovascular events. Therefore, the differentiation of other clinical causes of elevation of cardiac biomarkers and a detailed diagnostic approach based on clinical history and complementary studies are fundamental to define treatment, follow-up and impact on the evolution of patients.

Mourning and Takotsubo cardiomyopathy: neuroendocrine implications and nutritional management

SUMMARY This article aims to make reference to some recent mourning aspects considered risk factors for cardiovascular disease, specifically the Takotsubo cardiomyopathy. The objective was to describe the stress from the death of a loved one combining it to the possibility of occurrence of Takotsubo cardiomyopathy through the perception of a traumatic event by the cortex, which triggers the subcortical brain circuit affecting the endocrine response. Given the growing acknowledgement of this cardiomyopathy, it is possible to contextualize the nutritional behaviours and decisions surrounding it, whose benefits must exceed the condition of temporary cardiac dysfunction and extend to food choices that have some influence in the limbic system. It is a descriptive analysis that aims to problematize the theme into reflections based on this experience, considering the foundation with the science of nutrition.

RESUMO INTRODUÇÃO: Este artigo busca fazer referência a alguns aspectos do luto recente considerados fatores de risco para a doença cardiovascular, específicamente a cardiomiopatia de Takotsubo. Objetivou-se descrever o estresse proveniente da morte do ente querido aliando-o à possibilidade de ocorrência da cardiomiopatia de Takotsubo, mediante a percepção de um evento traumático pelo córtex que aciona o circuito cerebral subcortical tendo repercussões na resposta endócrina. Dado o crescente reconhecimento dessa cardiomiopatia, torna-se viável contextualizar as condutas nutricionais e as decisões que as norteiam, cujos benefícios devem ultrapassar a condição de disfunção cardíaca temporária e se estender às escolhas alimentares que exercem alguma influência no sistema límbico. Trata-se de uma análise descritiva que objetiva problematizar a temática em reflexões pautadas nessa vivência, considerando o alicerce com a ciência da nutrição.

Estrés parietal diastólico en la estenosis aórtica grave con fracción de eyección preservada: Relación con la insuficiencia cardíaca / Association between Diastolic Wall Stress in Severe Aortic Stenosis with Preserved Ejection Fraction and Heart Failure

RESUMEN: Introducción: El síndrome de Takotsubo (ST) es una miocardiopatía reversible que tiene diversas formas de presentación. Hasta el momento no se han publicado datos de ST en nuestro medio. Material y Métodos: Desde el 2005 al 2017 se incluyeron a 115 pacientes con diagnóstico de ST primario o secundario en el Hospital Italiano de Buenos Aires. El objetivo fue evaluar las características clínicas del ST durante la internación. Resultados: La mediana de edad de la población fue de 78 años (64-84), el 90% eran mujeres, y el 22% presentó enfermedad coronaria asociada. El 57% eran ST primarios, 31% tuvieron un gatillo emocional y 44%, físico. El síndrome de presentación fue como shock: 9%, insuficiencia cardiaca 12%, "tipo SCA" 70%, ACV/embolia 5% y, arritmias, 4%. La mediana de Fey al ingreso fue del 40% (36-50) y su recuperación, desde el ingreso al alta (mediana de internación de 4 días, 3-8), fue del 20%, p < 0.001. La mortalidad hospitalaria fue de 4/115 (3,48%). En el análisis univariado, las variables asociadas a mayor mortalidad fueron: shock respecto a otras formas de presentación (p = 0.0035) y ST secundario respecto al primario, p = 0.020. Además, existió una relación directa entre la mortalidad y los niveles de NT-pro-BNP máximo (p = 0.0082) y glóbulos blancos (p = 0.0101). Asimismo, la mortalidad hospitalaria mostró una relación inversa con el hematocrito (p = 0.0084) y con las alteraciones en el ECG de ingreso; es decir, que los pacientes que fallecieron durante la internación tuvieron ECG normal al ingreso con mayor frecuencia (p < 0.001). Conclusión: En este registro unicéntrico se observó que los pacientes tuvieron más comorbilidades y similar mortalidad respecto a registros internacionales.

ABSTRACT: Background: Takotsubo syndrome (TS) is a reversible cardiomyopathy with many different forms of presentations. There is no local data of TS published so far. Methods: One hundred and fifteen patients with either primary or secondary TS were retrospectively studied at Hospital Italiano de Buenos Aires from 2005 to 2017. The purpose of the study was to assess the clinical features of this population during hospitalization. Results: Median of age was 78 years (64-84); 90% of patients were female, and 22% had associated coronary artery disease. Fifty-seven percent of cases were primary TS, 31% experienced an emotional trigger and 44% had a physical origin. The presentation syndrome was as follows: 9% shock, 12% heart failure, 70 % mimicking acute coronary syndrome, 5% stroke/peripheral embolism and 4% arrhythmias. Median ejection fraction at admission was 40% (36-50) and recovery from admission to discharge [median hospital stay: 4 days (3-8)] was 20%, p <0.001. In-hospital mortality was 4/115 cases (3.48%). In univariate analysis, shock compared with other forms of presentation (p=0.0035) and secondary TS (p=0.020) were associated with higher in-hospital mortality. There was a direct relationship between in-hospital mortality and maximum NT-pro-BNP levels (p= 0.0082) and white cell count (p=0.0101). In addition, in-hospital mortality was inversely associated with hematocrit (p=0.0084) and with ECG abnormalities at admission; i.e. patients who died during hospitalization had more frequently normal ECG at admission, (p<0.001). Conclusion: Compared with international registries, this single center population had more comorbidities, but similar in-hospital mortality rates.

Características clínicas y evolutivas del síndrome de Takotsubo en un hospital universitario / Clinical Features and Outcomes of Takotsubo Syndrome at a University Hospital

RESUMEN: Introducción: El síndrome de Takotsubo (ST) es una miocardiopatía reversible que tiene diversas formas de presentación. Hasta el momento no se han publicado datos de ST en nuestro medio. Material y Métodos: Desde el 2005 al 2017 se incluyeron a 115 pacientes con diagnóstico de ST primario o secundario en el Hospital Italiano de Buenos Aires. El objetivo fue evaluar las características clínicas del ST durante la internación. Resultados: La mediana de edad de la población fue de 78 años (64-84), el 90% eran mujeres, y el 22% presentó enfermedad coronaria asociada. El 57% eran ST primarios, 31% tuvieron un gatillo emocional y 44%, físico. El síndrome de presentación fue como shock: 9%, insuficiencia cardiaca 12%, "tipo SCA" 70%, ACV/embolia 5% y, arritmias, 4%. La mediana de Fey al ingreso fue del 40% (36-50) y su recuperación, desde el ingreso al alta (mediana de internación de 4 días, 3-8), fue del 20%, p < 0.001. La mortalidad hospitalaria fue de 4/115 (3,48%). En el análisis univariado, las variables asociadas a mayor mortalidad fueron: shock respecto a otras formas de presentación (p = 0.0035) y ST secundario respecto al primario, p = 0.020. Además, existió una relación directa entre la mortalidad y los niveles de NT-pro-BNP máximo (p = 0.0082) y glóbulos blancos (p = 0.0101). Asimismo, la mortalidad hospitalaria mostró una relación inversa con el hematocrito (p = 0.0084) y con las alteraciones en el ECG de ingreso; es decir, que los pacientes que fallecieron durante la internación tuvieron ECG normal al ingreso con mayor frecuencia (p < 0.001). Conclusión: En este registro unicéntrico se observó que los pacientes tuvieron más comorbilidades y similar mortalidad respecto a registros internacionales.

ABSTRACT: Background: Takotsubo syndrome (TS) is a reversible cardiomyopathy with many different forms of presentations. There is no local data of TS published so far. Methods: One hundred and fifteen patients with either primary or secondary TS were retrospectively studied at Hospital Italiano de Buenos Aires from 2005 to 2017. The purpose of the study was to assess the clinical features of this population during hospitalization. Results: Median of age was 78 years (64-84); 90% of patients were female, and 22% had associated coronary artery disease. Fifty-seven percent of cases were primary TS, 31% experienced an emotional trigger and 44% had a physical origin. The presentation syndrome was as follows: 9% shock, 12% heart failure, 70 % mimicking acute coronary syndrome, 5% stroke/peripheral embolism and 4% arrhythmias. Median ejection fraction at admission was 40% (36-50) and recovery from admission to discharge [median hospital stay: 4 days (3-8)] was 20%, p <0.001. In-hospital mortality was 4/115 cases (3.48%). In univariate analysis, shock compared with other forms of presentation (p=0.0035) and secondary TS (p=0.020) were associated with higher in-hospital mortality. There was a direct relationship between in-hospital mortality and maximum NT-pro-BNP levels (p= 0.0082) and white cell count (p=0.0101). In addition, in-hospital mortality was inversely associated with hematocrit (p=0.0084) and with ECG abnormalities at admission; i.e. patients who died during hospitalization had more frequently normal ECG at admission, (p<0.001). Conclusion: Compared with international registries, this single center population had more comorbidities, but similar in-hospital mortality rates.

Síndrome de Takotsubo e o uso do InterTAK Diagnostic Score no diagnóstico diferencial com a síndrome coronariana aguda: relato de um caso / Takotsubo syndrome and the use of InterTAK Diagnostic Score in the differential diagnosis of acute coronary syndrome: a case report

A Cardiomiopatia de Takotsubo (CT) é uma síndrome cardíaca caracterizada por quadro clínico compatível com síndrome coronariana aguda (SCA), com alterações eletrocardiográficas, aumento de enzimas cardíacas e anormalidades na contratilidade ventricular, geralmente associada a artérias coronárias livres de obstruções ou espasmos significativos à cineangiocoronariografia. Por apresentar curso clínico semelhante ao do infarto agudo do miocárdio, muitas vezes é abordada como tal. O presente trabalho busca, ao relatar um caso clássico de CT, destacar a importância da realização do diagnóstico diferencial entre a CT e a SCA, usando como ferramenta o InterTAK Diagnostic Score. (AU)

Takotsubo cardiomyopathy (TC) is a cardiac syndrome characterized by clinical symptoms compatible with acute coronary syndrome (ACS), including electrocardiographic changes, increased cardiac enzymes, and ventricular wall motion abnormalities, usually associated with absence of obstructive coronary artery disease or significant spasms at coronary angiography. Because its clinical course is similar to that of acute myocardial infarction, TC is often treated as such. The present paper reports a classic case of TC seeking to highlight the importance of performing a differential diagnosis between TC and ACS, using a tool named InterTAK Diagnostic Score. (AU)

Cardiomiopatía de takotsubo secundaria a sepsis. Una asociación poco frecuente / Takotsubo cardiomyopathy secondary to sepsis. A little frequent association

Resumen La cardiomiopatía de takotsubo se distingue por alteraciones en la contractilidad apical del ventrículo izquierdo, dolor torácico, altera ciones electrocardiográficas y elevación enzimàtica, que semejan un síndrome coronario agudo, pero sin que haya alteraciones significativas en las arterias coronarias. Es desencadenado por estrés emocional o físico, como el que ocurre en hemorragia subaracnoidea, lesión cerebral traumática y sepsis. El mecanismo fisiopatogénico está relacionado con liberación masiva de catecolaminas, lo que induce miocardiopatía aguda, que se incluye en el síndrome neurocardiogénico. Describimos el caso de una paciente de 80 años que padeció sepsis secundaria a un cuadro neumónico y que sufrió de manera súbita insuficiencia cardiaca, edema pulmonar, alteraciones del segmento ST y de la onda T y elevación de enzimas cardiacas. En el ecocardiograma se observó hipocinesia apical, con movilidad anterobasal normal. En el ventriculograma se corroboraron las alteraciones de movilidad. Las arterias coronarias eran normales. Los intensivistas deben tener en mente la relación entre sepsis y cardiomiopatía de takotsubo.

Abstract Takotsubo cardiomyopathy (TC) is characterized by transient left ventricular apical wall motion abnormalities, chest pain with electro-cardiographic changes and increased myocardial enzymatic release mimicking acute coronary syndrome, but without significant coronary artery disease. It is usually precipitated by acute emotional or physical stressors, such as subarachnoid haemorrhage, traumatic brain injury or sepsis. The pathogenetic mechanism is related to catecholamine cardiomyopathy, rendering TC a type of neurocardiological disorder manifested as acute but reversible heart failure. A case example is described in which a 80 year-old woman with sepsis secondary to pneumonia developed suddenly left cardiac failure, lung edema, increased cardiac enzymes and ST-segment and T wave alterations. A left ventriculogram showed severe apical hipokinesis, a normal anterobasal segment motion without coronary artery obstruction. Intensivists should consider this syndrome in the differential diagnosis of septic patients presenting with clinical findings suggestive of acute coronary syndrome.