Arritmias ventriculares en el síndrome de takotsubo: cuestión de sexo / Sex-related risk of arrhythmia in takotsubo syndrome

Resumen El síndrome de takotsubo, también conocido como miocardiopatía de estrés, representa un difícil reto diagnóstico, pues en muchos casos su presentación es superponible al infarto de miocardio por ruptura de placa; el diagnóstico definitivo se basa en la ausencia de lesiones culpables en la coronariografía. La fisiopatología de la enfermedad no está por completo establecida, y tiene un pronóstico generalmente benigno. Sin embargo, existe un porcentaje no despreciable de pacientes que sufren complicaciones graves, entre las que destacan las arritmias malignas tipo taquicardia ventricular polimórfica por prolongación del intervalo QT. A pesar de que el síndrome de takotsubo afecta principalmente a las mujeres, quienes por otra parte también suelen tener intervalos QT más prolongados en condiciones basales, la muerte súbita de origen arrítmico aparece con mayor frecuencia en los hombres que sufren esta enfermedad. Se presentan dos casos de ensanchamiento extremo del intervalo QT corregido en pacientes con takotsubo que tuvieron desenlaces diferentes. El propósito de este trabajo es destacar y revisar las diferencias electrocardiográficas y pronósticas relacionadas con el sexo de los sujetos que desarrollan esta controvertida enfermedad.

Abstract Takotsubo syndrome, also known as stress cardiomyopathy, is a difficult diagnostic challenge as, in many cases, its presentation can overlap with that of myocardial infarction due to plaque rupture. The definitive diagnosis is based on the lack of culprit lesions on coronariography. The pathophysiology of the disease has not been completely ascertained, and it has a generally benign prognosis. However, a not inconsiderable percentage of patients experience serious complications, notably malignant arrhythmias like polymorphic ventricular tachycardia due to a prolonged QT interval. Despite takotsubo syndrome affecting mainly women who, furthermore, generally have longer basal QT intervals, sudden death due to arrhythmias is more common in men with this disease. Two cases are presented of extremely prolonged corrected QT intervals in patients with takotsubo, with different outcomes. The purpose of this paper is to highlight and review the electrocardiographic and prognostic differences related to the gender of the individuals who develop this controversial disease.

Arritmias graves en el síndrome de takotsubo: ¿cuándo dar de alta? / Severe arrhythmias in Takotsubo syndrome: when to discharge?

Resumen El síndrome de takotsubo o miocardiopatía por estrés es una alteración de la funcionalidad miocárdica, que se asocia con frecuencia a situaciones de estrés físico o emocional. Corresponde entre el 1 y el 2% de todos los ingresos a urgencias por síndrome coronario agudo y tiene una prevalencia y tasa de mortalidad de 4,1% y 2% a 8%, respectivamente. Hasta el 10% de los pacientes presenta algún tipo de complicación. En Colombia los datos epidemiológicos son limitados. En la actualidad se desconoce con exactitud la fisiopatología subyacente y no hay consenso acerca del tratamiento del síndrome y las complicaciones asociadas; por consiguiente, estos interrogantes son posibles temas de investigación. Se expone un caso clínico de características inusuales, que cursó con alteraciones electrocardiográficas, cinéticas y de conducción miocárdica infrecuentes, además de evolución clínica inesperada, que culminó en paro cardiorrespiratorio secundario a taquicardia ventricular polimórfica por persistencia del intervalo QT prolongado. Con base en la experiencia clínica y en la evidencia científica disponible se recomienda monitorizar estrechamente a los pacientes con alteración adquirida de la repolarización miocárdica hasta que esta se normalice y considerar la implantación de un dispositivo cardiaco tipo cardiodesfibrilador en casos de alto riesgo.

Abstract Takotsubo syndrome or stress cardiomyopathy is a myocardial functional disorder, which is often associated with situations of physical or emotional stress. It accounts for between 1% and 2% of all those admitted to the Emergency Department due to acute coronary syndrome, and has a prevalence and mortality rate of 4.1% and 2% to 8%, respectively. Up to 10% of the patients have some type of complication. Epidemiological data are scarce in Colombia. The underlying pathophysiology is still not exactly known, and there is no consensus on the treatment of the syndrome and the associated complications. Therefore, these questions are possible research topics. A clinical case of unusual characteristics is presented, which included rare electrocardiographic, kinetic, and myocardial conduction characteristics. It also had an unexpected clinical outcome, which culminated in cardiorespiratory arrest secondary to a polymorphic ventricular tachycardia due to persistence of the prolonged QT interval. Based on clinical experience and on the available scientific evidence, it is recommended to closely monitor patients with an acquired change in myocardial repolarisation until it returns to normal, and to consider an implantable cardioverter defibrillator in cases of high risk.

A Case of Takotsubo Cardiomyopathy Following Endovascular Abdominal Aortic Repair / 日本心臓血管外科学会雑誌

We describe a case of Takotsubo cardiomyopathy in an 88-year-old woman who underwent endovascular aneurysm repair (EVAR) for an abdominal aortic aneurysm. The patient developed cardiac arrest shortly after the surgery. Following immediate resuscitation, her electrocardiogram showed extensive ST segment elevation in leads V2-V6, and echocardiography revealed apical akinesis with basal hyperkinesis. Emergency coronary angiography confirmed the absence of coronary lesions, and she was diagnosed with Takotsubo cardiomyopathy. Her cardiac function improved within a few days following the administration of catecholamines. Although EVAR is a less invasive surgical procedure, it may trigger Takotsubo cardiomyopathy. Prompt diagnosis and appropriate management of Takotsubo cardiomyopathy are essential to treat critical conditions in the acute phase.

Recognition of neurogenic myocardial injury / 中国实用内科杂志

Transient,reversible myocardium injury can occur in patients with brain injury.Several pathophysiological mechanisms are involved in the development of such neurogenic myocardium injury.Excess catecholamine release plays a major role during myocardial injury.The clinical features include abnormal electrocardiographic,echocardiographic features and elevated biomarkers.In some patients stunned myocardium can be observed which may lead to hemodynamic instability or even cardiogenic shock.Inotropic agents and mechanical support are useful in improving cardiac function.β-adrenergic blockade is likely to attenuate the catecholamine toxicity but its use remains controversial.

Miocardiopatía inducida por estrés o síndrome de Takotsubo: a propósito de un caso / Cardiomyopathy induced by stress or Takotsubo syndrome: a report of one case

La cardiomiopatía inducida por estrés o Síndrome de Takotsubo se caracteriza por una disfunción aguda del ventrículo izquierdo caracterizado por acinesia o discinesia apical con hipercinesia basal a menudo reversible, en ausencia de obstrucción coronaria en la angiografía. La presentación clínica se asemeja al del Infarto Agudo de Miocardio; con un inicio súbito caracterizado por dolor precordial de tipo isquémico, disnea, palpitaciones, cambios electrocardiográficos, elevación de biomarcadores de necrosis miocárdica y en casos más graves y raros shock cardiogénico; el estrés emocional y físico severo suelen ser desencadenantes. Con el presente caso clínico, revisamos las características clínicas, diagnósticas y terapéuticas de ésta entidad poco frecuente que representa cerca del 1% de todos los pacientes con sospecha de síndrome coronario agudo.

Cardiomyopathy induced by stress or Takotsubo Syndrome is characterized by an acute dysfunction of the left ventricle characterized by apical akinesia or dyskinesia with often reversible basal hyperkinesia, in the absence of coronary occlusion on angiography. The clinical presentation resembles the Acute Myocardial Infarction, with a sudden onset characterized by a chest pain angina type, dyspnea, palpitations, electrocardiographic changes, elevation of cardiac biomarkers and cardiogenic shock in more serious and rare cases; the severe emotional and physical stress tend to be triggers. With this clinical case, we reviewed the clinical, diagnostic and therapeutic features of this rare entity which represents about 1% of all patients with suspected acute coronary syndrome.

Síndrome de takotsubo secundario a traumatismo raquimedular / Takotsubo syndrome secondary to spinal cord injury

Resumen Antecedentes: El síndrome de takotsubo secundario a traumatismo raquimedular cervical es infrecuente y no se describen series de casos en la literatura. Pacientes y método: Se describe el caso clínico de una mujer de 82 años que ingresó en la Unidad de Cuidados Intensivos tras traumatismo raquimedular cervical y como consecuencia desarrolló miocardiopatía de takotsubo. Resultado: Desarrollo de una miocardiopatía de takotsubo tras un traumatismo raquimedular cervical. Conclusiones: En la actualidad el diagnóstico de miocardiopatía de takotsubo en Cuidados Intensivos está en aumento, en parte por el uso de la ecocardiografía trastorácica por parte de los Intensivistas; con ello se descartan otras causas posibles de la misma y no sólo la cardiológica o la descarga catecolaminérgica secundaria a una situación de estrés.

Abstract Background: Takotsubo syndrome secondary to spinal cord injury is rare, and there are no case series described in the literature. Patients and method: A clinical case is presented of an 82 year-old woman admitted to the Intensive Care Unit after a spinal cord injury, and as a results developed Takotsubo cardiomyopathy. Results: A Takotsubo cardiomyopathy developed after a spinal cord injury. Conclusions: The diagnosis of Takotsubo cardiomyopathy is currently increasing in Intensive Care Units. This is partly due to use of transthoracic echocardiography by intensive care specialists. Using this technique they can rule out other possible causes of this condition, and not just the cardiological ones, or the catecholamine release following a stressful event.

Can you interpret the ECG under stress?

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.

Miocardiopatía por estrés secundaria a evento vascular cerebral isquémico / Stress cardiomyopathy secondary to ischemic cerebral vascular event

Resumen: Las manifestaciones cardiacas en el paciente neurocrítico, en especial pacientes con hemorragia subaracnoidea y evento vascular cerebral, ha sido tema de investigación en los últimos años. La manifestación va desde cambios electrocardiográficos, elevación de biomarcadores y colapso hemodinámico hasta la muerte secundaria al descontrol del equilibrio de electrólitos y de catecolaminas circulantes. El propósito de este artículo es identificar a este tipo de pacientes y realizar un diagnóstico diferencial con el síndrome coronario agudo con elevación del ST que se manifiesta en pacientes neurocríticos.

Abstract: Cardiac manifestations in patients with brain injury, especially patients with subarachnoid hemorrhage and cerebral vascular event have been the subject of research in recent years. The presentation goes from electrocardiographic changes, elevated biomarkers, hemodynamic collapse to death secondary to lose control of electrolyte balance and circulating catecholamines. The purpose of reporting this case is to present this important differential diagnosis of acute coronary syndrome with ST elevation that occurs in neurocritical patients.

Miocardiopatía Takotsubo postparto: parto distócico como posible factor desencadenante / Takotsubo cardiomyopathy: dystocic labor as a possible triggering factor

La miocardiopatía Takotsubo, o miocardiopatía por estrés, se define como una disfunción del segmento apical del ventrículo izquierdo, aguda, transitoria y reversible. Normalmente se relaciona con algún tipo de agente estresante, ya sea físico o emocional, pudiendo confundirse este cuadro con un síndrome coronario agudo. Se considera una patología rara, pero que es importante incluir en el diagnóstico diferencial de los trastornos cardiacos, sospechándolo previamente por la sintomatología. Está caracterizado por alteraciones en el electrocardiograma, como elevación del segmento ST en derivaciones precordiales e inversión de la onda T, elevación de las enzimas de necrosis miocárdica o patrones alterados en la ecocardiografía, como la disfunción ventricular apical con hiperquinesia de zonas basales. En cuanto a la fisiopatología, parece que la estimulación simpática juega un papel importante, en el que la disfunción ventricular se desencadena por algún tipo de estrés físico o emocional. Éste provoca una descarga de catecolaminas con un efecto cardiotóxico debido, en su mayor parte, al efecto del adenosín monofosfato cíclico. El tratamiento consiste en las medidas soporte de una miocardiopatía, evitando los fármacos teratogénicos o perjudiciales durante el periodo de lactancia. La evolución es favorable en la mayoría de los casos y el cuadro remite por completo, por lo que el pronóstico en líneas generales se considera bueno. En este trabajo se expone el caso de un parto instrumentado, en el que se manifiesta un cuadro compatible con una miocardiopatía Takotsubo, posiblemente relacionado con un procedimiento invasivo como factor desencadenante.

Takotsubo cardiomyopathy or stress cardiomyopathy is defined as an acute, transient, and reversible dysfunction of the apical segment of the left ventricle. It is usually associated with some sort of stressor, whether physical or emotional, and could be confused with an acute coronary syndrome. It is considered a rare disease, so it is important to include it in the differential diagnosis, previously suspecting the symptoms. It is characterized by alterations in the electrocardiogram such as ST segment elevation and inversion of the T wave in precordial leads, elevation of myocardial necrosis enzymes, or altered patterns on echocardiography such as apical ventricular dysfunction with hyperkinesia of basal areas. Regarding the pathophysiology, it seems that sympathetic stimulation plays an important role, in which ventricular dysfunction is triggered by some kind of physical or emotional stress. This causes a release of catecholamines with cardiotoxic effects due, mostly, to the effect of cyclic AMP. Treatment involves cardiomyopathy supportive care, avoiding teratogenic or harmful drugs during lactation. The evolution is favorable in most cases and the clinical picture abates completely, so the prognosis is generally considered good. In this paper, we expose a case of an instrumental labor in which a clinical picture compatible with Takotsubo cardiomyopathy is presented, triggered by an invasive procedure.

Transesophageal echo diagnosis of perioperative unusual transient left ventricular apical ballooning syndrome.

Stress cardiomyopathy, or Takotsubo syndrome, is a widely recognized cardiac pathology with a clinical presentation similar to acute coronary syndrome and related to physical or emotional stress. Perioperatively, it is challenging to identify it given the variety of forms and scenarios in which it can present. We describe a 22‑year‑old patient with an atypical presentation of Takotsubo syndrome during anesthesia induction, which highlights the usefulness of transesophageal echocardiography for the initial diagnosis.

A patient with stress induced cardiomyopathy that occurred after cessation of hormone replacement therapy for panhypopituitarism / 영남의대학술지

Stress induced cardiomyopathy (SC) is characterized by transient left ventricular (LV) dysfunction in the absence of coronary artery disease. We report on a patient with panhypopituitarism who developed SC resulting from withdrawal of hormonal replacement therapy (HRT). A 52-year-old male visited our hospital for progressively worsening dyspnea. The patient had discontinued HRT 7 days ago, which had been administered for 18 months after transsphenoidal adenomectomy for pituitary macroadenoma. Initial electrocardiogram showed marked sinus bradycardia. Transthoracic echocardiography showed apical ballooning with an LV ejection fraction of 25%. No significant obstructive lesions were observed on coronary angiography. With a clinical diagnosis of SC associated with panhypopituitarism, HRT was restarted, including glucocorticoid and thyroxine, along with standard heart failure management. His LV function had normalized at 2-month follow-up. He remains asymptomatic and administration of beta-blocker and angiotensin converting enzyme inhibitor were discontinued He currently only requires HRT.

Surgical Removal of a Left Ventricular Thrombus Which Showed Morphologic Changes Over Time in a Patient with Stress-Induced Cardiomyopathy

Although stress-induced cardiomyopathy (SCMP) is a reversible disease and the prognosis is usually excellent, several complications can occur and can result in fatal adverse events. The formation of left ventricular (LV) thrombus is one of these critical complications of SCMP. This report describes a case of SCMP complicated by formation of a LV thrombus that became increasingly mobile as LV contractility recovered, and for which surgical removal was performed. Here, we report a case of SCMP complicated by LV thrombus and review the literature regarding this topic.

Stress Cardiomyopathy due to Misuse of Transdermal Fentanyl Patches in an Elderly Patient

Stress cardiomyopathy is characterized by transient systolic dysfunction of the apical and/or mid segment of the left ventricle. The main pathophysiology of stress cardiomyopathy is the excessive release of catecholamine. Opioid withdrawal can initiate a surge of catecholamine and an attack of stress cardiomyopathy. In this case, we report a case of stress cardiomyopathy due to iatrogenic withdrawal from transdermal fentanyl.

Stress Related Cardiomyopathy during Flexible Bronchoscopy / 대한구급학회지

Flexible bronchoscopy is a safe medical procedure, but the incidence rate of major complications is 0.08-0.3%. Here, we report 2 cases of stress induced cardiomyopathy, which developed immediately after flexible bronchoscopy. Stress related cardiomyopathy was confirmed by EKG, echocardiography, and coronary angiogram. The cardiac functions of these patients were fully recovered with conservative treatment. Although, the pathogenesis of stress related cardiomyopathy is not well understood, post-bronchoscopy tachycardia or arrhythmia is thought to be associated with hypoxemia or catecholamine excess. Because the clinical presentation is quite similar to acute myocardial infarction, discrete evaluations are required for appropriate treatment.

Different Characteristics between Patients with Apical and Non-Apical Subtypes of Stress-Induced Cardiomyopathy

BACKGROUND: Stress-induced cardiomyopathy (SCM) is characterized by apical ballooning on echocardiography, but some of SCM patients show non-apical involvement and their characteristics are not well defined. METHODS: We investigated 56 patients that were diagnosed as SCM and divided them into 2 groups: apical ballooning syndrome (ABS, n = 49, 87.5%) and non-apical ballooning syndrome (N-ABS, n = 7, 12.5%) groups. Patients with N-ABS were significantly younger than those of the ABS group (52 +/- 11 vs. 73 +/- 10 years, p < 0.001). RESULTS: Types of preceding stressors and clinical presentation including chest pain, pulmonary edema, cardiogenic shock and in-hospital mortality were comparable between the two groups. In the N-ABS group, wall motion score index was significantly lower than in the ABS group (1.61 +/- 0.35 vs. 1.93 +/- 0.31, p = 0.016). On electrocardiogram (ECG), T-wave inversion (57.1% vs. 95.8%, p < 0.001) were less frequent in the N-ABS than in the ABS group. Furthermore, maximum QT and corrected QT (QTc) intervals in the N-ABS patients were significantly shorter than the ABS patients (QT, 419.9 +/- 66.1 vs. 487.3 +/- 79.6 ms, p = 0.038; QTc, 479.0 +/- 61.9 vs. 568.0 +/- 50.5 ms, p < 0.001). CONCLUSION: Patients with the N-ABS showed not only atypical echocardiographic findings, but also atypical clinical and ECG manifestations. Integrated consideration is needed to reach a diagnosis of the non-apical subtype of SCM.

Inverted-Takotsubo Cardiomyopathy in a Patient with Pulmonary Embolism

As the use of early coronary angiography and echocardiography become widely available in the setting of acute coronary syndrome, the gradual increase for variant forms of transient left ventricular (LV) apical ballooning syndrome have been recognized. This syndrome usually occurs in women and is frequently elicited by an intense emotional, psychological, and physical event. While the patients' characteristics between typical and non-typical LV ballooning syndrome seem to differ, the presentation, clinical features, and reversibility of LV wall motion abnormalities are similar. We present a middle-aged woman who experienced inverted takotsubo cardiomyopathy triggered by pulmonary embolism. To the best of our knowledge, this case is particularly unique and is rarely reported in the disease entity.

A Case of Transient Mid-Ventricular Ballooning Syndrome after Cardiac Arrest / 대한내과학회지

Stress-induced cardiomyopathy is characterized by transient wall-motion abnormalities involving the left ventricular apex. Emotional or physical stress might play a key role in this reversible form of cardiomyopathy, but the etiology remains unclear. Clinical features of stress-induced cardiomyopathyare similar to those of acute coronary syndrome, but there is no significant stenosis in the coronary arteries. Recently, transient mid-ventricular ballooning syndrome, a variant form of stress-induced cardiomyopathy in which only the mid-ventricle is affected, has been reported. Here, we report a case of a 42-year-old female patient who developed transient mid-ventricular ballooning syndrome after cardiac arrest during autologous fat transplantation.

Miocardiopatía por estrés como causa de muerte súbita durante un asalto: presentación de un caso y revisión del tema / Stress cardiomyopathy as a cause of sudden death during an assault: a case report and review of the literature

La muerte súbita de una persona durante un asalto o una agresión física resulta de gran importancia e interér en el medio forense debido a las interrogantes que genera la determinación de la causa y manera de muerte, principalmente en aquellas cuyos traumatismo por si solos no justifiquen la muerte. En estos casos especiales trasciende la Miocardiopatía por Estrés como una hipótesis que se debe analizar. En la actualidad, ésta patología se encuentra ampliamente descrita tanto a nivel de la medicina curativa como en la Patología Forense; y en ésta última su demostración objetiva es esencial, con el fin de cumplir los criterios de casualidad. En este artículo se expone la valoración de un caso valorado en la Sección de Patología Forense del Departamento de Medicina Legal de Costa Rica...

A Case of Anorexia Nervosa Complicated With Strongly Suspected Stress-Induced Cardiomyopathy and Mural Thrombus

Stress-induced cardiomyopathy is a unique reversible cardiovascular disease precipitated by acute emotional or physical stress. It is associated with a high prevalence of chronic anxiety disorder that precedes the onset of cardiomyopathy, as well as comorbid cardiovascular risk factors that are similar to the ST segment elevation of myocardial infarction. A thirty-five-year-old woman suffering from anorexia nervosa visited our hospital complaining of severe general weakness. She was diagnosed with stress-induced cardiomyopathy and mural thrombus using a transthoracic echocardiogram. Therefore, she was given anticoagulation therapy and nutrition with immediate psychiatric interventions. After two weeks of treatment, the follow-up echocardiogram indicated a significant improvement of the left ventricular dysfunction and mural thrombus.