Takotsubo syndrome: State-of-the-art review by an expert panel - Part 1.

Takotsubo syndrome (TTS) is an acute cardiac condition independent of epicardial coronary obstruction that mimics acute coronary syndrome and is characterized by acute heart failure with reversible ventricular motion abnormalities. This consensus paper is the result of a multinational effort aiming to summarize the current state of the art on TTS. Experts in the field provide a thorough and detailed review of this syndrome. Several novel and unique sections are emphasized in this document, including the current state of the art on genetics of takotsubo syndrome, microRNAs (miRs), racial differences, role of cardiac spectroscopy and intracoronary imaging, as well as mechanical circulatory support. In part 1 of this two-part manuscript, we discuss how TTS came to be known, several patterns and forms it can take in patients, epidemiology and pathophysiology of the syndrome, and clinical presentation.

Renal dysfunction in Takotsubo syndrome-role of segmental left ventricle strain analysis.

BACKGROUND: Takotsubo syndrome (TTS) is a peculiar clinical condition often resembling an acute coronary syndrome and mostly affecting postmenopausal women. We sought to describe the prevalence of acute kidney injury and acute renal failure in TTS patients during index event and assess the usefulness of speckle tracking echocardiography in predicting subjects at risk of developing acute kidney insult. METHODS: We conducted a retrospective descriptive study reviewing study with the discharge diagnosis of TTS between 2003-2016 at our Institution. One hundred and two patients met the Modified Mayo Clinic. Acute kidney injury (AKI) was defined as an increment of serum creatinine 2 times greater than baseline and/or at least 50% reduction in baseline eGFR. Acute renal failure (ARF) was defined as an increment of serum creatinine 3 times greater than baseline and/or at least 75% reduction in baseline eGFR as per RIFLE Classification. RESULTS: AKI/ARF patients had longer length of stay (24 vs 10 days, P = 0.02), had higher mean peak troponin (16.7 ng/mL vs 3.2, P < 0.05) and later peak creatinine day (10 vs 3, P < 0.05). LV Longitudinal strain in the basal segment and apex upon admission was significantly worse in the AKI/ARF group (-4.7 and -6.5, respectively, vs -8.6 and -9.1 in the non-AKI/ARF group, P < 0.05). CONCLUSIONS: One in every 10 TTS patients may develop AKI/ARF during the acute episode. Segmental longitudinal strain by speckle tracking may have important prognostic value in identifying TTS patients at risk of developing AKI/ARF.

Takotsubo syndrome: State-of-the-art review by an expert panel - Part 2.

In part 2 of this two-part manuscript on takotsubo syndrome (TTS), we discuss typical biomarkers (particularly excess catecholamines and what kinds of electrocardiographic information operators should look for) and numerous complications the syndrome can cause. This consensus paper is the result of a multinational effort aiming to summarize the current state of the art on TTS. Several novel and unique sections are emphasized in this document, including the current state of the art on genetics of takotsubo syndrome, microRNAs (miRs), racial differences, role of cardiac spectroscopy and intracoronary imaging, as well as mechanical circulatory support. New structured algorithms are also proposed to aid clinicians in the decision-making process as well as future directions for research given the current lack of evidence-based medical approaches.

Usefulness of left ventricular strain analysis in patients with takotsubo syndrome during acute phase.

BACKGROUND: Takotsubo syndrome (TTS) is peculiar clinical condition often resembling an acute coronary syndrome and mostly affecting postmenopausal women after a stressful trigger. TTS was initially thought to be a relatively benign condition. However, current data have shown it may be associated with considerable inpatient morbidity and carry a small, but important, mortality risk. METHODS: We hypothesized that left ventricular (LV) regional and global longitudinal strain (GLS) assessed with 2D speckle tracking echocardiography could identify early systolic functional impairment and predict in-hospital cardiovascular events. We conducted a retrospective descriptive study reviewing patients with the discharge diagnosis of TCM between 2003 and 2016 at our institution. RESULTS: One hundred patients with TSS met the Modified Mayo Clinic criteria. Using 2D speckle tracking echocardiography, two independent cardiologists assessed the LV GLS as well as the longitudinal strain (LS) of 7 individual segments [basal-septal (BS); mid-septal (MS), apical-septal (AS), apex, basal-lateral (BL), mid-lateral (ML), and apical-lateral (AL)]. The inter-observer variability was <5%. Mean age was 69.1 years, 87% were females, and 53% were African Americans. Mean initial LV EF was 32% ± 9.8%. In univariate analysis, patients with worse BL, ML, and GLS profiles (means: -5.7; -3.3, and -4, respectively) had higher in-hospital mortality (P < .05). Worse BL and ML profiles (means: -8.6 and -7.3, respectively) were associated with higher prevalence of MACE (major adverse cardiovascular outcomes) (P < .05). In a multivariate analysis, mid-lateral strain ≥ -7 and basolateral strain ≥ -10 were independent predictors of in-hospital mortality and MACE + in-hospital heart failure, respectively. CONCLUSIONS: Assessment of LV global and segmental longitudinal strain by speckle tracking has important prognostic value in the acute phase of TTS. Additional large-scale studies will be needed to confirm our findings.

Altered mental status in the emergency department - Can an electrocardiogram show the right way to go?

A 38-year-old African American male patient with a past medical history of human immunodeficiency virus and schizophrenia who was noncompliant with medications presented to the emergency department (ED) after activation of the local crisis response center for altered mental status. Upon arrival he was lethargic and uncooperative, unable to provide any significant details apart from pleuritic chest pain. His blood pressure was 133/88 mmHg, heart rate 43 beats per minute and initial body temperature 36.1 °C which prompted an electrocardiogram (EKG). This initial EKG was compared to a prior one obtained six months earlier during an ER visit for an acute psychotic episode. Three hours of being admitted he started shivering. Patient was found to be hypothermic with a rectal temperature of 28.9 °C. He was also hypoglycemic, pancytopenic and had positive urine cultures with >100,000 CFU/ml coagulase-negative Staphylococcus. There was no evidence of medication overdose. His CT scan of the brain did not show evidence of intracranial bleeding and his serum calcium was normal.

Patrón de Brugada intermitente en relación con cambios en la temperatura corporal / Intermittent Brugada pattern in relation to changes in body temperature

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Distinctive Electrocardiographic Features in African Americans Diagnosed with Takotsubo Cardiomyopathy.

BACKGROUND: Takotsubo cardiomyopathy (TC) can resemble acute anterior ST-elevation myocardial infarction. Most studies have examined TC in Asians and Caucasians (non-African Americans [AA]), while very few cases have been reported in AA. We aimed to assess the electrocardiographic features of TC in AA patients and compare them to non-AA TC patients. METHODS: We retrospectively compared electrocardiograms of 52 AA and 47 non-AA patients diagnosed with TC. All patients met the modified Mayo Clinic criteria for the diagnosis of TC. Information collected included PR interval, QRS duration and amplitude, QT interval in milliseconds (msec) adjusted for heart rate (QTc), ST-segment deviation at the J point in limb and precordial leads (≥1 mm), ST elevation (≥1 mm), and T-wave inversion (≥0.5 mm). RESULTS: T-wave inversion was more prevalent on presentation among AA patients (82% vs 48% in non-AA; P < 0.01), whereas ST depression was more common among non-AA (21% vs 7% in AA; P = 0.05). T-wave inversions in AA patients were frequent in both limb and precordial leads, whereas T-wave inversions in non-AA were limited to precordial leads. The average QTc upon presentation in AA was longer than non-AA (491 msec in AA vs 456 msec in non-AA; P < 0.01) as was the maximum average QTc during index hospitalization (527 msec in AA vs 497 msec in non-AA, P = 0.03). CONCLUSION: In patients presenting with TC, AA patients more frequently present with diffuse T-wave inversions and a more prolonged QTc, whereas non-AA patients more often present with ST depressions. AA patients also more frequently present with T-wave inversions diffusely, whereas non-AA patients present with T-wave inversions more limited to the precordial leads.

Antiplatelet therapy in Takotsubo cardiomyopathy: does it improve cardiovascular outcomes during index event?

Plasma catecholamines may play an important role in Takotsubo cardiomyopathy (TCM) pathophysiology. Patients with disproportionately high catecholamine responses to stressful events are prone to worse clinical outcomes. Catecholamines stimulate platelet activation and, therefore, may determine the clinical presentation and outcomes of TCM. We conducted a retrospective, descriptive study TCM patients admitted between 2003 and 2013 to Einstein Medical Center, Philadelphia, PA, USA and Danbury Hospital, Danbury, CT, USA. A total of 206 patients met Modified Mayo TCM criteria. Using a multiple logistic model, we tested whether aspirin, dual antiplatelet therapy (DAPT) aspirin + clopidogrel, beta blocker, statin, or ACE inhibitor use were independent predictors of major adverse cardiovascular events (MACE) during the index hospitalization. MACE was defined as in-hospital heart failure, in-hospital death, stroke or respiratory failure requiring mechanical ventilation. Incidence of in-hospital heart failure was 26.7 %, in-hospital death was 7.3 %, stroke was 7.3 % and MACE was 42.3 %. In a multiple logistic regression model (adjusted for gender, race, age, physical stressor, hypertension, diabetes, hyperlipidemia, smoking history, body mass index, initial left ventricular ejection fraction, single antiplatelet therapy, DAPT, beta blocker, statin, and ACE inhibitor) aspirin and DAPT at the time of hospitalization were independent predictors of a lower incidence of MACE during the index hospitalization (aspirin: OR 0.4, 95 % CI (0.16-0.9), P = 0.04; DAPT: OR 0.23; 95 % CI (0.1-0.55); P < 0.01. Physical stressor itself was also found to be an independent predictor of worse MACE: OR 5.1; 95 % CI (2.4-11.5); P < 0.01. In our study, aspirin and DAPT were independent predictors of a lower incidence of MACE during hospitalization for TCM. Prospective clinical trials are needed to confirm the findings of this study.

Myocardial infarction after taking eletriptan.

We report the case of a 53-year-old male patient with a medical history significant for paroxysmal atrial fibrillation, migraines with visual aura and non-obstructive coronary artery disease, who sustained a non-ST-elevation myocardial infarction a few hours after taking eletriptan as abortive therapy for migraine headaches. We believe this case implies a causal association between eletriptan and myocardial infarction, considering the timing of both drug intake and symptom onset. To the best of our knowledge this is the first reported myocardial infarction attributable to eletriptan overdose in a patient without obstructive coronary artery disease.