Risk factors for a broken heart: understanding drug-induced causes for Takotsubo syndrome and pharmacological treatment options.

INTRODUCTION: Takotsubo syndrome (TTS) is an acute inflammatory disorder involving first the vasculature and then the myocardium. It occurs relatively frequently, especially in aging women after acute physical and emotional stress. There is also increasing recognition that TTS attacks are sometimes precipitated by pharmacotherapy. AREAS COVERED: The pathogenesis of TTS is described, including components of a complex biochemical 'cascade' centering on aberrant post-receptor signaling following ß2-adrenoceptors stimulation and resultant nitric oxide (NO) release and development of nitrosative stress. Examples and significance of drug-induced TTS are also described. Currently available therapeutic information regarding TTS is presented, both for management of patients acutely and in the long-term. Furthermore, development of specific therapies to block components of the pathogenetic TTS 'cascade' is discussed. EXPERT OPINION: The biochemical 'cascade' in TTS revolves around an aberrant post-receptor response to ß2-adrenoceptor stimulation, increased responsiveness to NO and triggering of activation of poly(ADP-ribose) polymerase (PARP). In theory, interruption of this 'cascade' represents a logical approach to improving both symptomatic status and survival post TTS. Currently, there is some evidence supporting routine long-term treatment post TTS with either ACE inhibitors or angiotensin receptor antagonists, both to reduce risk of recurrence and to improve survival. Results of ongoing controlled clinical trials are awaited.