Tako-tsubo cardiomyopathy: is there a preferred time of onset?

Impact of Chronobiological Variation in Takotsubo Syndrome: Prognosis and Outcome

Background: A considerable amount of evidence has shown that acute cardiovascular diseases exhibit specific temporal patterns in their onset.

Aim: This study was performed to determine if takotsubo syndrome (TTS) shows chronobiological variations with short and long-term impacts on adverse events.

Design: Our institutional database constituted a collective of 114 consecutive TTS patients between 2003 and 2015.

Methods: Patients were divided into groups defined by the onset of TTS as per time of the day, day of the week, month and quarter of year.

Results: TTS events were most common afternoon and least common in the night, indicating a wave-like pattern (p = 0.001) of manifestation. The occurrence of TTS events was similar among days of the week and weeks of the month. TTS patients diagnosed in the month of November and subsequently in the fourth quarter showed a significantly longer QTc interval. These patients also revealed a significantly lower event-free-survival over a 1-year follow-up. In a multivariate Cox regression analysis, TTS events occurring in the fourth quarter of year (HR 6.8, 95%CI: 1.3–35.9; p = 0.02) proved to be an independent predictor of lower event-free-survival.

Conclusions: TTS seems to exhibit temporal preference in its onset, but nevertheless this possibly coincidental result needs to be analyzed in a large multicenter registry.

Gender Differences in the Circadian and Seasonal Variations in Patients with Takotsubo Syndrome: A Multicenter Registry at Eight University Hospitals in East Japan

Objective The aim of this study was to clarify the circadian and seasonal variations in addition to identify sex-based differences in Japanese patients with Takotsubo syndrome (TTS). Methods The authors conducted a retrospective observational study to analyse the differences between the groups based on sex. Patients The patients were registered out of each institute registry of the acute coronary syndrome (ACS) which contains a total of 10,622 cases in eight academic hospitals in east Japan. Results Data for 344 consecutive TTS (73 male and 271 female) were extracted from each hospital registry. In-hospital mortality was higher in the male group than in the female group (18% vs. 7%; p=0.005). With regard to the circadian variations in all study patients, TTS events occurred most often in the afternoon and least often during the night. Moreover, the patterns of circadian variations in the female and male groups were the same as that of all study patients. TTS events occurred most frequently in the autumn and least often in the spring in the whole study cohort. Moreover, the seasonal variation in the female group showed the same pattern as that of the whole cohort. However, there were no significant seasonal differences in the incidence of TTS in the male group. Conclusion In a multicenter study in Japan, seasonal variation was observed in the female group but not in the male group. Circadian variation was observed in both groups. These results suggested that the pathogenesis and clinical features of TTS might therefore differ according to sex.

The role of multimodality imaging in takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC) is a syndrome of transient left ventricular (LV) dysfunction mimicking acute coronary syndrome. Although the mechanisms underlying the occurrence of TC are unknown, several imaging techniques contribute to its diagnosis. Here we review the current knowledge about TC, in particular, the pathophysiology and the role of imaging including nuclear cardiovascular medicine.

Climatic variables in Takotsubo cardiomyopathy: role of temperature

BACKGROUND

Recent studies documented a seasonal (summer) and circadian (morning) temporal distribution of takotsubo cardiomyopathy (TTC).

AIM

The aim of our study was to investigate whether there is a relationship among season, temperature and the occurrence of TTC. A second aim of our study was the comparison of climatic variables in Takotsubo cardiomyopathy versus acute myocardial infarction (AMI).

METHODS

We enrolled consecutive patients with TTC in three Italian centres and, for comparison consecutive patients with AMI. The frequency of TTC and AMI patients according to month, season and quartiles of temperature (I quartile: 9.8-15°, II quartile: 15-19°, III quartile: 19-25° and IV quartile: 25-38°C) was reported. Climatic variables of TTC and AMI patients were compared.

RESULTS

We included in the study 85 patients with TTC and 900 patients with AMI. It was not observed a significant peak in the occurrence of TTC during summer time; however, when compared with AMI, TTC was more frequent in summer. We found an absolute higher frequency of TTC cases with warmer temperatures. TTC cases occurred during warmer temperatures than AMI.

CONCLUSION

Our study does not confirm a summer preference for TTC occurrence, as reported by previous studies, even if, compared with AMI, TTC is more frequent in summer. During warmest days, it was recorded the highest incidence of TTC.

Diurnal and twenty-four hour patterning of human diseases: cardiac, vascular, and respiratory diseases, conditions, and syndromes

Various medical conditions, disorders, and syndromes exhibit predictable-in-time diurnal and 24 h patterning in the signs, symptoms, and grave nonfatal and fatal events, e.g., respiratory ones of viral and allergic rhinorrhea, reversible (asthma) and non-reversible (bronchitis and emphysema) chronic obstructive pulmonary disease, cystic fibrosis, high altitude pulmonary edema, and decompression sickness; cardiac ones of atrial premature beats and tachycardia, paroxysmal atrial fibrillation, 3rd degree atrial-ventricular block, paroxysmal supraventricular tachycardia, ventricular premature beats, ventricular tachyarrhythmia, symptomatic and non-symptomatic angina pectoris, Prinzmetal vasospastic variant angina, acute (non-fatal and fatal) incidents of myocardial infarction, sudden cardiac arrest, in-bed sudden death syndrome of type-1 diabetes, acute cardiogenic pulmonary edema, and heart failure; vascular and circulatory system ones of hypertension, acute orthostatic postprandial, micturition, and defecation hypotension/syncope, intermittent claudication, venous insufficiency, standing occupation leg edema, arterial and venous branch occlusion of the eye, menopausal hot flash, sickle cell syndrome, abdominal, aortic, and thoracic dissections, pulmonary thromboembolism, and deep venous thrombosis, and cerebrovascular transient ischemic attack and hemorrhagic and ischemic stroke. Knowledge of these temporal patterns not only helps guide patient care but research of their underlying endogenous mechanisms, i.e., circadian and others, and external triggers plus informs the development and application of effective chronopreventive and chronotherapeutic strategies.

Heart and lung, a dangerous liaison-Tako-tsubo cardiomyopathy and respiratory diseases: A systematic review

AIM: To investigate the possible association between Tako-tsubo cardiomyopathy (TTC)-a reversible clinical condition mimicking an acute myocardial infarction characterized by multifactorial pathophysiologic mechanisms- and respiratory system diseases.

METHODS: We systematically searched PubMed and EMBASE medical information sources, to identify the different triggering causes, limiting our search to articles in English. The search keywords were: “tako-tsubo cardiomyopathy”, “takotsubo”, “takotsubo cardiomyopathy”, “broken heart syndrome”, “stress-induced cardiomyopathy”, “apical ballooning syndrome”, and “ampulla cardiomyopathy in combination with respiratory diseases, lung, pulmonary disease. For each kind of disease, we registered: author, year and country of study, patient sex, age, concurring situation, and outcome.

RESULTS: Out of a total of 1725 articles found, we selected 37 papers reporting a total of 38 patients. As expected, most patients were women (81.6%), mean age was 65 ± 10 years. Outcome was favorable in 100% of cases, and all the patients have been discharged uneventfully in a few days.

CONCLUSION: An association between respiratory diseases and TTC is likely to exist. Patients with severe respiratory diseases, due to the high dosages of β₂-agonists used or to the need of invasive procedures, are highly exposed to the risk of developing TTC.

Takotsubo cardiomyopathy: overview

Takotsubo cardiomyopathy (TTC) is a unique acute syndrome characterized by transient left ventricular systolic dysfunction in the absence of significant coronary artery disease, occurring mostly in postmenopausal women after emotional and/or physical stress. Given the nonspecific symptoms and signs, a high clinical index of suspicion is necessary to detect the disease in different clinical settings and scenarios. Noninvasive multimodality imaging may be useful to distinguish this cardiomyopathy from other acute cardiac and thoracic diseases. Coronary angiography remains, however, mandatory to differentiate TTC from acute coronary syndromes. This article reviews the clinical features and management of TTC and some new insights.

Characterization of predictors of in-hospital cardiac complications of takotsubo cardiomyopathy: multi-center registry from Tokyo CCU Network

BACKGROUND

Takotsubo cardiomyopathy (TC) is an acute cardiac syndrome characterized by transient left ventricular dysfunction and relatively good prognosis after discharge. However, cardiac complications during hospitalization remain to be fully determined. We attempted to determine features characterizing patients with adverse clinical outcome by comparing those with cardiac complication and without cardiac complication during hospitalization.

METHODS AND RESULTS

We investigated 107 patients with TC from the Tokyo CCU Network database, comprising 67 cardiovascular centers in the metropolitan area during January 1 to December 31, 2010. Cardiac complications were defined as cardiac death, pump failure (Killip grade≥II), sustained ventricular tachycardia or fibrillation (SVT/VF), and advanced atrioventricular block (AVB). Cardiac complications were observed in 41 patients (37 pump failure complicated by 3 cardiac deaths and 2 SVT/VF and 2 AVB without pump failure), and there was no cardiac complication in the remaining 66 patients. There was no difference in age, peak creatinine kinase level, C-reactive protein level and ST elevation on electrocardiogram. Multiple logistic regression analysis showed that white blood cell count (p=0.039) and brain natriuretic peptide (p=0.001) were independent predictors of in-hospital adverse cardiac complications.

CONCLUSIONS

Cardiac complications are relatively high in patients with TC during hospitalization. High white blood cell count and brain natriuretic peptide level are associated with poor clinical outcome in patients with TC.

Breaking heart: chronobiologic insights into takotsubo cardiomyopathy

A considerable amount of evidence has shown that the major acute cardiovascular diseases, ie, myocardial infarction, sudden cardiac death, stroke, pulmonary embolism, and rupture or dissection of aortic aneurysms do not occur randomly in time, but exhibit specific temporal patterns in their onset, according to time of day, month or season, and day of the week. This contributes to the definition of "chronorisk", where several factors, not harmful if taken alone, are capable of triggering unfavorable events when presenting all together within the same temporal window. This article reviews the actual knowledge about time of onset of takotsubo cardiomyopathy.

Twenty-four-hour patterns in occurrence and pathophysiology of acute cardiovascular events and ischemic heart disease

The scientific literature clearly establishes the occurrence of cardiovascular (CV) accidents and myocardial ischemic episodes is unevenly distributed during the 24 h. Such temporal patterns result from corresponding temporal variation in pathophysiologic mechanisms and cyclic environmental triggers that elicit the onset of clinical events. Moreover, both the pharmacokinetics and pharmacodynamics of many, though not all, CV medications have been shown to be influenced by the circadian time of their administration, even though further studies are necessary to better clarify the mechanisms of such influence on different drug classes, drug molecules, and pharmaceutical preparations. Twenty-four-hour rhythmic organization of CV functions is such that defense mechanisms against acute events are incapable of providing the same degree of protection during the day and night. Instead, temporal gates of excessive susceptibility exist, particularly in the morning and to a lesser extent evening (in diurnally active persons), to aggressive mechanisms through which overt clinical manifestations may be triggered. When peak levels of critical physiologic variables, such as blood pressure (BP), heart rate (HR), rate pressure product (systolic BP × HR, surrogate measure of myocardial oxygen demand), sympathetic activation, and plasma levels of endogenous vasoconstricting substances, are aligned together at the same circadian time, the risk of acute events becomes significantly elevated such that even relatively minor and usually harmless physical and mental stress and environmental phenomena can precipitate dramatic life-threatening clinical manifestations. Hence, the delivery of CV medications needs to be synchronized in time, i.e., circadian time, in proportion to need as determined by established temporal patterns in risk of CV events, and in a manner that averts or minimizes undesired side effects.

Chronobiological variation in the occurrence of Tako-tsubo cardiomyopathy: experiences of two tertiary cardiovascular centers

BACKGROUND

There have been few data to review and analyze the temporal preference of the onset of Tako-tsubo cardiomyopathy (TTC). Aim of this study was to investigate chronobiological variations in the occurrence of TTC and changes of these variations according to age and gender.

METHODS

One hundred and thirty-seven patients were enrolled from our TTC registry database from January 2004 to December 2010 in Korea.

RESULTS

The median age of the entire study population was 59 years (inter-quartile range 53-72 years). The majority of patients were women (n = 101, 74%). The onset of TTC differed as a function of season (P = .001), with the peak in July and the nadir in March. Events were most frequent in summer (n = 53%, 38.7%) and least so in winter (n = 26, 19%, chi-square = 13.92, P = .003). TTC was most frequent in the morning (n = 56, 40.9%) and least so at night (n = 22, 16.1%, chi-square = 21.98, P = .001). Also, TTC was most frequent on Monday (n = 34, 24.8%) and least so on Saturday (n = 7, 5.1%, chi-square = 30.44, P = .001). Stressor pattern, age and gender do not influence these increases of occurrence in summer, on Monday, and in the morning of TTC.

CONCLUSIONS

TTC seems to exhibit a temporal variation of occurrence with preferred peaks during morning, Monday, and summer. Stressor pattern, age and gender do not influence these temporal patterns of the occurrence of TTC. Further studies are needed to investigate the potential link between chronobiological variations of TTC onset and underlying pathophysiologic mechanisms.

Comparison of circadian rhythm patterns in Tako-tsubo cardiomyopathy versus ST-segment elevation myocardial infarction

Tako-tsubo cardiomyopathy (TTC) is an acute reversible cardiac condition usually triggered by stressful events, with a predilection for older women and clinical presentation often confused with acute coronary syndrome. Definition of the diurnal hourly pattern of TTC events may contribute to understanding the pathogenesis of this complex entity. We prospectively enrolled 186 consecutive patients with TTC (68 ± 14 years old, 95% women) and, for comparison, 2,975 patients with ST-segment elevation myocardial infarction (STEMI) at the Minneapolis Heart Institute over the same period. Circadian periodicity was analyzed for hourly occurrence of events throughout the day and for days of the week and months of the year. Occurrence of TTC showed a nonuniform distribution with a distinctive afternoon peak from 12:00 (noon) to 4:00 p.m., comprising 28% (n = 52) of all events, and with the nadir at 12 to 4 a.m. (chi-square 25.6, p <0.001). Patients with events within the peak were older (73 ± 13 years) than other patients (66 ± 13 years, p = 0.0025). Events were uniformly distributed over days of the week and months (p = 0.2 and 0.47, respectively). In contrast, patients with STEMI showed peak occurrence in the early morning hours, 8:00 a.m. to 12:00 p.m., comprising 24% of all events (chi-square 248, p <0.001). In conclusion, TTC events occurred in a circadian pattern with a peak in the afternoon hours, distinctive from the predilection of STEMI for morning hours. This timing of TTC events is most consistent with mechanisms underlying stressful life situations that usually trigger this condition.