Gender-related differences in takotsubo cardiomyopathy

An update on Takotsubo syndrome

ABSTRACT

Takotsubo syndrome (TTS) can be described as an acute, transiently occurring form of heart failure. It typically causes systolic dysfunction of the left ventricle (LV). Perhaps what is of most significance is the reversible nature of TTS, with many patients achieving recovery within a few weeks to months. TTS can be referred to by other names, attributed to its various precipitants, as well as the structural manifestations of the syndrome. Physical and emotional stressors have been identified as the most common of causes, hence the terms 'stress cardiomyopathy' and 'broken heart syndrome'. Precipitants can range from psychological, and hormonal, to molecular mechanisms. The symptoms of TTS can coalesce with other conditions and hence give rise to many differential diagnoses. Most patients present with dyspnoea and chest pain. The latter also presents in acute coronary syndrome (ACS); thus, ACS is a common differential diagnosis for TTS. The coronavirus disease 2019 (COVID-19) pandemic saw a drastic increase in mental health concerns which have persisted beyond this period. Further studies into personality disorders and their potential predisposition to COVID-19 and thus TTS would advance our understanding of the neuropsychiatric triggers of TTS. There is also a need for a single sensitive and specific diagnostic test for TTS as its diagnosis relies on the culmination of clinical presentation, echocardiography, cardiac catheterization, and cardiovascular magnetic resonance imaging (CMR).

Takotsubo Syndrome in New Zealand: Current Knowledge and Future Challenges

Takotsubo syndrome (TS), also known as apical ballooning syndrome is a transient stress-related cardiomyopathy characterised by acute but reversible left ventricular dysfunction. The condition tends to occur in postmenopausal women after a stressful event. At presentation TS typically mimics acute myocardial infarction (MI) and the incidence of TS has been increasing worldwide. This is likely a consequence of an improved awareness of the existence of this syndrome and easier access to early echocardiography and coronary angiography. However, its aetiology remains poorly understood and it is probably still underdiagnosed. Similar to other countries. TS is being increasingly recognised in New Zealand. In this review, we discuss the demographics, clinical features and outcomes of patients with TS in New Zealand. Doing so informs us not only of the pattern of disease in New Zealand but it also provides insights into the condition itself. This article is protected by copyright. All rights reserved.

Cardiovascular Imaging in Stress Cardiomyopathy (Takotsubo Syndrome)

Stress cardiomyopathy (Takotsubo syndrome) is a reversible syndrome stemming from myocardial injury leading to systolic dysfunction and is usually noted in the setting of a stressful event, be it an emotional or physical trigger. While the exact pathophysiology behind stress cardiomyopathy is yet unknown, there is ample evidence suggesting that neurocardiogenic mechanisms may play an important role. Although historically stress cardiomyopathy was generally thought to be a relatively benign condition, there is growing recognition of the cardiovascular complications associated with it despite its reversibility. Our review aims to shed light onto key cardiovascular imaging modalities used to diagnose stress cardiomyopathy while highlighting the role that imaging plays in assessing disease severity, identifying complications, dictating treatment approaches, and in short-term and long-term prognosis.

Conventional cardiovascular risk factors associated with Takotsubo cardiomyopathy: A comprehensive review

Takotsubo cardiomyopathy (TCM), characterized by transient left ventricular dysfunction, was first reported in Japan in 1990. Current research suggests that TCM can be affected by conventional cardiovascular factors such as hypertension (HTN), diabetes, hyperlipidemia (HLD), and obesity. Despite the increasing interest in this disease, research on TCM remains limited. Conventional cardiovascular factors are clinically related to the outcome of TCM. We reviewed the publications published in PubMed database between January 01 2010 and January 15 2021, and summarized the most current available evidence on the correlation between TCM and the conventional cardiovascular factors. TCM patients are predominantly postmenopausal women. Men and young patients are less commonly seen, but are prone to acute adverse complications and poor prognosis. HTN is common in patients with recurrent TCM. Existing evidence suggests that obesity and chronic kidney disease are related to poor prognosis in TCM. HLD is reported to be associated with fewer complications, though current evidence is limited. Finally, the relationship between diabetes and TCM prognosis is ambivalent. Current evidence suggests conventional cardiovascular risk factors are associated with the outcome of TCM, especially with mortality and complications. More prospective studies are needed to clarify the relationship between each risk factor and the prognosis of TCM.

Takotsubo cardiomyopathy and pituitary apoplexy: a case report

Background

Takotsubo cardiomyopathy (TTC) has been widely recognized in recent decades and is triggered by either physical or psychological stressors.

Case presentation

A 70-year-old woman presented to the Emergency Department due to confusion, hypotension, fever, chills, and cough. She had a one-year history of diabetes insipidus. Pituitary function examination at admission revealed decreased thyroid, sex and adrenal hormones. Pituitary MRI displayed findings suggestive of nonhemorrhagic pituitary apoplexy. Electrocardiogram (ECG) revealed T-wave inversion and extended QT interval. Transthoracic echocardiogram (TTE) showed left ventricular apical dysplasia and ballooning, accompanied by reduced left ventricular ejection fraction. Coronary angiography (CAG) revealed no obvious coronary arterial stenosis. The left ventriculogram demonstrated an octopus clathrate appearance. Most ECG and TTE changes recovered 10 days later.

Conclusions

To the best of our knowledge, this is the first report of newly diagnosed TTC associated with pituitary apoplexy.

Atypical Takotsubo Cardiomyopathy with Hypokinetic Left Mid-ventricle and Apical Wall Sparing: A Case Report and Literature Review

BACKGROUND

Takotsubo Cardiomyopathy (TTC) is an uncommon cause of acute reversible ventricular systolic dysfunction in the absence of obstructive Coronary Artery Disease (CAD). Typically manifesting as apical wall ballooning, TTC can rarely present atypically with apical wall sparing.

CASE REPORT

A 62-year-old female presented with complaints of chest pain and features mimicking acute coronary syndrome. Coronary angiogram revealed no obstructive CAD and left ventriculogram showed reduced ejection fraction, normal left ventricular apex and hypokinetic mid-ventricles consistent with atypical TTC. The patient was discharged home on heart failure medications and a follow-up transthoracic echocardiogram demonstrated improved left ventricular function with no wall motion abnormality.

CONCLUSION

This case report provides an insight into the diagnosis and management of TTC in the absence of pathognomic features.

Clinical Characteristics and Long-Term Mortality Rate in Female Patients with Takotsubo Syndrome Compared with Female Patients with ST-Elevation Acute Myocardial Infarction: A Retrospective Study from a Single Center

Background

Takotsubo syndrome (TTS) is characterized by acute transient, stress-induced, left ventricular systolic dysfunction, generally presenting with apical ballooning. It can mimic an acute coronary syndrome, but with a milder increase in cardiac enzymes and without culprit coronary artery disease on angiography. Data on long-term follow-up and survival in patients with TTS, compared with patients with ST-elevation myocardial infarction (STEMI), are scarce.

Purpose

To assess all-cause mortality rate and survival in a consecutive series of female patients with TTS compared with age- and sex-matched STEMI patients on long-term follow-up.

Methods and Results

We collected data of 65 TTS female patients (TTS group) with a mean age of 73.42 ± 11.35 years from 2001 to 2013. Collection of follow-up information was concluded for all patients in 2016. To compare the mortality and survival of TTS patients with those of the STEMI population, we used data from our STEMI Registry, a prospective registry of 7446 STEMI patients admitted from 2001 to 2013 to our cath-lab for primary percutaneous coronary intervention (p-PCI). From the registry, we selected 104 STEMI patients (STEMI group) comparable to our TTS group in terms of age (mean age of 72.33 ± 11.92 years) and sex. On follow-up examination after a median of 1000 days, the TTS group had a lower all-cause mortality rate than the STEMI group (7.69% versus 23.08%). This difference was statistically different between the two groups (log-rank test, p value = 0.03).

Conclusions

In our study, TTS and STEMI patients displayed a statistically significant difference in long-term survival. Specifically, the TTS group had a lower mortality rate than the STEMI group. This seems to suggest that TTS and STEMI are two different clinical entities with two different clinical outcomes.

Short-term remote ischemic conditioning may protect monkeys after ischemic stroke

Objective

We aimed to evaluate the safety and effectiveness of short-term remote ischemic postconditioning (RIPC) in acute stroke monkey models.

Methods

Acute stroke monkeys were allocated to four groups based on the number of limbs exposed to RIPC. RIPC was initiated by 5-min cuff inflation/deflation cycles of the target limb(s) for 5-10 bouts. Vital signs, skin integrity, brain MRI, and serum levels of cardiac enzymes (myoglobin, creatine kinase [CK], CK-muscle/brain [CK-MB]), one inflammatory marker (high-sensitivity C-reactive protein [hsCRP], and one endothelial injury marker (von Willebrand factor [vWF]) were assessed. Spetzler scores were used to assess neurological function.

Results

No significant differences in vital signs or local skin integrity were found. Short-term RIPC did not reduce infarct volume under any condition at the 24th hour after stroke. However, neurological function improved in multi-limb RIPC compared with sham and single-limb RIPC at the 30th day follow-up after stroke. Myoglobin, CK, and CK-MB levels were reduced after multi-limb RIPC, regardless of the number of bouts. Moreover, multi-limb RIPC produced a greater diminution in CK-MB levels, whereas two-limb RIPC was more effective in reducing serum CK levels at the 24th hour after stroke. hsCRP increased after 5 bouts of multi-limb RIPC before decreasing below baseline and single-limb RIPC levels. Serum vWF was decreased at later time points after RIPC in all RIPC groups.

Conclusions

Stroke monkeys in hyperacute stage may benefit from short-term RIPC; however, whether this intervention can be translated into clinical use in patients with acute ischemic stroke warrants further study.

Stress Cardiomyopathy Diagnosis and Treatment: JACC State-of-the-Art Review

Stress cardiomyopathy is an acute reversible heart failure syndrome initially believed to represent a benign condition due to its self-limiting clinical course, but now recognized to be associated with a non-negligible rate of serious complications such as ventricular arrhythmias, systemic thromboembolism, and cardiogenic shock. Due to an increased awareness and recognition, the incidence of stress cardiomyopathy has been rising (15-30 cases per 100,000 per year), although the true incidence is unknown as the condition is likely underdiagnosed. Stress cardiomyopathy represents a form of neurocardiogenic myocardial stunning, and while the link between the brain and the heart is established, the exact pathophysiological mechanisms remain unclear. We herein review the proposed risk factors and triggers for the syndrome and discuss a practical approach to diagnosis and treatment of the patients with stress cardiomyopathy, highlighting potential challenges and unresolved questions.

Takotsubo Syndrome: Contemporary Views on the Pathogenesis, Prevalence and Prognosis

Takotsubo syndrome (TTS) is a reversible left ventricular dysfunction characterized by local apical hypokinesia usually triggered by a physical or emotional stress. According to the last available data TTS may represent 2% of all admissions for acute coronary syndromes. Despite the reliable prevalence, diagnosis of TTS remains difficult. The initial presentation, both clinically and electrocardiographically, is similar to an acute myocardial infarction (AMI). The biomarker profile is also similar, although the peaks of troponin and creatinine kinase levels are lower, and brain natriuretic peptide levels are higher in patients with TTS compared with ST-segment elevation AMI. Modified Mayo diagnostic criteria are the most common for the diagnosis. Pathogenesis of TTS currently is not well understood. Catecholamines appear to play a central role in the pathophysiology of TTS. However, it is conceivable that some people have a genetic predisposition to stress-induced TTS. A genetic predisposition has been suggested based on the few familial TTS cases described. Despite reversible myocardial dysfunction, acute heart failure is the most common complication in the acute phase of TTS. In-hospital mortality rate is comparable to that of ST-segment elevation AMI. There are no randomized clinical trials to support specific treatment recommendations in TTS. It is believed that the tactics of managing patients with TTS hospitalized with suspicion of acute coronary syndrome should comply with the protocol of management of patients with AMI while acute coronary pathology is not excluded.

Down on your luck: cardiomyopathy precipitated by a bar fight

Takotsubo cardiomyopathy is characterized by transient loss of systolic function in the absence of coronary artery disease. It is significantly more common in post-menopausal women and is typically brought on by intense emotional stress. Pathophysiology is not completely elucidated, but it appears to be related, in part, to excess catecholamine; this results in coronary artery vasospasm, ischemia and eventual ventricular dysfunction. Patient presentation can vary widely, but typically presents similar to acute coronary syndrome. Management involves acute stabilization and monitoring, as well as guideline-directed medical therapy for heart failure. We report a very unique case of a healthy male patient presenting with nonanginal symptoms of racing heart, who was found to have cardiomyopathy following a physical encounter. This case serves to bring into awareness that intense physical encounters may be sufficient to induce cardiomyopathy without presenting angina.

Takotsubo Syndrome: Clinical Features, Pathogenesis, Treatment, and Relationship with Cerebrovascular Diseases

PURPOSE OF REVIEW

This review paper aims to provide a complete and updated overview on the clinical and pathophysiological aspects of Takotsubo syndrome (TTS), including prognosis, therapy, and the association with cerebrovascular conditions.

RECENT FINDINGS

TTS is an increasingly recognized non-ischemic cardiomyopathy characterized by sudden, temporary weakening of the myocardium, of which the pathogenesis is unknown. Although pathogenesis of TTS remains unclear, a complex interaction between catecholamine-mediated stimulation, myocardial stunning, and subsequent stress-related myocardial dysfunction seems to be the main pathophysiological mechanism. Stroke is linked to TTS by a dual relationship since it may induce TTS by catecholamine release even if TTS itself also may be complicated by left ventricular thrombi leading to stroke. Given its possible complications, including the association with neurological diseases, both cardiologist and neurologists should be aware about TTS in order to diagnose it promptly and to initiate appropriate therapeutic measures.

[Acute Stress and Broken Heart Syndrome. A Case Report]

INTRODUCTION

Stress has been associated with an acute heart failure syndrome of important morbidity and mortality.

METHODS

Case report and non-systematic review of the relevant literature.

CASE PRESENTATION

A 65-year-old woman with a history of an untreated generalized anxiety disorder, whom after the violent death of her son presented with oppressive chest pain irradiated to neck and left superior extremity, lasting for more than 30minutes, initial clinical suspect suggests acute coronary syndrome.

LITERATURE REVIEW

Tako-tsubo cardiomyopathy is characterized by a reversible left ventricular dysfunction and wall movement abnormalities, without any compromise of the coronary arteries, associated to high plasma levels of catecholamines which in most cases correlates with an acute stress of emotional or physical type.

CONCLUSIONS

Tako-tsubo cardiomyopathy has to be considered by physicians among the differential diagnosis when facing a patient with suspected acute coronary syndrome, especially in post-menopausal women with a history of psychiatric comorbidities such as a generalized anxiety disorder.

Trends in hospitalization for takotsubo cardiomyopathy in the United States

BACKGROUND

Takotsubo (or stress induced) cardiomyopathy is characterized by transient left ventricular systolic dysfunction. Recent trends in patient volume, characteristics, and outcomes in the United States are unknown.

METHODS

Using 2007-2012 National Inpatient Sample data, we identified 22,005 adults (≥18 years) with a primary and 31,942 adults with a secondary discharge diagnosis of takotsubo cardiomyopathy (International Classification of Diseases, Ninth Revision, code 429.83) who underwent diagnostic coronary angiography.

RESULTS

During 2007 to 2012, the incidence of takotsubo cardiomyopathy increased over 3-fold: 52/million discharges in 2007 to 178/million in 2012 (P < .001). We found a temporal increase in the prevalence of cardiac arrest, cardiogenic shock, cardiovascular risk factors (diabetes, hypertension), and psychiatric disorders (P trend < .0001 for all). In-hospital mortality was 1.1% and remained unchanged over this period (P = .22). Compared to the primary diagnosis group, mortality in the secondary diagnosis group was higher (1.1% vs 3.2%) and was associated with higher incidence of cardiogenic shock, cardiac arrest, and respiratory failure. Men represent 8% of patients in the primary diagnosis group and 12% in the secondary group. In both groups, men had a higher incidence of shock, cardiac arrest, and respiratory failure. Although their mortality was higher than women in the primary group (3.0% vs 0.9%, adjusted odds ratio 3.85, 1.74-8.51), it was comparable in the secondary group (4.8% vs 3.0%).

CONCLUSIONS

We found a marked increase in the hospitalization for takotsubo cardiomyopathy in the United States in recent years, suggesting higher incidence than prior reports. Although outcomes have remained favorable, there is an increasing burden of cardiovascular and psychiatric disorders in this population with growing cost of care. Risk of mortality is higher in men and in patients with underlying critical illness. The excess mortality in these groups appears to be mediated by greater severity of disease.

Gender Differences in Patients with Takotsubo Cardiomyopathy: Multi-Center Registry from Tokyo CCU Network

Background

The clinical features of gender differences in takotsubo cardiomyopathy (TC) remain to be determined. The aim of this study was to evaluate the differences in clinical characteristics of male and female patients with TC.

Methods

We obtained the clinical information of 368 patients diagnosed with TC (84 male, 284 female) from the Tokyo CCU Network database collected from 1 January 2010 to 31 December 2012; the Network is comprised of 71 cardiovascular centers in the Tokyo (Japan) metropolitan area. We attempted to characterize clinical differences during hospitalization, comparing male and female patients with TC.

Results

There were no significant differences in apical ballooning type, median echocardiography ejection fraction, serious ventricular arrhythmias (such as ventricular tachycardia or fibrillation), or cardiovascular death between male and female patients. Male patients were younger than female patients (median age at hospitalization for male patients was 72 years vs. 76 years for female patients; p = 0.040). Prior physical stress was more common in male than female patients (50.0% vs.31.3%; p = 0.002), while emotional stress was more common in female patients (19.0% vs. 31.0%; p = 0.039). Severe pump failure (defined as Killip Class > III) (20.2% vs. 10.6%; p = 0.020) and cardiopulmonary supportive therapies (28.6% vs. 12.7%, p < 0.001) were more common in male than female patients. Multivariate analysis revealed that male gender (odds ratio = 4.32, 95% CI = 1.41–13.6, p = 0.011) was an independent predictor of adverse composite cardiac events, including cardiovascular death, severe pump failure, and serious ventricular arrhythmia.

Conclusions

Cardiac complications in our dataset appeared to be more common in male than female patients with TC during their hospitalization. Further investigation is required to clarify the underlying mechanisms responsible for the observed gender differences.

Epidemiology and pathophysiology of Takotsubo syndrome

Takotsubo syndrome is an acute cardiac syndrome first described in 1990 and characterized by transient left ventricular dysfunction affecting more than one coronary artery territory, often in a circumferential apical, mid-ventricular, or basal distribution. Several pathophysiological explanations have been proposed for this syndrome and its intriguing appearance, and awareness is growing that these explanations might not be mutually exclusive. The reversible apical myocardial dysfunction observed might result from more than one pathophysiological phenomenon. The pathophysiology of Takotsubo syndrome is complex and integrates neuroendocrine physiology, potentially involving the cognitive centres of the brain, and including the hypothalamic-pituitary-adrenal axis. Cardiovascular responses are caused by the sudden sympathetic activation and surge in concentrations of circulating catecholamines. The multiple morphological changes seen in the myocardium match those seen after catecholamine-induced cardiotoxicity. The acute prognosis and recurrence rate are now known to be worse than initially thought, and much still needs to be learned about the epidemiology and the underlying pathophysiology of this fascinating condition in order to improve diagnostic and treatment pathways.

Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TTC) is an acute, stress-induced cardiomyopathy with an increased prevalence in post-menopausal women. The syndrome is most frequently precipitated by an acute emotional or physical stressor and mimics acute myocardial infarction with symptoms, electrocardiogram (ECG) changes and cardiac troponin elevation that are indistinguishable from those caused by plaque rupture or coronary thrombosis. Diagnosis of TTC is made when coronary angiography reveals no obstructive coronary artery disease and the left ventricle demonstrates apical ballooning and basal hypercontractility. Other ventricular patterns have also been described. An abnormal myocardial response to the catecholamine surge from an emotional or a physical stressor is implicated in the pathophysiology, but the reasons for the high prevalence of TTC presentations in post-menopausal women are unknown. Several mechanisms including multi-vessel coronary vasospasm, endothelial and coronary microvascular dysfunction and direct catecholamine toxicity have been proposed. No specific guidelines for treatment of TTC have been established, but treatment is based on the American Heart Association/American College of Cardiology guidelines for acute coronary syndrome/acute myocardial infarction and heart failure guidelines. In this review article, we discuss the characteristic clinical presentation of TTC and the commonly proposed mechanisms.

Gender-specific research for emergency diagnosis and management of ischemic heart disease: proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Research Workgroup

Coronary artery disease (CAD) is the most common cause of death for both men and women. However, over the years, emergency physicians, cardiologists, and other health care practitioners have observed varying outcomes in men and women with symptomatic CAD. Women in general are 10 to 15 years older than men when they develop CAD, but suffer worse postinfarction outcomes compared to age-matched men. This article was developed by the cardiovascular workgroup at the 2014 Academic Emergency Medicine (AEM) consensus conference to identify sex- and gender-specific gaps in the key themes and research questions related to emergency cardiac ischemia care. The workgroup had diverse stakeholder representation from emergency medicine, cardiology, critical care, nursing, emergency medical services, patients, and major policy-makers in government, academia, and patient care. We implemented the nominal group technique to identify and prioritize themes and research questions using electronic mail, monthly conference calls, in-person meetings, and Web-based surveys between June 2013 and May 2014. Through three rounds of nomination and refinement, followed by an in-person meeting on May 13, 2014, we achieved consensus on five priority themes and 30 research questions. The overarching themes were as follows: 1) the full spectrum of sex-specific risk as well as presentation of cardiac ischemia may not be captured by our standard definition of CAD and needs to incorporate other forms of ischemic heart disease (IHD); 2) diagnosis is further challenged by sex/gender differences in presentation and variable sensitivity of cardiac biomarkers, imaging, and risk scores; 3) sex-specific pathophysiology of cardiac ischemia extends beyond conventional obstructive CAD to include other causes such as microvascular dysfunction, takotsubo, and coronary artery dissection, better recognized as IHD; 4) treatment and prognosis are influenced by sex-specific variations in biology, as well as patient-provider communication; and 5) the changing definitions of pathophysiology call for looking beyond conventionally defined cardiovascular outcomes to patient-centered outcomes. These emergency care priorities should guide future clinical and basic science research and extramural funding in an area that greatly influences patient outcomes.

Takotsubo Cardiomyopathy: Typical and Atypical Variants, A Two-Year Retrospective Cohort Study

Background

Typical or classical takotsubo cardiomyopathy (TCM) is associated with the characteristic abnormality of a ballooned left ventricular apex with basal segmental hyperkinesis. TCM may not present with the “classical” wall motion abnormalities but can have a variety of segmental wall motion abnormalities. The aim of our work was to assess for any unique identifying factors that can help distinguish typical and atypical variants of TCM.

Methods

We studied 11 consecutive patients between 2010 and 2012 admitted with chest pain, electrocardiographic and cardiac biomarker changes consistent with acute coronary syndrome (ACS) who underwent left heart angiography and were clinically diagnosed to have TCM.

Results

Our study found no specific features distinguishing typical and atypical variants of TCM. In our study, all patients were female and all had excellent outcome. One patient was in fourth decade of life, three patients in fifth and sixth decade of life, while remaining were older. One patient had diabetes mellitus, five had hypertension, four had concurrent coronary artery disease, but no patient had any family history of TCM. Nine of 11 patients had immediate clear-cut stressors. Three patients had normal ECG, two with ST segment elevation, with nine patients having only modest troponin elevations. One patient had an anomalous RCA take-off from the right coronary cusp, otherwise remaining patients had normal anatomy. One patient had only apical involvement, remaining had multiple wall motion abnormalities, and all patients had involvement of the anterior wall. Four patients had apical sparing. No inverted TCM pattern with basal akinesis with normal wall motion in the midventricular and apical regions was found among our patients.

Conclusions

We report that the classification of TCM as typical versus atypical is probably not clinically meaningful. The regional wall motion abnormalities are related to catecholamine excess and to the susceptibility of that particular region to excess catecholamine. We do not know why such differences in regional susceptibility exist, and agree with the other authors that sub-classification would only add to confusion, and a delay in understanding of the disease process.

Epidemiology and clinical profile of Takotsubo cardiomyopathy

First described in Japan over 2 decades ago, takotsubo cardiomyopathy (TTC) has emerged as a unique cardiomyopathy with world-wide recognition, mimicking acute coronary syndrome. In early TTC experience, typical patients were older women, with a triggering emotional event, ST-segment elevation, and apical ballooning left ventricular (LV) contraction pattern. However, TTC is now more heterogeneous, occurring in males and younger individuals, without ST-segment elevation, as a spontaneous event in the absence of a trigger, and with diverse LV contraction patterns. Furthermore, TTC is more common than initially thought, now constituting 10% of women with suspected acute coronary syndrome. TTC is also associated with a broader range of psychological or physical triggers, including presentation during outpatient medical evaluations or hospitalization for acute illness. Although TTC has been considered a benign condition, it now carries a small but important risk for adverse outcomes, including cardiac arrest in 5%. Hemodynamic instability requiring intervention with vasopressor drugs or intra-aortic balloon pump is necessary in 15% and in-hospital mortality is approximately 5%, largely because of refractory cardiogenic shock or irreversible major comorbid conditions. Although complete cardiac recovery usually occurs rapidly, post-hospital survival may be less than the general population of similar age, largely because of concomitant illnesses. TTC may reoccur in up to 10% of patients, but β-blocking drugs are not absolutely preventive for initial or subsequent events.

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.

Sex differences in cardiomyopathies

Cardiomyopathies are a heterogeneous group of heart muscle diseases with a variety of specific phenotypes. According to the contemporary European Society of Cardiology classification, they are classified into hypertrophic (HCM), dilated (DCM), arrhythmogenic right ventricular (ARVC), restrictive (RCM), and unclassified cardiomyopathies. Each class is aetiologically further categorized into inherited (familial) and non-inherited (non-familial) forms. There is substantial evidence that biological sex is a strong modulator of the clinical manifestation of these cardiomyopathies, and sex-specific characteristics are detectable in all classes. For the clinician, it is important to know the sex-specific aspects of clinical disease expression and the potential modes of inheritance or the hereditary influences underlying the development of cardiomyopathies, since these may aid in diagnosing such diseases in both sexes.