Autonomic neurocardiogenic syndrome is stonewalled by the universal definition of myocardial infarction

Pheochromocytoma-induced cardiogenic shock: A multicentre analysis of clinical profiles, management and outcomes

OBJECTIVE

There is still uncertainty about the management of patients with pheochromocytoma-induced cardiogenic shock (PICS). This study aims to investigate the clinical presentation, management, and outcome of patients with PICS.

METHODS

We collected, retrospectively, the data of 18 patients without previously known pheochromocytoma admitted to 8 European hospitals with a diagnosis of PICS.

RESULTS

Among the 18 patients with a median age of 50 years (Q1-Q3: 40-61), 50% were men. The main clinical features at presentation were pulmonary congestion (83%) and cyclic fluctuation of hypertension peaks and hypotension (72%). Echocardiography showed a median left ventricular ejection fraction (LVEF) of 25% (Q1-Q3: 15-33.5) with an atypical- Takotsubo (TTS) pattern in 50%. Inotropes/vasopressors were started in all patients and temporary mechanical circulatory support (t-MCS) was required in 11 (61%) patients. All patients underwent surgical removal of the pheochromocytoma; 4 patients (22%) were operated on while under t-MCS. The median LVEF was estimated at 55% at discharge. Only one patient required heart transplantation (5.5%), and all patients were alive at a median follow-up of 679 days.

CONCLUSIONS

PICS should be suspected in case of a CS with severe cyclic blood pressure fluctuation and rapid hemodynamic deterioration, associated with increased inflammatory markers or in case of TTS progressing to CS, particularly if an atypical TTS echocardiographic pattern is revealed. T-MCS should be considered in the most severe cases. The main challenge is to stabilize the patient, with medical therapy or with t-MCS, since it remains a reversible cause of CS with a low mortality rate.

Recurrent Spontaneous Coronary Artery Dissection: Association with Takotsubo Syndrome and Fibromuscular Dysplasia; Comprehensive Review

Spontaneous coronary artery dissection (SCAD) is a non-traumatic, non-iatrogenic, and non-atherosclerotic separation or dissection of the coronary arterial wall by the formation of an intramural hematoma causing a false lumen leading to compression of the true lumen with a varying degree of coronary blood flow obstruction. One of the important and frequent complications of the disease is the in-hospital and long-term SCAD recurrence. SCAD associated with takotsubo syndrome (TS) has been described in case reports, series of cases and in some studies. Some investigators believe that the association of SCAD and TS is a misdiagnosis. The association of SCAD and fibromuscular dysplasia (FMD) has received major attention during the last 10 years. In this report, the short and long-term SCAD recurrence, SCAD association with TS and FMD are reviewed and demonstrated with illustrative images.

The role of central autonomic nervous system dysfunction in Takotsubo syndrome: a systematic review

Introduction

Takotsubo syndrome (TTS), also known as stress cardiomyopathy or “broken heart” syndrome, is a mysterious condition that often mimics an acute myocardial infarction. Both are characterized by left ventricular systolic dysfunction. However, this dysfunction is reversible in the majority of TTS patients.

Purpose

Recent studies surprisingly demonstrated that TTS, initially perceived as a benign condition, has a long-term prognosis akin to myocardial infarction. Therefore, the health consequences and societal impact of TTS are not trivial. The pathophysiological mechanisms of TTS are not yet completely understood. In the last decade, attention has been increasingly focused on the putative role of the central nervous system in the pathogenesis of TTS.

Conclusion

In this review, we aim to summarize the state of the art in the field of the brain–heart axis, regional structural and functional brain abnormalities, and connectivity aberrancies in TTS.

Plasma catecholamine levels in the acute and subacute stages of takotsubo syndrome: Results from the Stockholm myocardial infarction with normal coronaries 2 study

AIMS

It is well-accepted that takotsubo syndrome (TS) is characterized by a massive surge of plasma catecholamines despite lack of solid evidence. The objective of this study was to examine the hypothesis of a massive catecholamine elevation in TS by studying plasma-free catecholamine metabolites in patients participating in the Stockholm myocardial infarction (MI) with normal coronaries 2 (SMINC-2) study where TS constituted more than one third of the patients.

METHODS AND RESULTS

The patients included in the SMINC-2 study were classified, according to cardiac magnetic resonance (CMR) imaging findings (148 patients), which was performed at a median of 3 days after hospital admission. Plasma-free catecholamine metabolites; metanephrine, normetanephrine, and methoxy-tyramine were measured on day 2-4 after admission. Catecholamine metabolite levels were available in 125 patients. One hundred and ten (88%) of the 125 patients included in SMINC-2 study, and 38 (86.4%) of the 44 patients with TS had completely normal plasma metanephrine and normetanephrine levels. All patients had normal plasma methoxy-tyramine levels. Fourteen (11.2%) of the 125 patients included in SMINC-2 study, and 5 (11.6%) of the 43 patients with TS had mild elevations (approximately 1.2 times the upper normal limits) of either plasma metanephrine or normetanephrine. One patient with pheochromocytoma-triggered TS had marked elevation of plasma metanephrine and mild elevation of plasma normetanephrine. There were no significant differences between the number or degree of catecholamine metabolite elevations between the different groups of patients with CMR imaging diagnosis included in SMINC-2 study.

CONCLUSION

There was no evidence of massive catecholamine elevations in the acute and subacute stages of TS apart from one patient with pheochromocytoma-induced TS. Most of the TS patients had normal catecholamine metabolites indicating that blood-borne catecholamines do not play a direct role in the pathogenesis of TS.

Coronary microvascular dysfunction in Takotsubo syndrome: cause or consequence

Takotsubo syndrome (TS) is an acute cardiac disease entity, characterized by a transient myocardial stunning in a distinctive predominantly regional circumferential pattern. One of the discussed pathological mechanisms of TS is coronary ischemia including coronary microvascular dysfunction (CMVD). Many studies have revealed invasive or non-invasive signs of CMVD in patients with TS, and therefore some investigators believe that CMVD is the primary cause of TS. Nevertheless, other studies have not shown any sign of CMVD. In addition, those studies, which have shown signs of CMVD, do not reveal such signs in all the three coronary vessel distribution; some of the patients show signs of CMVD in two or only one coronary artery territory. Moreover, signs of CMVD in TS are more prevalent and more pronounced in the left anterior descending artery (LAD) distribution. The CMVD in TS is reversible in a pattern parallel to the improvement of myocardial wall motion abnormality. In this review, substantial evidences challenging CMVD as the primary cause of TS and supporting the concept that CMVD is a secondary or epiphenomenon in TS are provided. Furthermore, convincing explanation is given for the causes of the more prevalent and the more pronounced signs of CMVD observed in the LAD distribution.