Takotsubo cardiomyopathy systematic review: Pathophysiologic process, clinical presentation and diagnostic approach to Takotsubo cardiomyopathy

doi:10.1016/j.ijcard.2016.02.012

International Journal of Cardiology

Volume 209, 15 April 2016, Pages 196-205

https://doi.org/10.1016/j.ijcard.2016.02.012 Get rights and content

Highlights

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Takotsubo cardiomyopathy (TTC) is a transient reversible cardiomyopathy.
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TTC occurs typically in older women after emotional or physical stress.
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Clinical presentation of TTC is usually similar to acute coronary syndrome.
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Pathophysiology of TTC involves catecholamine cardiotoxicity.
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Prognosis is favorable but a small subset has life-threatening complications.

Abstract

Takotsubo cardiomyopathy (TTC) is characterized by transient left ventricular apical ballooning with the absence of coronary occlusion, which typically occurs in older women after emotional or physical stress. The pathophysiology of TTC is not well established, though several possible causes such as catecholamine cardiotoxicity, metabolic disturbance, coronary microvascular impairment and multivessel epicardial coronary artery spasm have been proposed. A number of diagnostic criteria have been suggested in the world and not unified as single, but the most common accepted one is Mayo Clinic proposed criteria. Since the clinical presentation of TTC is usually similar to acute coronary syndrome, differential diagnosis is essential to exclude other diseases and also for its treatment. Imaging modality including echocardiogram, angio CT and cardiac MRI, and lab tests for catecholamine, troponin T, creatine kinase MB and B-type natriuretic peptide can be useful to differentiate TTC from other diseases. Prognosis is generally favorable and in-hospital mortality is from 0% to within 10%.

Section snippets

Definition

In 1990, takotsubo cardiomyopathy (TTC) was initially reported by Sato et al. in Japan [1], [2]. “Takotsubo” is named after Japanese octopus trap, whose shape is similar to the appearance of the patient's left ventricle in systole. (Fig. 1) TTC is described as a transient reversible cardiomyopathy, which typically occurs in older women after emotional or physical stress [3], [4], [5]. The presenting features of TTC are similar to those of myocardial ischemia after acute plaque rupture, but the

Epidemiology

One study in the United States results show there were 6837 patients diagnosed with TTC in the Nationwide Inpatient Sample database of 2008 and women were found to have higher odds of developing TTC (odd ratio 8.8). In absolute number of admissions, 6178 (90.4%) were women, and 660 (9.6%) were men. Patients aged from 18 to 34 were 127 (1.9%), patients aged from 35 to 49 were 581 (8.5%), patients aged from 50 to 64 were 1975 (28.9%), patients aged from 65 to 79 were 2952 (43.2%), and patients ≥ 80

Pathophysiology

The pathophysiology of TTC is not well established, but several possible theories on mechanisms with this disorder have been proposed [5], [12], [13].

Clinical presentation

TTC represents an estimated 1% to 2% of patients who present with an acute coronary syndrome [6], [36], [37]. Of 1750 patients with TTC, 89.8% were women and the mean age was 66.4 ± 13.1 years. Emotional triggers were not as common as physical triggers (27.7% vs. 36.0%), and 28.5% of patients had no evident trigger [38]. In the acute phase, the clinical presentation, electrocardiographic findings, and biomarker profiles are often similar to those of an acute coronary syndrome [3], [4], [6], [38],

Diagnosis

There is no single universally accepted diagnostic definition of TTC. TTC is a very common illness, often undetected. Current diagnostic criteria are restrictive, and thus they need to be “liberalized”. We follow the opinion of John Madias that there are many atypical and mild forms of TTC and that many patients have a “takotsubo component” as comorbidity to an acute coronary syndrome [44]. Under this condition, we would like to introduce the fact that several diagnostic criteria have been

Differential diagnosis

As we already mentioned in the above diagnostic criteria, the following conditions must be excluded in the diagnosis of TTC.

Echocardiography

The typical finding is of apical ballooning of the left ventricle. This is due to akinesia, hypokinesia, or dyskinesia of the apical and middle segments of the LV and hyperkinesia of the basal segments [10], [49], [18]. (Fig. 2) Furthermore, the additional presence of right ventricular apical akinesia during echocardiographic examination makes the diagnosis of this syndrome very likely [71].

The median left ventricular ejection fraction on the initial echocardiogram was 20% (interquartile range,

Catecholamine

TTC may be caused by catecholamine-induced microvascular spasm or by direct catecholamine-associated myocardial toxicity [5]. Recent evidence suggests that the pathophysiology of TTC may lie in changes in β-adrenergic receptor signaling [19]. Wittstein et al. compared admission plasma catecholamine concentrations between a group of 13 patients with stress cardiopathy who had transient apical ballooning and a group of 7 patients hospitalized for acute myocardial infarction (Killip class III).

Treatment

Since the initial presentation mimics AMI, initial management should be directed toward the treatment of myocardial ischemia with oxygen inhalation, intravenous heparin, aspirin (the treatment of myocardial infarction imply double platelet antiaggregation) and β-blockers. After confirmation of TTC, aspirin (antiaggregation) can be discontinued if there is no incidental coronary artery disease. Thrombolytic agents should not be administered because they have no benefit in TTC, and can give rise

Prognosis

Prognosis is generally favorable, but a small subset has potentially life-threatening complications [82]. The in-hospital death rate ranges from 0% to within 10% [3], [8], [49], [84], [85]. One study of the national inpatient sample 2008 to 2009 with a total of 24,701 TTC patients notes in-hospital mortality was 1027 (4.2%). Of 24,701 patients with TTC, 8640 (34.5%) patients have acute cardiac complications such as acute CHF, cardiac shock, respiratory failure with CHF, cardiac arrest, etc. and

Conflict of interest

The authors report no relationships that could be construed as a conflict of interest.

Acknowledgment

The authors thank Prof. Yoshio Kobayashi , Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, for his permission of several clinical images.

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Concerns have been raised recently about takotsubo cardiomyopathy (TCM) after receiving COVID-19 vaccines, particularly the messenger RNA (mRNA) vaccines. The goal of this study was to compile case reports to provide a comprehensive overview of takotsubo cardiomyopathy (TCM) associated with COVID-19 vaccines. A systematic literature search was conducted in PubMed, Scopus, Embase, Web of Science, and Google Scholar between 2020 and June 1, 2022. The study included individuals who developed cardiac takotsubo cardiomyopathy from receiving COVID-19 vaccinations. Ten studies, including 10 cases, participated in the current systematic review. The mean age was 61.8 years; 90 % were female, while 10 % were male. 80 % of the patients received the mRNA COVID-19 vaccine, while 20 % received other types. In addition, takotsubo cardiomyopathy (TCM) occurred in 50 % of patients receiving the first dose and another 40 % after the second dose of COVID-19 vaccines. Moreover, the mean number of days to the onset of symptoms was 2.62 days. All cases had an elevated troponin test and abnormal ECG findings. The left ventricular ejection fraction (LVEF) was lower than 50 % in 90 % of patients. In terms of the average length of hospital stay, 50 % stayed for 10.2 days, and all cases recovered from their symptoms. In conclusion, takotsubo (stress) cardiomyopathy (TCM) complications associated with COVID-19 vaccination are rare but can be life-threatening. Chest pain should be considered an alarming symptom, especially in those who have received the first and second doses of the COVID-19 vaccine.
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ReviewTakotsubo cardiomyopathy systematic review: Pathophysiologic process, clinical presentation and diagnostic approach to Takotsubo cardiomyopathy

Highlights

Abstract

Section snippets

Definition

Epidemiology

Pathophysiology

Clinical presentation

Diagnosis

Differential diagnosis

Echocardiography

Catecholamine

Treatment

Prognosis

Conflict of interest

Acknowledgment

J. Am. Coll. Cardiol. Img.

Am. Heart J.

J. Am. Coll. Cardiol.

Chest

J. Cardiovasc. Magn. Reson.

J. Nucl. Cardiol.

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

Am. Heart J.

Am. J. Cardiol.

Am. J. Cardiol.

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

Int. J. Cardiol.

Rev. Esp. Cardiol.

Int. J. Cardiol.

Am. Heart J.

J. Am. Coll. Cardiol.

Cardiovasc. Revasc. Med.

Am. J. Cardiol.

Am. J. Cardiol.

J. Electrocardiol.

J. Am. Coll. Cardiol.

Am. J. Emerg. Med.

Mayo Clin. Proc.

J. Am. Coll. Cardiol.

Int. J. Cardiol.

Am. J. Cardiol.

J. Am. Coll. Cardiol.

Int. J. Cardiol.

J. Nucl. Cardiol.

J. Card. Fail.

J. Am. Coll. Cardiol.

Am. Heart J.

Int. J. Cardiol.

Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases

J. Cardiol.

Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction

J. Am. Coll. Cardiol.

Acute and reversible cardiomyopathy provoked by stress in women from the United States

Circulation

Neurohormonal features of myocardial stunning due to sudden emotional stress

N. Engl. J. Med.

Apical ballooning of the left ventricle: first series in white patients

Heart

Tomoike H, et a1:guidelines for diagnosis of Takotsubo (ampulla) cardiomyopathy

Circ. J.

Review
Takotsubo cardiomyopathy systematic review: Pathophysiologic process, clinical presentation and diagnostic approach to Takotsubo cardiomyopathy