Takotsubo cardiomyopathy associated with titration of duloxetine

Takotsubo cardiomyopathy is characterized by transient multisegmental left ventricular dysfunction, dynamic electrocardiographic changes that mimic acute myocardial infarction, and the absence of obstructive coronary disease. Takotsubo cardiomyopathy has been solidly associated with antecedent emotional and physical stressors that trigger catecholamine surges, which lead to coronary vasospasm or direct myocardial injury. Some medications can also cause catecholamine surges, although this phenomenon is not as well described. Duloxetine is a combined serotonin and norepinephrine reuptake inhibitor (SNRI). The basic goal of SNRIs is to increase catecholamine levels in neuronal tissue. However, the increased catecholamine levels may also affect the cardiovascular system.Herein, we report the case of a 59-year-old woman whose takotsubo cardiomyopathy was temporally associated with the titration of duloxetine. The duloxetine therapy was subsequently discontinued, and the patient's left ventricular function recovered completely 1 month after the index event. The purpose of this report is to alert clinicians to a possible association between SNRI medications and takotsubo cardiomyopathy.     

Atypical takotsubo cardiomyopathy: dobutamine-precipitated apical ballooning with left ventricular outflow tract obstruction

Takotsubo cardiomyopathy, or transient apical ballooning syndrome, is a recently recognized form of transient left ventricular dysfunction that is presumably caused by stress. Takotsubo cardiomyopathy can clinically resemble an acute coronary syndrome. Reported cases have been preceded by emotional stress or medical illness. Herein, we report a fatal case of takotsubo cardiomyopathy that followed a dobutamine stress test. We believe that the dobutamine infusion led to stress-induced cardiomyopathy with a dynamic left ventricular outflow tract obstruction. To our knowledge, there is only 1 other report of an association between dobutamine infusion and the development of takotsubo cardiomyopathy.     

Recurrent Takotsubo Cardiomyopathy Related to Recurrent Thyrotoxicosis

Takotsubo cardiomyopathy, or transient left ventricular apical ballooning syndrome, is characterized by acute left ventricular dysfunction caused by transient wall-motion abnormalities of the left ventricular apex and mid ventricle in the absence of obstructive coronary artery disease. Recurrent episodes are rare but have been reported, and several cases of takotsubo cardiomyopathy have been described in the presence of hyperthyroidism. We report the case of a 55-year-old woman who had recurrent takotsubo cardiomyopathy, documented by repeat coronary angiography and evaluations of left ventricular function, in the presence of recurrent hyperthyroidism related to Graves disease. After both episodes, the patient''s left ventricular function returned to normal when her thyroid function normalized. These findings suggest a possible role of thyroid-hormone excess in the pathophysiology of some patients who have takotsubo cardiomyopathy.     

Takotsubo syndrome: Advances in the understanding and management of an enigmatic stress cardiomyopathy

Takotsubo cardiomyopathy is a syndrome mimicking an acute myocardial infarction in absence of obstructive epicardial coronary artery disease to explain the degree of the wall motion abnormalities. Typically more common in the elderly women, this condition is usually triggered by unexpected emotional or physical stress situations, and is associated with electrocardiogram abnormalities and slight elevation of cardiac biomarkers. The pathophysiological mechanism is not clear yet, but it is believed that a high circulating concentration of catecholamines causes an acute dysfunction of the coronary microcirculation and metabolism of cardiomyocytes, leading to a transient myocardial stunning. Typically, it presents with acute left ventricular systolic dysfunction that in most cases is completely resolved at short term. Recurrences are rare and it is thought that the long-term prognosis is good. We present here a review of the clinical features, pathophysiology and management of this enigmatic condition.     

Recurrent takotsubo with prolonged QT and torsade de pointes and left ventricular thrombus

Takotsubo cardiomyopathy, also known as “takotsubo syndrome,” refers to transient apical ballooning syndrome, stress cardiomyopathy, or broken heart syndrome and is a recently recognized syndrome typically characterized by transient and reversible left ventricular dysfunction that develops in the setting of acute severe emotional or physical stress. Increased catecholamine levels have been proposed to play a central role in the pathogenesis of the disease, although the specific pathophysiology of this condition remains to be fully determined. At present, there have been very few reports of recurrent takotsubo cardiomyopathy. In this case report, we present a patient with multiple recurrences of takotsubo syndrome triggered by severe emotional stress that presented with recurrent loss of consciousness, QT prolongation, and polymorphic ventricular tachycardia (torsade de pointes) and left ventricular apical thrombus.     

Inverted takotsubo cardiomyopathy

Takotsubo cardiomyopathy is a transient acute left ventricular dysfunction characterized by left ventricular apical akinesis and ballooning without obstructive coronary disease described predominantly in post-menopausal women in the setting of acute emotional or physical stress. Recent reports have described isolated transient basal akinesis (inverted takotsubo cardiomyopathy) in mostly female patients with acute neurologic disorders or pheochromocytoma. We describe a rare case of a 78-year-old male with inverted takotsubo cardiomyopathy in the setting of acute abdominal pain attributed to biliary colic. A review of published literature reveals that inverted takotsubo cardiomyopathy precipitated by acute stress rather than an acute neurologic disorder appears to be an extremely rare presentation in a male patient. We discuss the relevant literature regarding incidence and reported gender distribution of inverted takotsubo cardiomyopathy.     

Spontaneous coronary artery dissection triggered post-ischemic myocardial stunning and takotsubo syndrome: two different names for the same condition

An acute coronary ischemic insult may “cause” prolonged post-ischemic myocardial stunning. In spite of being a major stress factor, acute coronary syndrome is regarded as an exclusion criterion for takotsubo syndrome. We describe the case of a 39-year-old female patient presented with anterior ST-elevation myocardial infarction. Emergency coronary angiography revealed spontaneous coronary artery dissection confirmed with intravascular ultrasound examination. The patient developed clinical, angiographic and cardiac image features consistent with both post-ischemic myocardial stunning and takotsubo syndrome. Complete healing of the coronary dissection occurred with conservative treatment. There was also resolution of the greatest part of the left ventricular dysfunction. The findings in the present case indicate that the post-ischemic myocardial stunning and takotsubo syndrome are two different names for the same clinical condition and that the acute coronary syndrome triggers rather than excludes takotsubo syndrome.     

The "broken heart syndrome": State of the art

Takotsubo cardiomyopathy is a reversible condition, characterized by transient left ventricular systolic dysfunction, that mimics an acute coronary syndrome. It usually occurs after physical or emotional stress, predominantly in postmenopausal women, although it also can affect younger age groups and males. It often presents as chest pain or dyspnea with electrocardiographic changes and mild elevation of cardiac enzymes suggesting acute myocardial infarction. Coronary angiography excludes obstructive coronary disease, and imaging reveals ventricular apical akinesia and compensatory hypercontractility of the basal segments. Various pathophysiological mechanisms have been proposed for the syndrome, such as occult atherosclerotic disease, multivessel spasm and/or microvascular dysfunction. However, the most widely accepted hypothesis at present is an excess of catecholamines causing calcium overload in cardiac myocytes, leading to disruption of contraction and ventricular function. Treatment is essentially supportive, with spontaneous and complete reversal of the changes within days or weeks. However, the presence of complications and comorbidities may predict a more adverse prognosis. As much is still unknown about takotsubo cardiomyopathy and the number of reported cases is growing, we present a literature review.     

Acute subarachnoid haemorrhage as a precipitant for takotsubo cardiomyopathy: a case report and discussion

Takotsubo cardiomyopathy is a recently recognised acute cardiac entity. It involves transient left ventricular apical ballooning, which is usually preceded by an episode of physiological or emotional stress. Its presentation may mimic acute myocardial infarction but there is no evidence of obstructive disease at coronary angiography. The aetiology of this condition has not been clearly defined, though a number of hypotheses have been put forward. Precipitating factors vary widely, including acute medical conditions and emotional stressors. We present a case of takotsubo cardiomyopathy precipitated by acute subarachnoid haemorrhage, the first report of this association in a Caucasian patient, and discuss the implications for clinicians involved in the management of such a case.     

Takotsubo cardiomyopathy in a patient with pulmonary embolism

Takotsubo cardiomyopathy is an acute cardiac syndrome characterized by transient regional wall motion abnormalities of the left ventricular apex or midventricle. Patients often present with chest pain or dyspnoea, ST-segment elevation, and minor elevations of cardiac enzyme levels. Takotsubo cardiomyopathy has been associated with severe emotional or physical stress such as severe burns, spinal cord injury, subarachnoid haemorrhage, and multiple traumas. We report a case of takotsubo cardiomyopathy in a 79-year-old woman with pulmonary embolism. Although pulmonary embolism has been listed as a potential cause of takotsubo cardiomyopathy, this is the first case reported with this association.     

Takotsubo cardiomyopathy followed by neurogenic stunned myocardium in the same patient: gradations of the same disease?

Takotsubo cardiomyopathy is a phenomenon of transient acute left ventricular dysfunction without obstructive coronary disease seen predominantly in postmenopausal women in the setting of acute emotional or physical stress. Neurocardiogenic injury from acute neurologic events such as intracranial bleeding can precipitate transient left ventricular dysfunction (termed 'neurogenic stunned myocardium') that may be indistinguishable from takotsubo cardiomyopathy. There is controversy about the diagnosis of takotsubo cardiomyopathy in the setting of acute neurologic disorders. We describe a case of a 67-year-old female who initially presented with takotsubo cardiomyopathy due to an acute gastrointestinal illness and 4 years later developed a recurrence in the setting of an ischemic cerebrovascular accident that was associated with more prominent EKG changes and much higher cardiac biomarker release but similar degree of left ventricular dysfunction. This case suggests that susceptibility to this disorder is likely due to patient-specific factors rather than etiology, and acute neurologic disorders should be included as precipitants of takotsubo cardiomyopathy. We also theorize that there may be patients with milder forms of stress-related cardiac injury who do not develop left ventricular dysfunction, being similar to the wide range of cardiac manifestations in patients with acute neurologic disorders. We review published literature on neurologic precipitants of takotsubo cardiomyopathy.     

Recurrence of stress-induced (takotsubo) cardiomyopathy

Takotsubo cardiomyopathy is a recently recognized form of transient left ventricular dysfunction that is presumably precipitated by stress and may clinically resemble an acute coronary syndrome. These patients have an akinetic left ventricular apex in an unusual shape that resembles a takotsubo. Although reports of single episodes of takotsubo cardiomyopathy are not infrequent in recent medical literature, we report a case of recurrence that may provide more insight into the nature of this syndrome.     

Takotsubo cardiomyopathy may be associated with cardiac geometric features as observed in hypertensive heart disease

Takotsubo cardiomyopathy is a clinical entity with a relatively new described acute and reversible left ventricular (LV) dysfunction triggered by emotional stress. Different observations have represented that takotsubo cardiomyopathy may be associated with similar LV myocardial geometry as described by novel quantitative echocardiographic methods in hypertensive heart disease. Therefore, acute emotional stress in takotsubo cardiomyopathy or chronic stress by increased afterload in hypertension possibly represents similar morphologic and functional features on the basis of heart.     

Hyponatremia--an unusual trigger of Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is an acute cardiac entity with clinical manifestations similar to myocardial infarction, accounting for 1-2% of acute coronary syndrome admissions. Its underlying pathophysiology is not yet well established. It is usually associated with acute physical or emotional stress, but the list of potential triggers has grown as the condition attracts the attention of the medical community. In order to diagnose the condition correctly and to gain new insights into it, we need to know its potential triggers as well as its clinical presentation and diagnostic criteria. We report a case of takotsubo cardiomyopathy triggered by hyponatremia.     

Takotsubo cardiomyopathy: An under-recognized myocardial syndrome

Takotsubo cardiomyopathy is characterized by reversible left ventricular dysfunction with apical ballooning and is triggered by marked psychological or physiological stress in the absence of significant epicardial coronary artery disease. Clinically, this unique myocardial syndrome mimics acute myocardial infarction, and it has been considered to be a rare entity with a good prognosis. The literature on takotsubo cardiomyopathy is limited by selection bias and patient heterogeneity, but recent data suggest the syndrome is more prevalent, e.g., in critically ill, non-cardiac patients. Prompt diagnosis and aggressive therapy are essential for a rapid recovery. Clinicians should increase their awareness of this syndrome and more research should be carried out on the epidemiology, pathophysiology, and treatment of takotsubo cardiomyopathy.     

Takotsubo cardiomyopathy, or broken-heart syndrome

Takotsubo cardiomyopathy mimics acute coronary syndrome and is accompanied by reversible left ventricular apical ballooning in the absence of angiographically significant coronary artery stenosis. In Japanese, "takotsubo" means "fishing pot for trapping octopus," and the left ventricle of a patient diagnosed with this condition resembles that shape. Takotsubo cardiomyopathy, which is transient and typically precipitated by acute emotional stress, is also known as "stress cardiomyopathy" or "broken-heart syndrome."Herein, we describe the clinical angiographic characteristics of 4 patients who exhibited this syndrome, and we review the existing literature and propose reasons to conduct prospective studies.     

Inverted Takotsubo Cardiomyopathy and the Fundamental Diagnostic Role of Echocardiography

Takotsubo cardiomyopathy is characterized by the development of transient focal wall-motion abnormalities that involve the apical and midventricular segments, in the absence of obstructive coronary artery disease. A variant, inverted takotsubo cardiomyopathy, was described in 2010. We report 3 cases in which each patient''s transthoracic echocardiogram revealed the characteristic basal and midventricular segmental akinesis of this variant. This pattern is not associated with coronary artery distribution, and it therefore can be differentiated from coronary artery disease with the use of echocardiography, by evaluating the distribution and temporal changes of akinetic areas.Key words: Cardiomyopathies/diagnosis/physiopathology, echocardiography, takotsubo cardiomyopathy/diagnosis, ventricular dysfunction, left/diagnosisTakotsubo cardiomyopathy is a syndrome characterized by transient apical and midventricular akinesis that is typically precipitated by acute stress. A variant, with akinesis of the mid and basal left ventricular (LV) segments and sparing of the apex, has been called inverted (or atypical) takotsubo cardiomyopathy. We describe 3 cases of this variant in which the transthoracic echocardiograms (TTEs) and temporal evolution of the condition were diagnostic. Each patient was emergently admitted to Barnes-Jewish Hospital in St. Louis and examined there; the TTEs were reviewed by a visiting cardiologist (AM).     

Biventricular Takotsubo syndrome in a patient with coronary abnormality and end-stage renal disease

The Takotsubo syndrome is a clinical entity consisting of transient, regional left ventricular (LV) contraction abnormalities in the absence of significant epicardial coronary artery disease. Patients usually present with acute hemodynamic deterioration following an emotional or physical stress. The Takotsubo syndrome is uncommon among patients with end-stage renal disease (ESRD) and patients with congenital coronary abnormalities, such as right coronary artery (RCA) originating from left sinus of Valsalva. Here we describe a patient presenting with acute respiratory distress and anterolateral ST-T segment changes, with negative troponin-I and elevated levels of brain natriuretic peptide. Coronary angiography showed a right coronary artery arising from the left sinus of Valsalva without obstructive coronary artery disease, while ventriculography and echocardiogram showed findings compatible with apical ballooning. Magnetic resonance imaging confirmed the diagnosis of a biventricular Takotsubo cardiomyopathy.     

The Role of Optical Coherence Tomography in Clarifying the Mechanisms for Dobutamine Stress Echocardiography‐Induced Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy is a clinical disorder characterized by a transient dilatation and akynesis or dyskinesis of the left ventricular (LV) apex, mimicking an anterior wall acute myocardial infarction in the absence of significant coronary artery disease (CAD). It typically occurs during an episode of severe emotional or physical stress. Recent reports suggested the potential of dobutamine stress echocardiography (DSE) in inducing the aforementioned syndrome. The transient dysfunction of the LV does not fit any known coronary distribution. Furthermore, there is no obstructive CAD demonstrated at angiography to account for the observed dysfunction. Consequently, the pathophysiology of this syndrome is still undetermined. Here, we report a case of DSE‐induced Takotsubo cardiomyopathy in which high‐resolution intracoronary imaging was utilized to exclude possible vessel alterations to help provide potential mechanistic explanations for the development of this condition.     

Acute stress cardiomyopathy

A unique syndrome of heart failure and transient left ventricular systolic dysfunction precipitated by acute emotional or physical stress has recently emerged in the medical literature. The syndrome is referred to by several names, including stress cardiomyopathy, takotsubo cardiomyopathy, left ventricular apical ballooning syndrome, and broken heart syndrome. Because most patients with stress cardiomyopathy present with chest pain, electrocardiographic abnormalities, elevated cardiac enzymes, and focal left ventricular wall motion abnormalities, it is not surprising that for years this syndrome went relatively unrecognized because physicians mistook it for acute myocardial infarction. As reports of this condition have increased worldwide during the past 5 years, it has become clear that stress cardiomyopathy has unique clinical features that can be readily distinguished from those of an acute myocardial infarction. This article reviews the clinical features of stress cardiomyopathy and discusses potential pathophysiologic mechanisms of this disorder.