Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review.

AIMS: To clarify the major features of the apical ballooning syndrome, we performed a systematic review of the existing literature. METHODS AND RESULTS: Review of all relevant case series using the MEDLINE and EMBASE databases resulted in the identification of 14 studies. These studies suggest that the apical ballooning syndrome accounts for approximately 2.0% of ST-segment elevation infarcts, with most cases described in post-menopausal women. The most common clinical presentations are chest pain and dyspnoea, reported in 67.8 and 17.8% of the patients, respectively. Cardiogenic shock (4.2% of the patients) and ventricular fibrillation (1.5%) were not infrequent. ST-segment elevation was reported in 81.6% of the patients, T wave abnormalities in 64.3%, and Q waves in 31.8%. Cardiac biomarkers were usually mildly elevated, as reported in 86.2% of the patients. Typically, patients had left ventricular (LV) dysfunction on admission, with mean ejection fraction ranging from 20 to 49%. However, over a period of days to weeks, all patients experienced dramatic improvement in LV function. The onset of symptoms was often preceded by emotional (26.8%) or physical stress (37.8%). Norepinephrine concentration was elevated in 74.3% of the patients. Prognosis was generally excellent, with full recovery in most patients. In-hospital mortality was 1.1%. Only 3.5% of the patients experienced a recurrence. CONCLUSION: Clinicians should consider this syndrome in the differential diagnosis of patients presenting with chest pain, especially in post-menopausal women with a recent history of emotional or physical stress.     

Prevalence of stress-induced myocardial stunning (Tako-Tsubo cardiomyopathy) among patients undergoing emergency coronary angiography for suspected acute myocardial infarction

Stress-induced myocardial stunning is defined as a syndrome of acute chest pain, ST-T changes on the ECG and transient left ventricular apical wall motion abnormalities mimicking acute myocardial infarction but with surprisingly normal coronary angiography findings.

The aim of this retrospective study is to assess the prevalence of stress-induced myocardial stunning among patients undergoing urgent coronary angiography for suspected acute myocardial infarction.

During a four-year period (2002–2005), a total of 5876 patients underwent urgent coronary angiography for suspected acute myocardial infarction at three tertiary centers. Four patients fulfilled the diagnostic criteria for stress-induced myocardial stunning. Thus, the cath-lab prevalence of stress-induced myocardial stunning (i.e. among patients undergoing urgent coronary angiography for suspected acute myocardial infarction) was estimated as 1 per 1469 ST-elevation coronary angiograms (i.e. 0.07%) The estimated annual population incidence of this rare disorder was calculated as 0.00006%.

Stress-induced myocardial stunning is an extremely rare syndrome among patients undergoing emergency coronary angiography for suspected acute myocardial infarction.     

Apical ballooning syndrome, emotional stress and women: reply

In our systematic overview, we found that apical ballooningsyndrome is preceded by an emotional stressor in 27% of casesand by a physical stressor in 38%.¹ uli suggests that emotionalstress may be a more frequent trigger, especially in women.Indeed, in his meta-analysis     

Tako-Tsubo cardiomyopathy (apical ballooning) with parvovirus B19 genome in endomyocardial biopsy

The phenomenon of transient apical ballooning is a rare underlying cause of severe left ventricular dysfunction and has been described as Tako-Tsubo-like cardiomyopathy. Acute myocarditis has been reported to masquerade as acute myocardial infarction or vice versa and is considered as differential diagnosis in this phenomenon. We present here a case of an adult female who was admitted to our cardiology department with chest pain, electrocardiographic and echocardiographic features, suggestive of an acute anterior myocardial infarction, preceded by physical and emotional stress. Coronary angiography demonstrated coronary arteries without relevant atherosclerotic lesions; left ventriculography showed a severe anteroapical dysfunction. Right ventricular endomyocardial biopsy showed normal cardiac tissue, but was positive for Parvovirus B19. Follow-up (2 months later) showed complete regression of regional wall motion abnormalities in transthoracic echocardiography.     

Relationship between pattern of Tako-Tsubo cardiomyopathy and age: from midventricular to apical ballooning syndrome

Several patterns of Tako-Tsubo cardiomyopathy (TTC) have been recently published. However, its physiopathology is still unclear. We report the case of a 63-year-old woman who had a previous history of transient midventricular ballooning and was admitted 11 years after the first TTC, for a recurrence of typical pattern of TTC. Our report suggests that age could affect the left ventricular pattern of TTC and should be taken into account for a correct diagnosis of TTC.     

Human stress cardiomyopathy mimicking acute myocardial syndrome

Two cases of transient acute cardiomyopathy occurring in the immediate aftermath of intense emotional stress and without any identified aetiology are described. These two case reports, mimicking cases of acute cardiomyopathy described in patients with pheochromocytoma, suggest the possibility in man of acute catecholamine induced cardiomyopathy related to major emotional stress alone, a phenomenon so far reported only in animal experimental models.

Keywords: acute cardiomyopathy;  catecholamines;  stress     

Takotsubo cardiomyopathy (left ventricular ballooning syndrome) induced during dobutamine stress echocardiography

A 75-year-old woman presented with left ventricular apical ballooningsyndrome mimicking acute anterior myocardial infarction. Shehad a long history of chest tightness and was undergoing a contraststress echocardiogram because of frequent re-admissions withchest pain, all with normal ECGs and troponins. A standard dobutamine/atropine protocol had been used. The patient developed central crushing chest pain, marked STelevation, transient slowing of heart rate and left ventricularapical ballooning. She was admitted to the coronary care unitand received thrombolysis. Echocardiography showed no mitralregurgitation, normal pulmonary artery systolic pressure andno intraventricular gradient. Immediate troponin T was significantlyraised and peaked at 6 h. The patient underwent coronary angiographythe next day. This showed systolic left ventricular apical ballooningand no coronary lesions or vasospasm. A further contrast echo2 weeks later showed complete resolution of the wall motionabnormalities. Left ventricular apical ballooning or takotsubo syndrome canlead to cardiogenic shock but has a favourable prognosis comparedto myocardial infarction. This patient was noted to be unusuallyanxious about having a stress echocardiogram and mental stressmight be a precipitating factor, furthermore, this responseduring dobutamine stress echocardiography favours a catecholaminerelated disease mechanism.     

Apical hypertrophic cardiomyopathy mimics acute coronary syndrome

We present a case who was initially thought to have an acute coronary syndrome but who was later diagnosed to have an apical hypertrophic cardiomyopathy. Interestingly, the diagnosis could be established with left heart catheterization, not echocardiography.     

Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome

Takotsubo is a reversible cardiomyopathy, often triggered by a stressful event. It combines clinical features mimicking a myocardial infarction, transient apical ballooning of the left ventricle, normal coronary arteries and a small rise in troponin level. There is a striking female predominance with mean age ranging from 65 to 76 years among series. Preceding stressful event is documented in 50 to 100% of patients. The most common clinical presentation is an angor-like chest pain with ST-segment elevation on the electrocardiogram (70%). The prognosis is excellent even if serious complications may occur: pulmonary oedema, cardiogenic shock, transient dynamic intraventricular gradient, life-threatening arrhythmias. In-hospital mortality is in the range of 0 to 10%. The recurrence rate is low. The precise physiopathology of the syndrome remains unknown but catecholamine mediated myocardial stunning is the most favored explanation.