Transient Left Ventricular Dysfunction from Cardiomyopathies to Myocardial Viability: When and Why Cardiac Function Recovers.

Transient left ventricular dysfunction (TLVD), a temporary condition marked by reversible impairment of ventricular function, remains an underdiagnosed yet significant contributor to morbidity and mortality in clinical practice. Unlike the well-explored atherosclerotic disease of the epicardial coronary arteries, the diverse etiologies of TLVD require greater attention for proper diagnosis and management. The spectrum of disorders associated with TLVD includes stress-induced cardiomyopathy, central nervous system injuries, histaminergic syndromes, various inflammatory diseases, pregnancy-related conditions, and genetically determined syndromes. Furthermore, myocardial infarction with non-obstructive coronary arteries (MINOCA) origins such as coronary artery spasm, coronary thromboembolism, and spontaneous coronary artery dissection (SCAD) may also manifest as TLVD, eventually showing recovery. This review highlights the range of ischemic and non-ischemic clinical situations that lead to TLVD, gathering conditions like Tako-Tsubo Syndrome (TTS), Kounis syndrome (KS), Myocarditis, Peripartum Cardiomyopathy (PPCM), and Tachycardia-induced cardiomyopathy (TIC). Differentiation amongst these causes is crucial, as they involve distinct clinical, instrumental, and genetic predictors that bode different outcomes and recovery potential for left ventricular function. The purpose of this review is to improve everyday clinical approaches to treating these diseases by providing an extensive survey of conditions linked with TLVD and the elements impacting prognosis and outcomes.

Broken Heart: A Clear Case of Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TC) is a recognized clinical syndrome characterized by reversible cardiomyopathy with a distinctive left ventricular apical ballooning appearance. TC is associated with risk factors such as estrogen deficiency, emotional and physical stress, and genetic factors. The clinical presentation of TC can be like that of a myocardial infarction. While catecholamine-induced myocardial stunning is suggested by current evidence, the exact pathophysiological mechanisms remain uncertain. Diagnostic criteria, including the InterTAK Diagnostic Criteria, have been established by the Takotsubo International Registry. Supportive and symptomatic medication constitutes the mainstay of treatment, with a focus on improving left ventricle (LV) function over several days, leading to full recovery within three to four weeks. Given its resemblance to myocardial infarction, cautious diagnosis and management are essential for optimal outcomes. We present the case of a previously healthy 35-year-old female who presented with chest pain and dyspnea after discovering her father's death. On examination, she exhibited hypotension, bradycardia, and a new-onset left bundle branch block (LBBB) in her electrocardiogram. Her left ventricular ejection fraction (LVEF) on presentation was 22%, and troponin T (TnT) levels were notably elevated at 430 (normal ranges < 14). After two days of treatment and monitoring at the cardiac intensive care unit (CICU), she improved clinically, and her LVEF improved to 52%.

Trastornos del ritmo cardiaco en pacientes con síndrome de Tako-tsubo / Heart rate disorders in patients with Tako-tsubo syndrome

Objetivos El presente estudio pretende evaluar la incidencia, el pronóstico y el tratamiento de los trastornos del ritmo (TdR) en el síndrome de Tako-tsubo (STT). Antecedentes El STT se asocia frecuentemente a TdR. El valor pronóstico de estos TdR aún no está bien caracterizado en el STT. Material y métodos Se analizaron los TdR de los pacientes incluidos en el REgistro nacional multicéntrico sobre síndrome de Tako-tsubo, ingresados entre 2002 y 2018, aportados por 38 hospitales de todo el país. Analizamos en los pacientes TdR previos, en el ingreso y en el seguimiento a largo plazo. Resultados Se describió cualquier tipo de TdR en 259 (23,5%) casos, de una cohorte de 1.097 pacientes consecutivos con STT. Los TdR se presentan más en pacientes con diabetes mellitus, tabaquismo, hiperuricemia, apnea del sueño y anemia, además de con una fracción de eyección del ventrículo izquierdo (FEVI) menor al ingreso. El TdR más frecuente fue el inicio de fibrilación auricular. Durante el ingreso hospitalario, los pacientes con TdR mostraron más complicaciones, como shock al ingreso, hemorragia mayor, insuficiencia renal aguda y el combinado de infecciones. En el seguimiento, presentaron mayor mortalidad y numéricamente más episodios adversos combinados. Conclusiones Los TdR no son infrecuentes en fase aguda del STT. El STT asociado a TdR se presenta con más complicaciones y peor pronóstico tanto hospitalario como a largo plazo (AU)

Objectives This study sought to evaluate the incidence, prognosis and treatment of heart rhythm disorders (HRD) in Tako-tsubo syndrome (TTS). Background TTS is associated with HRD. The HRD prognostic value is not well characterized in TTS yet. Methods The HRD of patients included in the National Registry of Tako-tsubo syndrome, admitted between 2002 and 2018 and coming from 38 hospitals throughout the country, was analyzed. We analyzed any heart rhythm disorder in patients presented before admission, at admission and in long-term follow-up. Results All types of HRD were described in 259 (23.5%) cases, from a cohort of 1,097 consecutive patients with TTS. HRD was more associated with diabetes mellitus, smoking, hyperuricemia, sleep apnea, anemia with a worse LVEF on admission. The most frequent HRD was a new onset of atrial fibrillation. During hospitalization, patients with HRD showed more complications such as shock on admission, major bleeding, acute renal failure, and combined infections. At follow-up, they presented higher mortality and more major adverse cardiac events, but with a non-significant correlation. Conclusions The incidence of HRD in patients with TTS is not infrequent. TTS, when associated with HRD, presents more complications and a worse prognosis both in hospital and in the long term (AU)

[Heart rate disorders in patients with Tako-tsubo syndrome]. / Trastornos del ritmo cardiaco en pacientes con síndrome de Tako-tsubo.

OBJECTIVES: This study sought to evaluate the incidence, prognosis and treatment of heart rhythm disorders (HRD) in Tako-tsubo syndrome (TTS). BACKGROUND: TTS is associated with HRD. The HRD prognostic value is not well characterized in TTS yet. METHODS: The HRD of patients included in the National Registry of Tako-tsubo syndrome, admitted between 2002 and 2018 and coming from 38 hospitals throughout the country, was analyzed. We analyzed any heart rhythm disorder in patients presented before admission, at admission and in long-term follow-up. RESULTS: All types of HRD were described in 259 (23.5%) cases, from a cohort of 1,097 consecutive patients with TTS. HRD was more associated with diabetes mellitus, smoking, hyperuricemia, sleep apnea, anemia with a worse LVEF on admission. The most frequent HRD was a new onset of atrial fibrillation. During hospitalization, patients with HRD showed more complications such as shock on admission, major bleeding, acute renal failure, and combined infections. At follow-up, they presented higher mortality and more major adverse cardiac events, but with a non-significant correlation. CONCLUSIONS: The incidence of HRD in patients with TTS is not infrequent. TTS, when associated with HRD, presents more complications and a worse prognosis both in hospital and in the long term.

Valor pronóstico del intervalo Tpeak-Tend en el desarrollo de arritmias ventriculares subagudas intrahospitalarias en el síndrome de tako-tsubo / Prognostic value of the Tpeak-Tend interval for in-hospital subacute ventricular arrhythmias in tako-tsubo syndrome

Introducción y objetivos El valor de los parámetros del electrocardiograma (ECG) de repolarización asociados al riesgo de arritmias ventriculares (AVs) en el síndrome de tako-tsubo es controvertido. Nuestro objetivo fue identificar predictores ECG de AVs subagudas, definidas como aquellas ocurridas después de las primeras 48 horas desde el ingreso. Métodos Estudio observacional unicéntrico de pacientes ingresados en el servicio de cardiología entre 2012 y 2018 con diagnóstico de síndrome de tako-tsubo. La recogida de datos incluyó el ECG de 12 derivaciones al ingreso y a las 48 horas, registros de telemetría continua, analíticas, ecocardiografía transtorácica y angiografía coronaria durante la hospitalización. Los eventos de AVs se definieron como: extrasístoles ventriculares ≥ 2.000 en registros de telemetría de 24 horas, fibrilación ventricular, taquicardia ventricular (TV) sostenida, TV polimórfica y TV no sostenida. Resultados Se incluyeron 87 pacientes (edad 72±12 años). Durante una hospitalización mediana de 8 días se registraron AVs subagudas en 22 pacientes (25%) tras una mediana de 91 horas desde el ingreso. Las AVs subagudas se asociaron a aumento de la mortalidad hospitalaria (p=0,030). El intervalo Tpeak-Tend corregido global (promedio de las 12 derivaciones del ECG) a las 48 horas del ingreso fue un predictor independiente de AVs subagudas, superior al intervalo QT corregido (p=0,040). Un valor de corte 108ms en el Tpeak-Tend corregido global mostró una sensibilidad del 71% y especificidad del 72% para AVs subagudas. Conclusiones En pacientes con síndrome de tako-tsubo, las AVs subagudas se asocian a alteraciones de la repolarización que pueden detectarse en el ECG convencional mediante el intervalo Tpeak-Tend (AU)

Introduction and objectives The clinical value of electrocardiogram (ECG) repolarization parameters associated with ventricular arrhythmias (VAs) in tako-tsubo syndrome is still under debate. We aimed to evaluate ECG predictors of subacute VAs, defined as those occurring after the first 48hours from admission. Methods This single-center observational study enrolled patients admitted to the cardiology department between 2012 and 2018 with a confirmed diagnosis of tako-tsubo syndrome. Data collection included a 12-lead ECG on admission and at 48hours, continuous telemetry monitoring, blood testing, transthoracic echocardiography, and coronary angiography during hospitalization. VAs events were defined as: premature ventricular contractions ≥ 2000 within a 24-hour window of telemetry monitoring, ventricular fibrillation, sustained ventricular tachycardia (VT), polymorphic VT, and non-sustained VT. Results A total of 87 patients (age 72±12 years) were enrolled. During a median of 8 days of hospitalization, subacute VAs were documented in 22 patients (25%) after a median of 91hours from admission. Subacute VAs were associated with an increase in mortality during hospitalization (P=.030). The corrected global (mean of the 12-lead ECG values) Tpeak-Tend interval at 48hours from admission was an independent predictor of subacute VAs and was statistically superior to the standard corrected QT interval (Z test, P=.040). A cut-off of 108 msec for the corrected global Tpeak-Tend yielded a 71% sensitivity and 72% specificity for subacute VAs. Conclusions In patients with tako-tsubo syndrome, subacute VAs are associated with repolarization alterations that can be identified on conventional ECG using the Tpeak-Tend interval (AU)

Prognostic value of the Tpeak-Tend interval for in-hospital subacute ventricular arrhythmias in tako-tsubo syndrome.

INTRODUCTION AND OBJECTIVES: The clinical value of electrocardiogram (ECG) repolarization parameters associated with ventricular arrhythmias (VAs) in tako-tsubo syndrome is still under debate. We aimed to evaluate ECG predictors of subacute VAs, defined as those occurring after the first 48hours from admission. METHODS: This single-center observational study enrolled patients admitted to the cardiology department between 2012 and 2018 with a confirmed diagnosis of tako-tsubo syndrome. Data collection included a 12-lead ECG on admission and at 48hours, continuous telemetry monitoring, blood testing, transthoracic echocardiography, and coronary angiography during hospitalization. VAs events were defined as: premature ventricular contractions ≥ 2000 within a 24-hour window of telemetry monitoring, ventricular fibrillation, sustained ventricular tachycardia (VT), polymorphic VT, and non-sustained VT. RESULTS: A total of 87 patients (age 72±12 years) were enrolled. During a median of 8 days of hospitalization, subacute VAs were documented in 22 patients (25%) after a median of 91hours from admission. Subacute VAs were associated with an increase in mortality during hospitalization (P=.030). The corrected global (mean of the 12-lead ECG values) Tpeak-Tend interval at 48hours from admission was an independent predictor of subacute VAs and was statistically superior to the standard corrected QT interval (Z test, P=.040). A cut-off of 108 msec for the corrected global Tpeak-Tend yielded a 71% sensitivity and 72% specificity for subacute VAs. CONCLUSIONS: In patients with tako-tsubo syndrome, subacute VAs are associated with repolarization alterations that can be identified on conventional ECG using the Tpeak-Tend interval.

Differentiating typical Tako-tsubo syndrome from extensive anterior STEMI: Look behind the anterior wall.

BACKGROUND: Tako-tsubo syndrome (TTS) in its most typical form shares common features with anterior ST-segment elevation myocardial infarction (AMI) during acute presentation. Differential diagnosis between the two conditions is often challenging especially if ST-segment elevation is associated with extensive apical akinesis. METHODS: We sought to systematically analyze ECG and echocardiographic parameters including LV longitudinal strain and two new indexes: the inferior-apex ratio (IAR) and the inferior-lateral-apex ratio (ILAR), to assess if ventricular involvement may be different in TTS and AMI. RESULTS: A retrospective cohort study was conducted with two groups: patients with TTS (n = 22) and patients with extensive anterior STEMI (n = 22). Lack of ST elevation in V1 was associated with TTS with sensitivity and specificity of 86%, positive and negative predictive value of 86%. Longitudinal strain in mid inferior and mid inferior-lateral segments were more compromised in TTS: -4.3 ± 6.4% and -5.4 ± 5.4% in TTS versus -10.2 ± 5.5% and -9.9 ± 4.9% in AMI, respectively (p < .01 for all). By multivariate analysis, both longitudinal strain values, inferior-apical ratio (IAR) < 1 and inferior-lateral-apical ratio (ILAR) < 1 were independently associated with diagnosis of TTS during acute phase. CONCLUSIONS: Our results suggest that impaired contractility extending beyond apex to mid inferior and inferior-lateral walls can be easily assessed by IAR and ILAR, and these indexes facilitate non-invasive differentiation of TTS from extensive anterior STEMI.

Pheochromocytoma-Induced Tako-Tsubo Syndrome: An Uncommon Presentation.

BACKGROUND: A pheochromocytoma-induced tako-tsubo syndrome is a life-threatening complication of the rare endocrinological disease. The association between the two syndromes is known, though seldom reported in literature, but the categorization is still debated. CASE REPORT: In this article, we provide two examples of clinical presentation of this rare condition, its diagnosis using point-of-care ultrasound, its management in the emergency department, and finally, a literature review. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In case of a tako-tsubo syndrome-like myocardial dysfunction in a patient with unknown medical history, or recorded hypertensive or tachycardic peaks, a point-of-care ultrasound scan extended to the kidneys could help evaluate for a reversible underlying trigger cause such as pheochromocytoma.

Características clínicas, demográficas y epidemiológicas de una cohorte de pacientes con síndrome de Takotsubo entre 2011 y 2016 en Medellín, Colombia / Clinical, demographic and epidemiological characteristics of a cohort of patients with Takotsubo's syndrome from 2011 to 2016 in Medellin, Colombia

Resumen Introducción: El síndrome de Takotsubo es una disfunción ventricular aguda de carácter temporal, usualmente reversible, secundaria a eventos estresantes que comprometen el eje cerebro-corazón. Objetivo: describir las características clínicas, epidemiológicas y desenlaces de una cohorte de pacientes con síndrome de Takotsubo en Medellín-Colombia. Materiales y métodos: Estudio observacional, descriptivo, ambispectivo, realizado en una cohorte de pacientes. Se revisaron las historias clínicas de pacientes que ingresaron al servicio de urgencias de una institución de tercer nivel de complejidad de la ciudad de Medellín entre enero de 2011 y diciembre de 2016 con diagnóstico de síndrome de Takotsubo. Se diseñó un cuestionario para recolectar variables demográficas, clínicas, de laboratorio e imagenológicas. Se obtuvieron medidas de frecuencia y análisis estadístico con el programa SPSS versión 21. Resultados: El 66,7% de los pacientes fueron mujeres, la mortalidad fue del 11,1% y la recurrencia del 5,6%. La mayoría de los casos tuvieron un desencadenante conocido (94,5%), siendo la infección el más frecuente (44,4%). El 77,8% de los pacientes presentó disnea al ingreso y el 27,8% requirió uso de algún vasopresor. El promedio de la fracción de eyección del ventrículo izquierdo inicial fue del 34.17+7.8 con evidencia de mejoría en el control, promedio luego del control= 54,81+10.2. Discusión y conclusiones: El síndrome de Takotsubo es una condición infrecuente, las mujeres son la población más afectada y la mayoría de los casos obedece a un factor desencadenante. La mortalidad reportada está dentro de lo esperado y se evidenció un buen pronóstico a mediano plazo. MÉD.UIS. 2020;34(1):27-33.

Abstract Introduction: Takotsubo syndrome is an acute, usually reversible, temporal ventricular dysfunction secondary to stressful events that compromise the brain-heart axis. The study's objective is to describe the clinical, epidemiological characteristics and outcomes of a cohort of patients with Takotsubo syndrome in Medellin-Colombia. Methods: Observational, descriptive, ambispective study performed in a cohort of patients. We reviewed the medical records of patients who entered the emergency department of a third-level complex institution of Medellin between January 2011 and December 2016 with Takotsubo syndrome diagnosis. A questionnaire was designed to collect demographic, clinical, laboratory, and imaging variables. Frequency measures and statistical analyses were obtained with the SPSS version 21 program. Results: 66.7% of the patients were women, mortality was 11.1%, and recurrence was 5.6%. The majority of the cases had a known trigger (94.5%), being the infection the most frequent (44.4%), 77.8% of the patients presented dyspnea on admission, and 27.8% required the use of vasopressor. The mean baseline left ventricular ejection fraction was 34.17 + 7.8 with evidence of improvement in control, average after control = 54.81 + 10.2. Discussion and conclusions: Takotsubo syndrome is an uncommon condition. Women are the most affected population and most cases are due to a secondary cause. The reported mortality is within expectations, and a good medium-term cardiac prognosis was evidenced. MÉD.UIS. 2020;34(1):27-33.

Real-time validation of the Sgarbossa and modified Sgarbossa criteria in intermittent left bundle branch block.

The modified Sgarbossa criteria have been established to aid in the diagnosis of ST-elevation myocardial infarction in patients with left bundle branch block. Thus far, the sensitivities and specificities of the Sgarbossa signs have only been evaluated retrospectively in cohorts of patients with and without occlusive myocardial infarctions. These statistical analyses were based on correlating ST abnormalities with serum markers of myocardial injury and/or results of emergent cardiac catheterization. We present a patient with acute cardiovascular emergency where electrocardiograms revealed intermittent left bundle branch block. In serial ECGs, highly dynamic ST abnormalities on the narrow QRS beats were associated with similarly dynamic ST changes in the left bundle branch block beats. Our findings provided direct and real-time confirmation of the usefulness of the Sgarbossa and the modified Sgarbossa criteria in the diagnosis of acute ST elevation in patients with left bundle branch block.

Tako-tsubo Syndrome as First Manifestation in a Case of Pheochromocytoma Developed From a Non-functional Adrenal Incidentaloma.

Background: Pheochromocytoma is a catecholamine secreting tumor that, in extremely rare cases, may develop over time from a non-functional adrenal adenoma. Catecholamine excess can lead to a kind of cardiomyopathy similar to that seen in tako-tsubo syndrome (TTS). Case report: A 69 years old female with a history of type 2 diabetes, hypertension, and a non-functional right adrenal adenoma diagnosed 3 years earlier was referred to our center for further investigations. During the evaluation, she had a hypertensive crisis with chest pain, tachycardia, and diaphoresis. Suspecting an acute coronary syndrome, she underwent coronary angiography, which showed the typical features of TTS. The high 24 h-urinary metanephrines excretion and abdominal MRI findings were suggestive of pheochromocytoma. Right laparoscopic adrenalectomy was performed, with the resolution of all symptoms. Pathology findings confirmed the diagnosis of pheochromocytoma. After 12 months, the patient was still asymptomatic, with the echocardiography displaying a complete recovery of the left-ventricular function. Conclusions: The development of a pheochromocytoma from an adrenal non functional adenoma is an extremely rare event, but potentially life-threating because of the catecholamine-associated cardiovascular toxicity. In particular, TTS is a form of cardiomyopathy that has been increasingly described as associated with catecholamine-secreting tumors. The exclusion of pheochromocytoma in a patient with TTS has important therapeutic implications, since the administration of ß-blockers may be extremely harmful in patients with catecholamine surge in the absence of adequate α-blockage.

[Necrotizing esophagitis by stress-cardiomyopathy with right ventricular insufficiency]. / Nekrotisierende Ösophagitis bei Stresskardiomyopathie mit Rechtsherzversagen.

Acute necrotizing esophagitis ("black esophagus") is defined as complete necrosis of the esophageal mucosa, which typically affects the entire circumference. We report a case of a healthy 62-year-old woman, who became hemodynamically unstable due to stress cardiomyopathy with acute right heart failure. Transfusion-dependent anemia occurred 24 h later and an upper gastrointestinal endoscopy revealed a black discoloured mucosa of the distal esophagus. After hemodynamic stabilization and treatment with proton pump inhibitors and sucralfate, complete healing of the esophageal mucosa was achieved.

Coronary Inflammation by Computed Tomography Pericoronary Fat Attenuation in MINOCA and Tako-Tsubo Syndrome.

Background The pericoronary fat attenuation index (pFAI) has emerged as a marker of coronary inflammation, which is measurable from standard coronary computed tomography angiography (CCTA). It compares well with gold-standard methods for the assessment of coronary inflammation and can predict future cardiovascular events. pFAI could prove invaluable to differentiate an inflammatory from a noninflammatory coronary artery status, helping unravel the mechanisms subtending an event classified as myocardial infarction with nonobstructive coronary arteries (MINOCA) or Tako-Tsubo syndrome (TTS). Methods and Results Patients admitted with MINOCA and TTS between 2011 and 2018, who had both CCTA and cardiac magnetic resonance during or shortly after the acute phase, were selected and pFAI measured in their CCTA; pFAI was also measured in control subjects who had CCTA for atypical chest pain workup, no obstructive coronary artery disease found in their CCTA, and no cardiac events at 2-year follow-up. In the n=106 MINOCA/TTS patients, mean pFAI was -68.37±8.29 versus -78.03±6.20 in the n=106 controls (P<0.0001), and the difference was confirmed also when comparing mean pFAI in each coronary artery between MINOCA/TTS and controls (P<0.0001). Nonobstructive coronary plaques at CCTA, high-risk plaques in particular, were more frequently found (P<0.01) in the MINOCA/TTS group compared with controls. Conclusions In MINOCA and TTS patients, CCTA is not only able to detect angiographically invisible atherosclerotic plaques, but its diagnostic yield can be expanded using the simple measurement of pFAI to characterize pericoronary fat tissue; in MINOCA/TTS mean pFAI demonstrates higher values compared with controls, a finding that has been associated with coronary artery inflammation.

Discrepant myocardial microvascular perfusion and mechanics after acute myocardial infarction: Characterization of the "Tako-tsubo effect" with real-time myocardial perfusion contrast echocardiograph.

BACKGROUND: In patients with acute anterior myocardial infarction (MI), sometimes an "apical ballooning" contractile dysfunction pattern that exceeds factual myocardial injury is identified in the ventriculography and bedside echocardiography. The hemodynamic consequences/sequela of this "Tako-tsobu effect" has not been well delineated. Of note, this anatomic imaging finding often misleads frontline physicians who assume reciprocal causation of persistent cardiac pump failure and ventricular pressure overload. METHODS AND RESULTS: Using real-time myocardial perfusion contrast echocardiography (MCE), we investigated myocardial (microvascular) perfusion in 60 patients after acute MI and coronary revascularization. Twenty-eight percent of the studied patients showed significantly mismatched myocardial perfusion and contractile defects. In these patients, an integrated imaging assessment with coronary angiography/ventriculography, deformation echocardiography, and MCE proved that the myocardial mechanic abnormalities significantly exceeded the defected perfusion areas. Compared with 72% of the patients without perfusion-contractility mismatch, apparently worse systolic functions (left ventricular ejection, wall motion score, and systolic longitudinal strain) in these patients did not change diastolic ventricular filling pressures (E/E' and E/A) or hemodynamic consequences/adverse events. Both systolic and diastolic functions in patients with perfusion-contractility mismatch appeared to be comparable with those in patients with Tako-tsubo syndrome. CONCLUSIONS: Real-time MCE identifies discrepant myocardial microvascular perfusion and mechanics in patients with acute MI. The "Tako-tsubo effect" in patients with perfusion-contractility mismatch does not cause diastolic filling pressure change or worse hemodynamic consequence/cardiac event.

Cardiomiopatía de tako-tsubo en un paciente con estenosis aórtica moderada. Caso clínico y revisión bibliográfica / Tako-tsubo cardiomyopathy in a patient with moderate aortic stenosis. Case report and literature review

El síndrome de tako-tsubo (STT) o cardiomiopatía inducida por estrés es una afección cardíaca que se manifiesta de manera similar a un infarto de miocardio, aunque tiene características particulares: estrés agudo físico y/o psíquico, como causa desencadenante, cambios del segmento ST y onda T en el electrocardiograma, elevación moderada de los biomarcadores de mionecrosis (troponina ultrasensible), trastorno de la movilidad miocárdica de los segmentos medios y apicales del ventrículo izquierdo y arterias coronarias sin lesiones angiográficamente evidentes (obstrucción o ruptura de placa). El presente artículo describe a una paciente de sexo femenino de 67 años de edad, que ingresó al hospital por dolor precordial opresivo característico de un síndrome coronario agudo, cambios electrocardiográficos inespecíficos de isquemia y arterias coronarias normales, cuyo diagnóstico fue síndrome de tako-tsubo y, concomitantemente, estenosis aórtica moderada secundaria a válvula aórtica bivalva de patrón típico (fusión de la coronaria derecha e izquierda); esta asociación patológica no está descrita en la literatura médica. Se realizó una revisión bibliográfica poniendo hincapié en el diagnóstico de esta infrecuente patología.

Tako-tsubo syndrome (STT) or stress-induced cardiomyopathy is a cardiac condition with a clinical presentation similar to a myocardial infarction and specific features of this syndrome, such as: causes triggering of acute physical and / or psychic stress, ST segment changes, and T wave on the electrocardiogram, moderate elevation of myonecrosis biomarkers (ultrasensitive troponin), myocardial mobility disorder of the mid and apical segments of the left ventricle and coronary arteries without any evident angiographical lesions (obstruction or plaque rupture). This article will describe a female patient of 67 years old, who entered in the hospital due to oppressive precordial pain characteristic of an acute coronary syndrome, non-specific electrocardiographic changes of ischemia and normal coronary arteries, which we concluded with takotsubo syndrome; concomitantly moderate aortic stenosis secondary to a trival aortic valve with raphe confirmed by echocardiography; Clinical association is not described in medical literature. Later we will make a bibliographical review on the subject with emphasis on the diagnosis of this infrequent pathology.Key words: urethra, foreign body.

Takotsubo Syndrome is Associated with Mood Disorders and Antidepressants Use, not with Anxiety and Impairment of Quality of Life Due to the Psychiatric Disorder.

BACKGROUND: The aim was to study the association between mood and anxiety disorders and the Tako-Tsubo Syndrome (TTS) and to determine the role of antidepressants and the impairment of quality of life due the comorbid psychiatric disorder. METHODS: Case-control study: 19 consecutive patients (17 female) with TTS compared to 76 controls without TTS, were randomly selected from the database of a nationwide epidemiological study after matching (gender, age and residence) by controls. Psychiatric diagnoses were carried out according to the ICD-10 using semi-structured interview tools (ANTAS-SCID) administered by clinical staff. Quality of Life (Qol) was assessed by means of SF-12. RESULTS: Only Major Depressive Disorders (MDD) showed higher frequencies in cases with statistical significance difference (p=0.014) as well as at least one Mood Disorder Diagnosis [MDD or BD] (p=0.002). The lifetime prevalence of at least one anxiety disorder with no comorbid mood disorder did not show a higher frequency in cases (p=0.57).The score at SF-12 in the TTS group was similar to those of controls (p=0.71)In the TTS group, the score at SF-12 in people with one mood or anxiety diagnosis (N=7) was similar to those without mood or anxiety diagnosis (p=0.75). The use of antidepressants was higher in TTS group (15.79% vs 1.31%; p=0.030). CONCLUSION: The study shows an association between TTS with depressive disorders and antidepressants use and does not confirm the association with anxiety syndromes. The study suggests the need to investigate the possible interactions between antidepressants use and mood disorders in studies with appropriate design and sample size.

Abnormal coronary vasoreactivity in transient left ventricular apical ballooning (tako-tsubo) syndrome.

BACKGROUND: The exact etiology and pathophysiologic mechanisms of tako-tsubo syndrome (TTS) remain controversial. OBJECTIVE: To further evaluate the abnormal coronary vasoreactivity and its possible anatomical substrate in TTS. METHODS: We studied 47 patients (46 women; age 67±12years) who underwent diagnostic cardiac catheterization and evaluation of coronary vasoreactivity by sequential acetylcholine (Ach), nitroglycerine and adenosine testing with angiographic and intracoronary pressure-Doppler flow monitoring. Coronary artery wall morphology was also evaluated by intravascular ultrasound (IVUS) imaging in 45 vessels of 43 patients. RESULTS: Abnormal coronary vasoconstriction to Ach stimulation was elicited in 40 patients (85%) involving the LAD artery and its branches in 39 (83%). Abnormal microvascular function was seen in 39 (83%) patients. Overall, hyperemic microvascular resistance index (HMR) was higher and Doppler coronary flow velocity reserve (CFVR) was lower in the LAD artery territory as compared to the reference territories (2.64±1.23 vs 2.05±0.56; p=0.008 and 1.95±0.7 vs 2.3±0.6; p=0.018, respectively). IVUS revealed no plaque rupture, dissection or thrombosis but occult plaque formation and myocardial bridging were found as a possible anatomical substrate of endothelial dysfunction in 67% and 48.8% patients respectively. CONCLUSIONS: A global failure of coronary vasomotor function was demonstrated in most TTS patients. These findings implicate abnormal vasoconstrictive response to the activation of the sympathetic system as a potential mechanism involved in the pathogenesis of myocardial stunning in TTS. PERSPECTIVES: Competency in medical knowledge: Abnormal coronary vasoconstriction secondary to endothelial dysfunction may actively contribute to the clinical manifestation of acute coronary syndromes in patients with non-obstructive coronary disease. Translational outlook 1: TTS patients reveal a global failure of vasomotor function with both vasoconstrictive response to acetylcholine and increased hyperemic microvascular resistances in the territory of myocardial stunning. They may also show occult coronary atherosclerosis and myocardial bridging as the anatomic substrates of endothelial dysfunction. Translational outlook 2: The cardiac phenotype of TTS includes a high prevalence of coronary vasomotor disturbances. These findings implicate abnormal vasoconstrictive response to the activation of the sympathetic system as a potential mechanism involved in the pathogenesis of TTS in post-menopausal women. Thus, a systematic evaluation of coronary vasoreactivity could better characterize the syndrome.

Tako-tsubo Syndrome in Men: Rare, but With Poor Prognosis.

INTRODUCTION AND OBJECTIVES: Tako-tsubo syndrome is a potentially serious disease during the acute phase. It mimics myocardial infarction, but with no potentially causative coronary lesions. The aim of this study was to analyze the clinical course and outcome of patients with tako-tsubo syndrome by sex. METHODS: We analyzed the characteristics of patients included in the RETAKO registry from 2003 to 2015, a multicenter registry with participation of 32 Spanish hospitals. RESULTS: Of 562 patients included, 493 (87.7%) were women. Chest pain was less frequent as an initial symptom in men than in women (43 [66.2%] vs 390 [82.8%]; P < .01). The prognosis was worse in men, with higher in-hospital mortality (3 [4.4%] vs 1 [0.2%]; P < .01), longer intensive care stay (4.2 ± 3.7 vs 3.2 ± 3.2 days; P = .03) and a higher frequency of severe heart failure (22 [33.3%] vs 95 [20.3%]; P = .02). However, dynamic obstruction at the left-ventricular outflow tract occurred exclusively in women (39 [7.9%] vs 0 [0.0%]; P = .02). The incidence of functional mitral regurgitation was also higher in women (52 [10.6%] vs 2 [2.9%]; P = .04). CONCLUSIONS: Tako-tsubo syndrome shows wide differences by sex in terms of its incidence, presentation, and outcomes. Prognosis is worse in men.