Epidemiology, pathogenesis, and management of takotsubo syndrome

Abstract

Takotsubo syndrome is a recently recognized acute cardiac disease entity with a clinical presentation resembling that of an acute coronary syndrome. The typical takotsubo syndrome patient has a unique circumferential left (bi-) ventricular contraction abnormality profile that extends beyond a coronary artery supply territory and appears to follow the anatomical cardiac sympathetic innervation. The syndrome predominantly affects postmenopausal women and is often preceded by emotional or physical stress. Patients with predisposing factors such as malignancy and other chronic comorbidities are more prone to suffer from takotsubo syndrome. The pathogenesis of takotsubo syndrome is elusive. Several pathophysiological mechanisms involving myocardial ischemia (multivessel coronary artery spasm, microvascular dysfunction, aborted myocardial infarction), left ventricular outlet tract obstruction, blood-borne catecholamine myocardial toxicity, epinephrine-induced switch in signal trafficking, and autonomic nervous system dysfunction have been proposed. The syndrome is usually reversible; nevertheless, during the acute stage, a substantial number of patients develop severe complications such as arrhythmias, heart failure including pulmonary edema and cardiogenic shock, thromboembolism, cardiac arrest, and rupture. Treatment of precipitating factors, predisposing diseases, and complications is fundamental during the acute stage of the disease. The epidemiology, pathogenesis, and management of takotsubo syndrome are reviewed in this paper.

Clinical features, complications, and outcomes of exogenous and endogenous catecholamine‐triggered Takotsubo syndrome: A systematic review and meta‐analysis of 156 published cases

“…Furthermore, almost all TS studies have, apart from PPGL‐induced TS, shown either normal or mild to moderate plasma epinephrine elevation . Consequently, it is justified to conclude that there is no direct causal relation between epinephrine and TS but epinephrine may, as any other physical trigger factor, induce TS through sympathetic nervous system hyper‐activation including cardiac sympathetic nerve terminals with norepinephrine seethe and spill over …”

“…Takotsubo syndrome (TS) is an acute cardiac disease entity with a clinical presentation resembling that of an acute coronary syndrome . The syndrome is characterized by a striking regional left ventricular wall motion abnormality (LVWMA) with a circumferential pattern extending beyond the coronary artery supply territory and resulting in a conspicuous ballooning of the left ventricle during systole .…”

Thrombo‐embolic complications in takotsubo syndrome: Review and demonstration of an illustrative case

“…The disease is characterized by relatively high complication rates during the acute and sub‐acute stages . One‐fifth to two‐thirds of patients with TS may develop complications depending on the type of trigger factor, emotional or physical, presence of chronic comorbidities, gender, and age of the patients . One of the serious complications of TS is thrombo‐embolism in addition to heart failure, pulmonary edema, cardiogenic shock, cardiac arrest, life‐threatening arrhythmias, left ventricular outlet tract obstruction, mitral regurgitation, cardiac rupture, and death .…”

The case of the women with the broken heart

“…Another cause is the stress mediated from the brain by direct impact to the nerve-threads in the heart. Activation of the sympathetic nervous system causes reduced contractile function in the myocardium (ischemia caused by catecholamine-induced spasm in coronary arteries) [2,4]. One can say that Takotsubo starts in the brain but strikes in the heart Almost 90% of the patients with broken hearts are women, most of them after menopause.…”

“…The explanation could be that postmenopausal women have lost their protective effect of estrogens which include the protection of circulating catecholamines. Nevertheless, Takotsubo is often linked to physical or mental stress before the onset of illness [4]. Cases involving children has also been reported [8,9].…”