Takotsubo Cardiomyopathy—Acute Cardiac Dysfunction Associated With Neurological and Psychiatric Disorders

Abstract

Takotsubo cardiomyopathy (TTC) is an acute and reversible cardiac wall motion abnormality of the left myocardium. Although many studies focused on etiology, diagnostic and treatment of TTC, precise clinical guidelines on TTC are not available. Research revealed emotional and physical triggering factors of TTC and emphasized the association of TTC with psychiatric and particularly acute neurological disorders. Similar clinical presentation of acute coronary syndrome (ACS) and TTC patients, makes an anamnestic screening for TTC risk factors necessary. In psychiatric anamnesis affective disorders and chronic anxiety disorders are presumably for TTC. Subarachnoid hemorrhages and status epilepticus are typical acute neurological associated with a higher risk for TTC. Moreover, magnetic resonance imaging (MRI) studies reveled brain alterations of the limbic system and reduced connectivity of central autonomic nervous system structures. Diagnosis of TTC is made by elevation of cardiac enzymes, electrocardiogram (ECG) and visualization of myocardial wall motion. Major differential diagnoses like acute coronary syndrome and myocarditis are hereby in synopsis with anamnesis with respect of possible emotional and physical triggering factors of TTC ruled out. In most cases the TTC typical wall motion abnormalities resolve in weeks and therapy is only necessary in hemodynamic instable patients and if rare complications, like cardiac wall ruptures occur. Recently, the two-parted International expert consensus document on Takotsubo syndrome was published, providing a detailed characterization of TTC and allows clinicians to understand this cardiac dysfunction with a multidisciplinary view.

Stress induced (Takotsubo) cardiomyopathy triggered by the COVID‑19 pandemic

“…The hypothalamic-pituitary-adrenal axis (HPA-axis) is a major neuroendocrine system which regulates the release of cortisol from the adrenal gland, shifting the metabolism to higher stress levels. Higher serum cortisol levels and increased sympathetic activity may cause myocardial damage ( 5 ). Consequently, acute psychological or physical stress mediated via the sympathetic-adrenal- medulla axis with catecholamine release in the adrenal medulla and the HPA axis with consecutive cortisol release from the adrenal cortex may act as a trigger for TC ( 5 ).…”

“…Higher serum cortisol levels and increased sympathetic activity may cause myocardial damage ( 5 ). Consequently, acute psychological or physical stress mediated via the sympathetic-adrenal- medulla axis with catecholamine release in the adrenal medulla and the HPA axis with consecutive cortisol release from the adrenal cortex may act as a trigger for TC ( 5 ). Additionally, regional differences in myocardial expression of β2-adrenergic receptor density have been shown, which mediate the cellular effects of the increased catecholamine blood concentrations and explain the regional left ventricular myocardial stunning ( 5 ).…”

Role of Depression and Anxiety Disorders in Takotsubo Syndrome: The Psychiatric Side of Broken Heart

“…The typical patient with primary TTS is a post-menopausal woman who has experienced severe, unexpected emotional or physical stress [4,28]. Some authors have recently described that in patients with pre-admission anxiety disorders, TTS was predominantly triggered by exclusively emotional stress.…”

“…Although the pathophysiology of TTS is not fully understood, much evidence has been documented. At the very beginning, spasms of coronary arteries were identified as TTS's underlying mechanism, although this hypothesis was later refuted [28]. However, it is well known that brain neurons that mediate vasoconstriction innervate coronary microcirculation, supports the concept that regional myocardial stunning among patients with TTS may be of neurogenic origin [22].…”

Commentary: Takotsubo Cardiomyopathy-Acute Cardiac Dysfunction Associated With Neurological and Psychiatric Disorders

“…With interest we read the review article by Buchmann et al about Takotsubo cardiomyopathy (TTC), an acute reversible heart failure syndrome, triggered by neurological or psychiatric disorders (1). The authors concluded that the international expert consensus document on TTC, published by Ghadri et al (2), “should be used in the daily clinical routine to provide excellent patient care” (1). We have the following comments and concerns.…”