Takotsubo cardiomyopathy induced during dobutamine stress echocardiography: an exhaustive review

Abstract

Funding Acknowledgements Type of funding sources: None. Introduction. Takotsubo cardiomyopathy (TTC) mimics an acute coronary syndrome and corresponds to an acute reversible stress-induced cardiomyopathy. Dobutamine Stress Echocardiography (DSE) has been widely used for more than 30 years and is considered as one of the gold standard non-invasive test to detect myocardial ischemia. DSE responsible for a TTC is a rare clinical entity. Purpose. Dobutamine induced takotsubo Cardiomyopathy (TTC-DSE) is an exceptional situation. We systematically search for TTC-DSE observations to analyse the specific characteristics of such a cohort. Methods and Results. We conducted an extensive search in Medline, and the Cochrane Central Registry of Controlled Trials, using the key words "acute cardiomyopathy, takotsubo syndrome and DSE". File selection was based on the following criteria : (a) occurrence of TTC during DSE, (b) Mayo Clinic criteria (1) associating transient left ventricular systolic dysfunction, absence of significant coronary stenosis, ST-T abnormalities on EKG, moderate troponin elevation, and absence of pheochromocytoma or myocarditis. We identified 30 clinical observations of TTC-DSE published between 2006 and 2019, mostly from USA and Europe publications. Symptoms appear at high dobutamine dosages (30 or 40 gammas/kg/min: 24/30), rarely during recovery (4/30). These patients have the typical features of TTC : (1) strong predominance of a female population (26 women; 86.7%), aged over 50 years (24; 93.3%); (2) depression and/or anxiety (8 pts; 26.7%); (3) ECG: ST elevation (21 pts; 70 %), ST depression (2 pts), no ST change (4 pts), and left conduction block (3 pts); (4) emergency coronary angiography without significant coronary lesion; (5) angiographic left ventricular ejection fraction (LVEF), calculated in 18/30pts : < 40% for 14/18 pts; (6) segmental LV impairment (echo or angio): apical n = 17 (77.3%); mid-ventricular n = 3 (13.6%); reverse n = 2 (9%) and unspecified (8 pts); (7) low peak of Troponin: 2.65 ± 2.04 ng/ml; (8) one death from an acute heart failure (old lady 86 years age, with intra ventricular gradient), and rapid recovery of LVEF in other patients (29 pts). Despite the heterogeinity in TTC-DSE patients and large cohort of patients in the TTC publications, TTC-DSE and TTC patients have comparable caracteristics. Conclusion. TTC-DSE is an exceptional, but severe complication of DSE. It provides a unique opportunity to observe TTC in the acute phase. These observational studies show a similar profile between TTC-DSE and TTC patients. Mortality remains low in TTC-DSE cohort, probably because of prompt interruption of the test. Rapid recovery of LV function is consistent. High level of sympathetic stimulation secondary to dobutamine infusion, and frequent anxiety associated with DSE, are probably the major determinants of TTC-DSE. However, the rarity of the TTC-DSE, compared to the widespread daily practice of DSE in echo-laboratories, remains unexplained.