ABSTRACT Objective: We sought to describe clinical characteristics of emergency department patients ultimately diagnosed with Takotsubo Cardiomyopathy (TCM) and to explore the causal role that stress may play in its pathogenesis. Methods:
We performed a retrospective chart review analyzing all myocardial infarction patients with non-obstructive coronary artery disease on cardiac catheterization to assess for the presence of TCM. Various clinical data, including the pres-ence of stressors, from emergency department records were reported. We also analyzed factors from several studies (including ours) to assess the true causality of stress in the development of TCM. Results: Twelve ED patients out of 2,179 charts reviewed were identified as having TCM. Most were female, post-menopausal, and had chest pain, but only half had a specific stressful event identified in the ED. One-third of patients had no stressful event identified during their hospital stay. Several other studies suggest that stressful events are associated with increased diagnoses of TCM, but we found that causality of stress cannot be substantiated. Conclusion: Stressful events are often not identified in emergency department patients ultimately diagnosed with TCM. The causative nature of stress in the development of TCM cannot be firmly established from any existing data.
Cite this paper
nullE. Quattromani, A. Aldeen, W. Mosley II and D. Courtney, "A Case Series and Review of Takotsubo Cardiomyopathy: Does Stress Really Cause the Stress Cardiomyopathy?," International Journal of Clinical Medicine, Vol. 2 No. 1, 2011, pp. 28-34. doi: 10.4236/ijcm.2011.21007.
 T. M. Pilgrim and T. R. Wyss, “Takotsubo Cardiomyopathy or Transient Left Ventricular Apical Ballooning Syndrome: A Systematic Review,” International Journal of Cardiology, Vol. 124, No. 3, 2008, pp. 283- 292. doi:10.1016/j.ijcard.2007.07.002
S. Kawai, H. Suzuki, H. Yamaguchi, et al., “Ampulla Cardiomyopathy (Takotsubo Cardiomyopathy)-Reversible Left Ventricular Dysfunction: With St Segment Elevation,” Japanese Circulation Journal, Vol. 64, No. 2, 2000, pp. 156-159. doi:10.1253/jcj.64.156
S. Kurisu, H. Sato, T. Kawagoe, et al., “Tako-Tsubo-Like Left Ventricular Dysfunction with St-Segment Elevation: A Novel Cardiac Syndrome Mimicking Acute Myocardial Infarction,” American Heart Journal, Vol. 143, No. 3, 2002, pp. 448-455. doi:10.1067/mhj.2002.120403
K. Tsuchihashi, K. Ueshima, T. Uchida, et al., “Transient Left Ventricular Apical Ballooning without Coronary Artery Stenosis: A Novel Heart Syndrome Mimicking Acute Myocardial Infarction. Angina Pectoris-Myocardial Infarction Investigations in Japan,” Journal of the American College of Cardiology, Vol. 38, No. 1, 2001, pp. 11-18.
K. A. Bybee, T. Kara, A. Prasad, et al., “Systematic Review: Transient Left Ventricular Apical Ballooning: A Syndrome That Mimics ST-Segment Elevation Myocardial Infarction,” Annals of Internal Medicine, Vol. 141, No. 11, 2004, pp. 858-865.
C. H. Hennekens and J. E. Buring, “Epidemiology in Medicine,” Brown, MA: Little, Boston, 1987.
M. Sato, S. Fujita, A. Saito, et al., “Increased Incidence of Transient Left Ventricular Apical Ballooning (So-Called ‘Takotsubo’ Cardiomyopathy) after the Mid-Niigata Prefecture Earthquake,” Japanese Circulation Society, Vol. 70, No. 8, 2006, pp. 947-953. doi:10.1253/circj.70.947
L. Y. Lin, C. C. Wu, Y. B. Liu, et al., “Derangement of Heart Rate Variability during a Catastrophic Earthquake: A Possible Mechanism for Increased Heart Attacks,” Pacing and Clinical Electrophysiology, Vol. 24, No. 11, 2001, pp. 1596-1601.
J. Leor and R. A. Kloner, “The Northridge Earthquake as a Trigger for Acute Myocardial Infarction,” American Journal of Cardiology, Vol. 77, No. 14, 1996, pp. 1230- 1232. doi:10.1016/S0002-9149(96)00169-5
S. Suzuki, S. Sakamoto, M. Koide, et al., “Hanshin-Awaji Earthquake as a Trigger for Acute Myocardial Infarction,” American Heart Journal, Vol. 134, 1997, pp. 974- 977. doi:10.1016/S0002-8703(97)80023-3
S. R. Meisel, I. Kutz, K. I. Dayan, et al., “Effect of Iraqi Missile War on Incidence of Acute Myocardial Infarction and Sudden Death in Israeli Civilians,” Lancet, Vol. 338, No. 8768, 1991, pp. 660-661.
V. Culic, D. Eterovic and D. Miric, “Meta-Analysis of Possible External Triggers of Acute Myocardial Infarction,” International Journal of Cardiology, Vol. 99, No. 1, 2005, pp. 1-8. doi:10.1016/j.ijcard.2004.01.008
M. Gianni, F. Dentali, A. M. Grandi, et al., “Apical Ballooning Syndrome or Takotsubo Cardiomyopathy: A Systematic Review,” European Heart Journal, Vol. 27, No. 13, 2006, pp. 1523-1529.
R. Kvetnansky, E. L. Sabban and M. Palkovits, “Catecholaminergic Systems in Stress: Structural and Molecular Genetic Approaches,” Physiological Reviews, Vol. 89, No. 2, 2009, pp. 535-606.
K. Pacak and M. Palkovits, “Stressor Specificity of Central Neuroendocrine Responses: Implications for Stress- Related Disorders,” Endocrine Reviews, Vol. 22, No. 4, 2001, pp. 502-548. doi:10.1210/er.22.4.502
I. S. Wittstein, D. R. Thiemann, J. A. Lima, et al., “Neurohumoral Features of Myocardial Stunning due to Sudden Emotional Stress,” The New England Journal of Medicine, Vol. 352, No. 6, 2005, pp. 539-548.
H. Mori, S. Ishikawa, S. Kojima, et al., “Increased Responsiveness of Left Ventricular Apical Myocardium to Adrenergic Stimuli,” Cardiovascular Research, Vol. 27, No. 2, 1993, pp. 192-198.
T. Ueyama, K. Kasamatsu, T. Hano, et al., “Emotional Stress Induces Transient Left Ventricular Hypocontraction in the Rat via Activation of Cardiac Adrenoceptors: A Possible Animal Model of ‘Tako-Tsubo’ Cardiomyopathy,” Japanese Circulation Society, Vol. 66, No. 7, 2002, pp. 712-713. doi:10.1253/circj.66.712
P. Angelini, “Transient Left Ventricular Apical Ballooning: A Unifying Pathophysiologic Theory at the Edge of Prinzmetal Angina,” Catheter Cardiovasc Interv, Vol. 71, No. 3, 2008, pp. 342-352.
S. Arora, F. Alfayoumi and V. Srinivasan, “Transient Left Ventricular Apical Ballooning after Cocaine Use: Is Catecholamine Cardiotoxicity the Pathologic Link?” Mayo Clinic Proceedings, Vol. 81, No. 6, 2006, pp. 829-832.
C. Spes, A. Knape and H. Mudra, “Recurrent Tako- Tsubo-Like Left Ventricular Dysfunction (Apical Ballooning) in a Patient with Pheochromocytoma—A Case Report,” Clinical Research in Cardiology, Vol. 95, No. 5, 2006, pp. 307-311. doi:10.1007/s00392-006-0374-y
H. G. Van Spall, J. D. Roberts, A. M. Sawka, et al., “Not a Broken Heart,” Lancet, Vol. 370, No. 9587, 2007, p. 628. doi:10.1016/S0140-6736(07)61302-6
M. Hassan, K. M. York, H. Li, et al., “Association of Beta1-Adrenergic Receptor Genetic Polymorphism with Mental Stress-Induced Myocardial Ischemia in Patients with Coronary Artery Disease,” Archives of Internal Medicine, Vol. 168, No. 7, 2008, pp. 763-770.
A. Prasad, A. Lerman and C. S. Rihal, “Apical Ballooning Syndrome (Tako-Tsubo or Stress Cardiomyopathy): A Mimic of Acute Myocardial Infarction,” American Heart Journal, Vol. 155, No. 3, 2008, pp. 408-417.
R. A. Regnante, R. W. Zuzek, S. B. Weinsier, et al., “Clinical Characteristics and Four-Year Outcomes of Patients in the Rhode Island Takotsubo Cardiomyopathy Registry,” American Journal of Cardiology, Vol. 103, No. 7, 2009, pp. 1015-1019.
J. S. Steinberg, A. Arshad, M. Kowalski, et al., “Increased Incidence of Life-Threatening Ventricular Arrhythmias in Implantable Defibrillator Patients after the World Trade Center Attack,” Journal of the American College of Cardiology, Vol. 44, No. 6, 2004, pp. 1261- 1264. doi:10.1016/j.jacc.2004.06.032
B. Jancin, “Takotusbo Cardiomyopathy Called Deceptively Dangerous,” ACEP News, Vol. 8, 2007.