Clinical correlates and prognostic impact of neurologic disorders in Takotsubo syndrome

AbstractCardiac alterations are frequently observed after acute neurological disorders. Takotsubo syndrome (TTS) represents an acute heart failure syndrome and is increasingly recognized as part of the spectrum of cardiac complications observed after neurological disorders. A systematic investigation of TTS patients with neurological disorders has not been conducted yet. The aim of the study was to expand insights regarding neurological disease entities triggering TTS and to investigate the clinical profile and outcomes of TTS patients after primary neurological disorders. The International Takotsubo Registry is an observational multicenter collaborative effort of 45 centers in 14 countries (ClinicalTrials.gov, identifier NCT01947621). All patients in the registry fulfilled International Takotsubo Diagnostic Criteria. For the present study, patients were included if complete information on acute neurological disorders were available. 2402 patients in whom complete information on acute neurological status were available were analyzed. In 161 patients (6.7%) an acute neurological disorder was identified as the preceding triggering factor. The most common neurological disorders were seizures, intracranial hemorrhage, and ischemic stroke. Time from neurological symptoms to TTS diagnosis was ≤ 2 days in 87.3% of cases. TTS patients with neurological disorders were younger, had a lower female predominance, fewer cardiac symptoms, lower left ventricular ejection fraction, and higher levels of cardiac biomarkers. TTS patients with neurological disorders had a 3.2-fold increased odds of in-hospital mortality compared to TTS patients without neurological disorders. In this large-scale study, 1 out of 15 TTS patients had an acute neurological condition as the underlying triggering factor. Our data emphasize that a wide spectrum of neurological diseases ranging from benign to life-threatening encompass TTS. The high rates of adverse events highlight the need for clinical awareness.

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Case report of Takotsubo syndrome following seizures in a patient with pyruvate carboxylase deficiency

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab011 ◽

2021 ◽

Vol 5 (3) ◽

Author(s):

Nikhil Sahdev ◽

Onyedikachi Oji ◽

Aswin Babu ◽

Smita Dutta Roy

Keyword(s):

Case Report ◽

Pyruvate Carboxylase ◽

Acute Infection ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Clinical State ◽

Takotsubo Syndrome ◽

Ventricular Ejection Fraction ◽

Cardiac Symptoms ◽

Pyruvate Carboxylase Deficiency

Abstract Background Takotsubo syndrome (TS) is defined as transient left ventricular dysfunction, which is often related to an emotional or physically stressful event. We describe a case of TS in a lady with pyruvate carboxylase deficiency (PCD). Pyruvate carboxylase deficiency is rare condition with the majority of those affected demonstrating signs of failure to thrive, recurrent seizures, and metabolic acidosis. To our knowledge, this is the first documented case of TS in an individual with PCD. Case summary This 28-year-old female presented to the emergency department after a tonic-clonic seizure. For 4 days prior to the presentation, she had been suffering from cough and pyrexia. On Day 2, she developed abdominal pain associated with tachycardia and hypotension, and an elevated troponin (791 ng/L). The echocardiogram showed a severely impaired left ventricular systolic function, regional wall motion abnormalities (RWMAs), and a visually estimated left ventricular ejection fraction of 25–30%. Eight days following admission her clinical state significantly improved, with a reduction troponin to 60 ng/L. A repeat echocardiogram on Day 9 showed complete resolution of cardiac function with no RWMAs. Following this, she was discharged from hospital the next day with a diagnosis of TS. Discussion This is the first case report of TS in a patient with PCD. In this case, multiple aetiologies of TS such as emotional and physical stress, seizures, and acute infection were considered. This case also highlights that TS should be an important differential diagnosis in patients presenting with cardiac symptoms.

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Elderly woman presenting with multivessel coronary artery disease and Takotsubo syndrome

BMJ Case Reports ◽

10.1136/bcr-2021-242367 ◽

2021 ◽

Vol 14 (7) ◽

pp. e242367

Author(s):

Hari Vivekanantham ◽

Martin Scoglio ◽

Philipp Suter ◽

Stephane Cook ◽

Yann Roux ◽

...

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Takotsubo Syndrome ◽

Left Main ◽

Ventricular Ejection Fraction ◽

Coronary Syndrome ◽

Left Anterior Descending Artery ◽

Artery Disease

Takotsubo syndrome is an acute and often reversible condition, with initial presentation mimicking acute coronary syndrome. Typically, patients present with left ventricular regional wall motion abnormalities, without a corresponding coronary artery obstruction on angiography. Coexistence of a coronary artery disease is possible and may render the distinction between the two entities particularly challenging. We report the case of a 94-year-old woman with chest pain after an emotional upset and acute myocardial injury. Transthoracic echocardiogram (TTE) revealed a severely reduced left ventricular ejection fraction (LVEF) with apical ballooning. Coronary angiogram showed significant stenosis of the distal left main coronary artery and of the mid-left anterior descending artery, as well as a 30%–50% stenosis of the mid-distal right coronary artery. Revascularisation was deferred and antiplatelet as well as heart failure therapy begun. A repeat TTE 6 days later revealed a quasi-normalised LVEF. Ultimately, percutaneous coronary revascularisation of the left main and left anterior descending artery was performed, with favourable outcome at 6-month follow-up.

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Serum autotaxin level predicts future cardiac events in patients with dilated cardiomyopathy

European Heart Journal ◽

10.1093/eurheartj/ehab724.1730 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

T Araki ◽

T Okumura ◽

T Mizutani ◽

Y Kimura ◽

S Kazama ◽

...

Keyword(s):

Survival Analysis ◽

Dilated Cardiomyopathy ◽

Volume Fraction ◽

Left Ventricular ◽

Cox Proportional Hazards ◽

Left Ventricular Ejection ◽

Myocardial Inflammation ◽

Prognostic Impact ◽

Cardiac Events ◽

Ventricular Ejection Fraction

Abstract Background Autotaxin (ATX) has been reported to promote myocardial inflammation and subsequent cardiac remodeling through lysophosphatidic acid (LPA) production. However, the prognostic impact of ATX has not been clarified in dilated cardiomyopathy (DCM). Purpose We aimed to investigate the prognostic impact of ATX in patients with DCM. Methods We enrolled 104 DCM patients (49.8 years, 76 males). The subjects underwent blood sampling, echocardiography, cardiac catheterization, and endomyocardial biopsy. Gender differences in serum ATX levels have been reported, thus we divided the subjects into two groups using median serum ATX levels for men and women: High-ATX group and Low-ATX group. All patients were followed up by expert cardiologists. The cardiac event was defined as a composite of cardiac death and hospitalization for worsening heart failure. Results Eighty-nine percent of the subjects were classified as New York Heart Association functional class I or II. Female patients had higher serum ATX levels than male patients, with median values of 257.0 ng/mL and 203.5 ng/mL, respectively (Figure A). The average left ventricular ejection fraction and brain natriuretic peptide levels were 30.6% and 122.5 pg/mL. In survival analysis, cumulative event-free probability was significantly lower in High ATX group (p=0.007, Figure B). In Cox proportional hazards analysis, High-ATX was one of the independent predictors of composite cardiac events (Hazards Ratio, 2.575; p=0.043). On the other hand, high sensitive C-reactive protein and collagen volume fraction in myocardial samples were not significant predictors. Conclusion High serum ATX level was associated with poor prognosis in patients with DCM. FUNDunding Acknowledgement Type of funding sources: None. Gender difference in autotaxin levels Survival analysis of cardiac events

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Abstract 14471: Prognostic Impact of Sarcopenia in Men versus Women With Acute Decompensated Heart Failure and Preserved Left Ventricular Ejection Fraction

Circulation ◽

10.1161/circ.142.suppl_3.14471 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Takanari Kimura ◽

Shungo Hikoso ◽

Nakatani Daisaku ◽

Shunsuke Tamaki ◽

Masamichi Yano ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Acute Decompensated Heart Failure ◽

Decompensated Heart Failure ◽

Left Ventricular ◽

Fat Free Mass ◽

Left Ventricular Ejection ◽

Prognostic Impact ◽

Ventricular Ejection Fraction ◽

Multicenter Observational Study

Background: Sarcopenia is associated with poor prognosis in chronic heart failure. Fat-free mass index (FFMI) is an indicator of resting energy expenditure and has been used for the clinical diagnosis of sarcopenia. However, the prognostic impact of sarcopenia diagnosed by FFMI remains to be elucidated in patients admitted with acute decompensated heart failure (ADHF) and preserved LVEF (HFpEF), relating to gender. Methods: Patients' data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT-HFpEF) study, which is a prospective multicenter observational registry for ADHF patients with LVEF ≥50% in Osaka. We studied 621 patients who survived to discharge (men, n=281 and women, n=340). Fat-free mass (FFM) was estimated by the formula [FFM (kg) = 7.38 + 0.02908 х urinary creatinine (mg/day)] and normalized by the square of the patient’s height in meters to calculate FFMI at discharge. Sarcopenia was defined as FFMI <17 kg/m2 in men and <15 kg/m2 in women. The endpoint was all-cause death. Results: During a follow-up period of 1.5±0.8 yrs, 102 patients died (men, n=46 and women, n=56). At multivariate Cox analysis, FFMI was significantly associated with the mortality independently of age, estimated glomerular filtration rate, NT-proBNP and LVEF in both men (p=0.0155) and women (p=0.0223). Patients with sarcopenia had a significantly higher risk of all-cause death than those without sarcopenia in both genders (Figure). Conclusions: In this multicenter study, sarcopenia diagnosed by FFMI was shown to be associated with poor clinical outcome in HFpEF patients admitted with ADHF in both genders.

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Atrial mechanics and their prognostic impact in Takotsubo syndrome: a cardiovascular magnetic resonance imaging study

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jey219 ◽

2019 ◽

Vol 20 (9) ◽

pp. 1059-1069 ◽

Cited By ~ 4

Author(s):

Sören J Backhaus ◽

Thomas Stiermaier ◽

Torben Lange ◽

Amedeo Chiribiri ◽

Johannes Uhlig ◽

...

Keyword(s):

Cardiovascular Magnetic Resonance ◽

Magnetic Resonance ◽

Left Ventricular ◽

Right Atrial ◽

Left Ventricular Ejection ◽

Prognostic Impact ◽

Takotsubo Syndrome ◽

Pump Function ◽

Booster Pump

AbstractAimsThe exact pathophysiology of Takotsubo syndrome (TTS) remains not fully understood with most studies focussing on ventricular pathology. Since atrial involvement may have a significant role, we assessed the diagnostic and prognostic potential of atrial cardiovascular magnetic resonance feature tracking (CMR-FT) in TTS.Methods and resultsThis multicentre study recruited 152 TTS patients who underwent CMR on average within 3 days after hospitalization. Reservoir [total strain εs and peak positive strain rate (SR) SRs], conduit (passive strain εe and peak early negative SRe), and booster pump function (active strain εa and peak late negative SRa) were assessed in a core laboratory. Results were compared with 21 control patients with normal biventricular function. A total of 20 patients underwent follow-up CMR (median 3.5 months, interquartile range 3–5). All patients were approached for general follow-up. Left atrial (LA) but not right atrial (RA) reservoir and conduit function were impaired during the acute phase (εs: P = 0.043, εe: P < 0.001, SRe: P = 0.047 vs. controls) and recovered until follow-up (εs: P < 0.001, SRs: P = 0.04, εe: P = 0.001, SRe: P = 0.04). LA and RA booster pump function were increased in the acute setting (LA-εa: P = 0.045, SRa: P = 0.002 and RA-εa: P = 0.004, SRa: P = 0.002 vs. controls). LA-εs predicted mortality [hazard ratio 1.10, 95% confidence interval (CI) 1.01–1.20; P = 0.037] irrespectively of established cardiovascular risk factors (P = 0.019, multivariate analysis) including left ventricular ejection fraction (LVEF) (area under the curve 0.71, 95% CI 0.55–0.86, P = 0.048).ConclusionTTS pathophysiology comprises transient impairments in LA reservoir and conduit functions and enhanced bi-atrial active booster pump functions. Atrial CMR-FT may evolve as a superior marker of adverse events over and above established parameters such as LVEF and atrial volume.

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Concomitant myopericarditis and takotsubo syndrome following immune checkpoint inhibitor therapy

BMJ Case Reports ◽

10.1136/bcr-2020-235265 ◽

2020 ◽

Vol 13 (9) ◽

pp. e235265 ◽

Cited By ~ 1

Author(s):

Nicholas Yick Loong Tan ◽

Nandan S Anavekar ◽

Brandon M Wiley

Keyword(s):

Immune Checkpoint ◽

Immune Checkpoint Inhibitor ◽

Checkpoint Inhibitor ◽

Left Ventricular ◽

Inhibitor Therapy ◽

Left Ventricular Ejection ◽

Cardiac Complications ◽

Takotsubo Syndrome ◽

Ventricular Ejection Fraction ◽

Checkpoint Inhibitor Therapy

A 62-year-old man with metastatic hepatocellular carcinoma presented with ST elevation myocardial infarction had received one dose of nivolumab 3 weeks prior. Cardiac catheterisation was negative for obstructive coronary artery disease. He was transferred to the cardiac intensive care unit due to ventricular arrhythmias and markedly elevated troponin T levels. Transthoracic echocardiogram showed severely depressed left ventricular ejection fraction of 18% (normal 55%–70%) with mid and apical ballooning consistent with takotsubo syndrome (TTS). Intravenous glucocorticoids were administered due to suspicion for superimposed myocarditis. Cardiac MRI 3 days later showed mid-myocardial and subepicardial delayed enhancement in the inferior and lateral walls as well as apex indicative of myopericarditis. He clinically improved on steroids and was discharged with outpatient follow-up. This case highlights major cardiac complications that may arise with immune checkpoint inhibitor therapy. In addition, it emphasises the importance of assessing for concomitant myocarditis even when initial imaging suggests TTS.

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The prognostic impact of catheter ablation for atrial fibrillation after heart failure hospitalization on long-term mortality – Propensity-score matching analysis

European Heart Journal ◽

10.1093/ehjci/ehaa946.0531 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

Y Iwanami ◽

K Jujo ◽

S Higuchi ◽

T Abe ◽

M Shoda ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Catheter Ablation ◽

Propensity Score ◽

Left Ventricular ◽

Lower Mortality ◽

Left Ventricular Ejection ◽

Prognostic Impact ◽

Ventricular Ejection Fraction ◽

All Cause Mortality

Abstract Background In the last two decades, catheter ablation (CA) for atrial fibrillation (AF) including pulmonary vein isolation (PVI) has been developed as a standard and effective treatment for atrial fibrillation (AF). In patients with chronic heart failure with reduced left ventricular ejection fraction (LVEF) (HFrEF), PVI CA for AF dramatically improves LVEF, resulting in better clinical prognoses. On the contrary, there still has been no data that PVI CA for AF improves the prognosis in heart failure patients with preserved LVEF (HFpEF). Purpose The aim of this study was to evaluate the prognostic impact of PVI CA for AF after the hospitalization due to decompensation of heart failureHF, focusing on LVEF. Methods From the database including 1,793 consecutive patients who were hospitalized due to congestive HF, we ultimately analyzed 624 AF patients who were discharged alive. They were assigned into two groups due that PVI CA for AF procedure done after the index hospitalization for HF; the PVI CA group (n=62) and Non-PVI CA group (n=562). For the two groups, we performed propensity-score (PS) matching using variables as follows: age, sex, LVEF, brain natriuretic peptide (BNP), blood urea nitrogen (BUN) and estimated glomerular filtration rate (eGFR) at discharge. Further analysis was performed separately in HFrEF (LVEF <50%) and HFpEF (LVEF >50%). The primary endpoint of this study was death from any cause. Results In unmatched patients, Kaplan-Meier analysis showed that patients in the PVI CA group had a significantly lower all-cause mortality than those in the Non-PVI CA group during 678 median follow-up period (Log-rank test: P=0.003, Figure A). In 96 PS-matched patients, patients in the PVI CA group still had lower mortality rate than those in the Non-PVI CA group (hazard ratio 0.28, 95% confidence interval 0.09–0.86, p=0.018, Figure B). When the whole study population was classified into HFrEF and HFpEF, HFrEF patients who received PVI showed a significantly lower mortality than those who did not (p=0.007); whereas, in HFpEF patients, PVI CA for AF did not make statistical difference in all-cause mortality (p=0.061). Conclusions In this observational study, PVI CA for AF may improve the mortality in HF patients with reduced LVEF. However, the prognostic impact of PVI CA for AF was not observed in HF patients with preserved LVEF. Funding Acknowledgement Type of funding source: None

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Myocarditis and pericarditis

10.1093/med/9780199687039.003.0058_update_001 ◽

2017 ◽

Author(s):

Michel Noutsias ◽

Bernhard Maisch

Keyword(s):

Dilated Cardiomyopathy ◽

Clinical Management ◽

Acute Myocarditis ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Histological Evaluation ◽

Prognostic Impact ◽

Inflammatory Cardiomyopathy ◽

Ventricular Ejection Fraction ◽

Cardioverter Defibrillator

Transition of acute myocarditis to dilated cardiomyopathy occurs in approximately 20% of patients within a follow-up period of 33 months. Recent research has revealed the adverse prognostic impact of several clinical parameters for this scenario. Acute myocarditis and its sequelae dilated cardiomyopathy and inflammatory cardiomyopathy are often caused by viral infections. Histological evaluation of endomyocardial biopsies is critical for the diagnosis of the cardiomyopathy entity and for the clinical management of around 20% of the patients. Additionally, contemporary diagnostic procedures of endomyocardial biopsies are indispensable for the selection of inflammatory cardiomyopathy patients who will likely benefit from immunosuppression or antiviral (interferon) treatment. Immunoadsorption, with subsequent immunoglobulin substitution, is a further promising immunomodulatory treatment option for dilated cardiomyopathy patients, targeting primarily the anticardiac autoantibodies. Cardiac magnetic resonance has emerged as a valuable diagnostic approach for myocarditis and pericarditis. Myocardial late gadolinium enhancement has been associated with adverse outcome and sudden cardiac death. Bridging of the first 3 months with a wearable cardioverter–defibrillator, until a definitive decision on the implantation of an implantable cardioverter–defibrillator, is a growingly recognized cornerstone in the clinical management of patients with acute myocarditis with depressed left ventricular ejection fraction of <40% and new-onset dilated cardiomyopathy, respectively. Acute pericarditis is labelled idiopathic or suspected viral without adequate proof of the respective aetiology. Non-steroidal anti-inflammatory drugs and colchicine are proven and safe therapeutic mainstays for pericarditis, including the first attack. Pericardiocentesis is a lifesaving treatment of cardiac tamponade. Pericardioscopy and epicardial biopsies can contribute to the aetiological differentiation of pericardial effusions.

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Takotsubo Syndrome in Patients with COVID-19: a Systematic Review of Published Cases

SN Comprehensive Clinical Medicine ◽

10.1007/s42399-020-00557-w ◽

2020 ◽

Vol 2 (11) ◽

pp. 2102-2108 ◽

Cited By ~ 2

Author(s):

Sandeep Singh ◽

Rupak Desai ◽

Zainab Gandhi ◽

Hee Kong Fong ◽

Shriya Doreswamy ◽

...

Keyword(s):

Case Reports ◽

Hypertensive Crisis ◽

Apical Ballooning ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Cardiac Complications ◽

Time Interval ◽

Takotsubo Syndrome ◽

Ventricular Ejection Fraction ◽

Successful Recovery

AbstractTakotsubo syndrome (TTS) is caused by catecholamine surge, which is also observed in COVID-19 disease due to the cytokine storm. We performed a systematic literature search using PubMed/Medline, SCOPUS, Web of Science, and Google Scholar databases to identify COVID-19-associated TTS case reports and evaluated patient-level demographics, clinical attributes, and outcomes. There are 12 cases reported of TTS associated with COVID-19 infection with mean age of 70.8 ± 15.2 years (range 43–87 years) with elderly (66.6% > 60 years) female (66.6%) majority. The time interval from the first symptom to TTS was 8.3 ± 3.6 days (range 3–14 days). Out of 12 cases, 7 reported apical ballooning, 4 reported basal segment hypo/akinesia, and 1 reported median TTS. Out of 12 cases, during hospitalization, data on left ventricular ejection fraction (LVEF) was reported in only 9 of the cases. The mean LVEF was 40.6 ± 9.9% (male, 46.7 ± 5.7%, and female, 37.7 ± 10.6%). Troponin was measured in all 12 cases and was elevated in 11 (91.6%) without stenosis on coronary angiography except one. Out of 11 cases, 6 developed cardiac complications with 1 case each of cardiac tamponade, heart failure, myocarditis, hypertensive crisis, and cardiogenic shock in 2. Five patients required intubation, 1 patient required continuous positive airway pressure, and 1 patient required venovenous extracorporeal membrane oxygenation. The outcome was reported in terms of recovery in 11 (91.6%) out of 12 cases, and a successful recovery was noted in 10 (90.9%) cases. COVID-19-related TTS has a higher prevalence in older women. Despite a lower prevalence of cardiac comorbidities in COVID-19 patients, direct myocardial injury, inflammation, and stress may contribute to TTS with a high complication rate.

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