scholarly journals Takotsubo syndrome: hyperthyroidism, pheochromocytoma, or both? A case report

2021 ◽  
Vol 5 (8) ◽  
Author(s):  
Gaetano Marino ◽  
Alberto Michielon ◽  
Maria Beatrice Musumeci ◽  
Camillo Autore
Keyword(s):  
Immune Response ◽  
Aortic Dissection ◽  
Thyroid Hormones ◽  
Myocardial Fibrosis ◽  
Myocardial Dysfunction ◽  
Left Ventricular ◽  
Adrenergic System ◽  
Graves Disease ◽  
Takotsubo Syndrome

Abstract Background Takotsubo syndrome (TTS) is a transient left ventricular dysfunction usually with apical akinesia (classical pattern). Other less frequent variants have been described: the mid-ventricular pattern is characterized by hypokinesia of the mid-left ventricle and hypercontractile apical and basal segments; the inverted or basal pattern is characterized by basal and mid-ventricular segment hypokinesia or akinesia with preserved contractility or hypercontractility of apical segments and finally the focal pattern. There are also biventricular variants and forms with exclusive involvement of the right ventricle. There is a correlation between endocrine disorders and TTS, the one most frequently described is with pheochromocytoma. Catecholamine-mediated myocarditis, focal and diffuse myocardial fibrosis, and myocardial dysfunction are described in pheochromocytoma. Case summary We describe a case of a 69-year-old patient with a recent diagnosis of hypertension and Graves’ disease, hospitalized for persistent chest pain, hypertensive crisis, tachycardia, dyspnoea, and diaphoresis. Thyroid hormones, antibodies to TSH receptors, and hs-troponin I were increased. Electrocardiogram showed sinus tachycardia at 130 b.p.m., first-degree atrioventricular block, signs of left ventricular hypertrophy with inverted T wave in V4–V6. Echocardiogram demonstrated left ventricular apical and para-apical akinesia. Coronary angiography ruled out an obstructive coronary artery disease. Computed tomography angiogram aortic dissection ruled out aortic dissection but incidentally revealed a left adrenal mass compatible with a pheochromocytoma. Plasma and urinary metanephrines were increased. A TTS secondary to pheochromocytoma and hyperthyroidism was diagnosed. Pharmacological treatment included nitrates, urapidil and esmolol IV and methimazole at high doses. Type 2 multiple endocrine neoplasia has been excluded. After a complete haemodynamic stability on 20th day of hospitalization, the patient underwent an adrenalectomy. Discussion High levels of catecholamines in pheochromocytoma can lead to myocardial dysfunction. Similarly, an excess of thyroid hormones with up-regulation of adrenergic system can lead to myocardial dysfunction. These two conditions, if both present, define a high haemodynamic risk profile. How do catecholamines interact with the thyroid gland? The clinical case is of interest as a relationship has been hypothesized between the incretion of plasma catecholamines and Graves’ disease. We suppose an imbalance of the immune system with a predominance of the T helper-type 2 (Th2)-mediated response. Predominance of Th2-mediated immune response may induce humoral immunity causing Graves’ disease. In addition Th2 cytokines are strong inducers of M2 macrophages (alternatively activated) that are involved in autoimmune diseases, myocarditis, and myocardial fibrosis. Knowing the interaction between the cardiovascular system, immune response, and endocrine glands can help define the patient's risk class, possible complications, and follow-up.

scholarly journals Takotsubo Syndrome: Contemporary Views on the Pathogenesis, Prevalence and Prognosis

2018 ◽  
Vol 14 (4) ◽  
pp. 598-604 ◽  
Author(s):  
A. S. Shilova ◽  
A. O. Shmotkina ◽  
A. A. Yafarova ◽  
M. Yu. Gilyarov
Keyword(s):  
Genetic Predisposition ◽  
Randomized Clinical Trials ◽  
Myocardial Dysfunction ◽  
Specific Treatment ◽  
Left Ventricular ◽  
Takotsubo Syndrome ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
St Segment ◽  
Reversible Left Ventricular Dysfunction

Takotsubo syndrome (TTS) is a reversible left ventricular dysfunction characterized by local apical hypokinesia usually triggered by a physical or emotional stress. According to the last available data TTS may represent 2% of all admissions for acute coronary syndromes. Despite the reliable prevalence, diagnosis of TTS remains difficult. The initial presentation, both clinically and electrocardiographically, is similar to an acute myocardial infarction (AMI). The biomarker profile is also similar, although the peaks of troponin and creatinine kinase levels are lower, and brain natriuretic peptide levels are higher in patients with TTS compared with ST-segment elevation AMI. Modified Mayo diagnostic criteria are the most common for the diagnosis. Pathogenesis of TTS currently is not well understood. Catecholamines appear to play a central role in the pathophysiology of TTS. However, it is conceivable that some people have a genetic predisposition to stress-induced TTS. A genetic predisposition has been suggested based on the few familial TTS cases described. Despite reversible myocardial dysfunction, acute heart failure is the most common complication in the acute phase of TTS. In-hospital mortality rate is comparable to that of ST-segment elevation AMI. There are no randomized clinical trials to support specific treatment recommendations in TTS. It is believed that the tactics of managing patients with TTS hospitalized with suspicion of acute coronary syndrome should comply with the protocol of management of patients with AMI while acute coronary pathology is not excluded.

Endocrine autoimmunity

2011 ◽  
pp. 34-44 ◽  
Author(s):  
Matthew J. Simmonds ◽  
Stephen C. L. Gough
Keyword(s):  
Immune Response ◽  
Type 1 Diabetes ◽  
Immune System ◽  
Endocrine System ◽  
Graves Disease ◽  
Self Tolerance ◽  
Autoimmune Attack ◽  
Endocrine Organs

Dysfunction within the endocrine system can lead to a variety of diseases with autoimmune attack against individual components being some of the most common. Endocrine autoimmunity encompasses a spectrum of disorders including, e.g., common disorders such as type 1 diabetes, Graves’ disease, Hashimoto’s thyroiditis, and rarer disorders including Addison’s disease and the autoimmune polyendocrine syndromes type 1 (APS 1) and type 2 (APS 2) (see Table 1.6.1). Autoimmune attack within each of these diseases although aimed at different endocrine organs is caused by a breakdown in the immune system’s ability to distinguish between self and nonself antigens, leading to an immune response targeted at self tissues. Investigating the mechanisms behind this breakdown is vital to understand what has gone wrong and to determine the pathways against which therapeutics can be targeted. Before discussing how self-tolerance fails, we first have to understand how the immune system achieves self-tolerance.

scholarly journals Effect of Irbesartan on AGEs-RAGE and MMPs systems in rat type 2 diabetes myocardial-fibrosis model

2019 ◽  
Vol 244 (7) ◽  
pp. 612-620 ◽  
Author(s):  
Ye Hongwei ◽  
Cao Ruiping ◽  
Fang Yingyan ◽  
Zhang Guanjun ◽  
Hu Jie ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Body Weight ◽  
Myocardial Fibrosis ◽  
Fasting Blood Glucose ◽  
Left Ventricular ◽  
Heart Weight ◽  
Sensitivity Index ◽  
Protein Expressions ◽  
Diabetes Patients

To investigate the effect of Irbesartan on the changes of myocardial advanced glycation end products and their receptor (AGEs-RAGE), and matrix metalloproteinases (MMPs) systems in rat type 2 diabetes myocardial fibrosis model. All male Sprague-Dwaley rats were randomly divided into four groups: control (CON), high glucose and high-caloric diet (HC), type 2 diabetes (T2DM) and Irbesartan + T2DM (Ir+T2DM) groups. At 12th week, the fasting blood glucose (FBG) and fasting serum insulin (FINS) levels, insulin resistance index (IRI), insulin sensitivity index (ISI), body weight (BW), the ratio of heart weight/body weight (H/B), left ventricular weight index (LVWI), and cardiac col I, col III contents, plasma MMP-2, MMP-9 levels were evaluated. The protein expressions of col I, AGE, RAGE, MMP-2, MMP-14, and TIMP-2 were analyzed by Western blot. In the T2DM group, FBG, H/B, LVWI, IRI were increased ( P < 0.01), while FINS, BW, ISI were decreased in contrast to the CON and HC groups ( P < 0.05–0.01). In the Ir+ T2DM group, BW was higher, IRI, H/B, LVWI were lower than in the T2DM group. Compared with the CON and HC groups, the contents of col I and col III, the protein expressions of col I, AGE, RAGE, TIMP-2 and MMP-14 were increased, MMP-2 protein expression, the ratios of MMP-2/TIMP-2 and MMP-14/TIMP-2, MMP-2, and MMP-9 levels were decreased in the T2DM group ( P < 0.01). After Irbesartan treatment, all parameters were reversed. Irbesartan can ameliorate myocardial fibrosis in type 2 diabetes rat model, the likely mechanisms may be related to the down-regulation of AGEs-RAGE system and changes of MMPs pathway. Impact statement There are about 425 million diabetes patients (20–79 years) in the world according to the International Diabetes Federation Diabetes Atlas – 8th Edition. The cardiovascular complication is one of the major causes of death in diabetes patients. Myocardial fibrosis is one of the serious pathological changes, so investigating the pathogenesis of myocardial fibrosis has the significant value. Our study aims to investigate the effect of Irbesartan (the angiotensin II receptor antagonist) on the changes of AGE-RAGE system and MMP family components, and analyzes the potential mechanisms in type 2 diabetes-induced myocardial fibrosis. Our results provide the theoretical base for better understanding the pathogenesis in type 2 diabetes-induced myocardial complication. It is useful for clinicians to select the effective therapeutic measures for treatment of type 2 diabetes-induced organ fibrosis.

scholarly journals Assessment of Myocardial Dysfunction by Three-Dimensional Echocardiography Combined With Myocardial Contrast Echocardiography in Type 2 Diabetes Mellitus

2021 ◽  
Vol 8 ◽  
Author(s):  
Wei Li ◽  
Xiao-zhou Lv ◽  
Jia Liu ◽  
Jia-hui Zeng ◽  
Min Ye ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Myocardial Dysfunction ◽  
Microvascular Complications ◽  
Contrast Echocardiography ◽  
Three Dimensional ◽  
Left Ventricular ◽  
Dimensional Echocardiography ◽  
Three Dimensional Echocardiography

Background: We aimed to explore the value of combining real-time three-dimensional echocardiography (RT-3DE) and myocardial contrast echocardiography (MCE) in the left ventricle (LV) evaluating myocardial dysfunction in type 2 diabetes mellitus (T2DM) patients.Patients and Methods: A total of 58 T2DM patients and 32 healthy individuals were selected for this study. T2DM patients were further divided into T2DM without microvascular complications (n = 29) and T2DM with microvascular complications (n = 29) subgroups. All participants underwent RT-3DE and MCE. The standard deviation (SD) and the maximum time difference (Dif) of the time to the minimum systolic volume (Tmsv) of the left ventricle were measured by RT-3DE. MCE was performed to obtain the perfusion measurement of each segment of the ventricular wall, including acoustic intensity (A), flow velocity (β), and A·β.Results: There were significant differences in all Tmsv indices except for Tmsv6-Dif among the three groups (all P &lt; 0.05). After heart rate correction, all Tmsv indices of the T2DM with microvascular complications group were prolonged compared with the control group (all P &lt; 0.05). The parameters of A, β, and A·β for overall segments showed a gradually decreasing trend in three groups, while the differences between the three groups were statistically significant (all P &lt; 0.01). For segmental evaluation of MCE, the value of A, β, and A·β in all segments showed a decreasing trend and significantly differed among the three groups (all P &lt; 0.05).Conclusions: The RT-3DE and MCE can detect subclinical myocardial dysfunction and impaired myocardial microvascular perfusion. Left ventricular dyssynchrony occurred in T2DM patients with or without microvascular complications and was related to left ventricular dysfunction. Myocardial perfusion was reduced in T2DM patients, presenting as diffuse damage, which was aggravated by microvascular complications in other organs.

Mechanisms of takotsubo syndrome

ESC CardioMed ◽  
2018 ◽  
pp. 1280-1283
Author(s):  
Leonarda Galiuto ◽  
Filippo Crea
Keyword(s):  
Cell Survival ◽  
Left Ventricular Dysfunction ◽  
Functional Recovery ◽  
Ventricular Dysfunction ◽  
Myocardial Dysfunction ◽  
Microvascular Dysfunction ◽  
Left Ventricular ◽  
Takotsubo Syndrome ◽  
Microvascular Spasm

The pathogenesis of takotsubo syndrome can be considered the result of a catecholamine surge that, in predisposed and susceptible individuals, produces microvascular spasm responsible for myocardial dysfunction. The reversibility of microvascular dysfunction along with the activation of the cell survival cascade guarantees prompt and complete functional recovery in the majority of patients. Yet, about 20% of patients have serious in-hospital complications probably related to the severity of left ventricular dysfunction and/or lack of resolution. The reasons for these different outcomes are still unknown.

scholarly journals Myocardial fibrosis in asymptomatic and symptomatic chronic severe primary mitral regurgitation and relationship to tissue characterisation and left ventricular function on cardiovascular magnetic resonance

2020 ◽  
Vol 22 (1) ◽  
Author(s):  
Boyang Liu ◽  
Desley A. H. Neil ◽  
Monisha Premchand ◽  
Moninder Bhabra ◽  
Ramesh Patel ◽  
...  
Keyword(s):  
Cardiovascular Magnetic Resonance ◽  
Magnetic Resonance ◽  
Mitral Regurgitation ◽  
Exercise Capacity ◽  
Myocardial Fibrosis ◽  
Myocardial Dysfunction ◽  
Global Longitudinal Strain ◽  
Left Ventricular ◽  
Lv Function ◽  
Tissue Characterisation

Abstract Background Myocardial fibrosis occurs in end-stage heart failure secondary to mitral regurgitation (MR), but it is not known whether this is present before onset of symptoms or myocardial dysfunction. This study aimed to characterise myocardial fibrosis in chronic severe primary MR on histology, compare this to tissue characterisation on cardiovascular magnetic resonance (CMR) imaging, and investigate associations with symptoms, left ventricular (LV) function, and exercise capacity. Methods Patients with class I or IIa indications for surgery underwent CMR and cardiopulmonary exercise testing. LV biopsies were taken at surgery and the extent of fibrosis was quantified on histology using collagen volume fraction (CVFmean) compared to autopsy controls without cardiac pathology. Results 120 consecutive patients (64 ± 13 years; 71% male) were recruited; 105 patients underwent MV repair while 15 chose conservative management. LV biopsies were obtained in 86 patients (234 biopsy samples in total). MR patients had more fibrosis compared to 8 autopsy controls (median: 14.6% [interquartile range 7.4–20.3] vs. 3.3% [2.6–6.1], P < 0.001); this difference persisted in the asymptomatic patients (CVFmean 13.6% [6.3–18.8], P < 0.001), but severity of fibrosis was not significantly higher in NYHA II-III symptomatic MR (CVFmean 15.7% [9.9–23.1] (P = 0.083). Fibrosis was patchy across biopsy sites (intraclass correlation 0.23, 95% CI 0.08–0.39, P = 0.001). No significant relationships were identified between CVFmean and CMR tissue characterisation [native T1, extracellular volume (ECV) or late gadolinium enhancement] or measures of LV function [LV ejection fraction (LVEF), global longitudinal strain (GLS)]. Although the range of ECV was small (27.3 ± 3.2%), ECV correlated with multiple measures of LV function (LVEF: Rho = − 0.22, P = 0.029, GLS: Rho = 0.29, P = 0.003), as well as NTproBNP (Rho = 0.54, P < 0.001) and exercise capacity (%PredVO2max: R = − 0.22, P = 0.030). Conclusions Patients with chronic primary MR have increased fibrosis before the onset of symptoms. Due to the patchy nature of fibrosis, CMR derived ECV may be a better marker of global myocardial status. Clinical trial registration Mitral FINDER study; Clinical Trials NCT02355418, Registered 4 February 2015, https://clinicaltrials.gov/ct2/show/NCT02355418

scholarly journals Current Knowledge and Future Challenges in Takotsubo Syndrome: Part 1—Pathophysiology and Diagnosis

2021 ◽  
Vol 10 (3) ◽  
pp. 479
Author(s):  
Elias Rawish ◽  
Thomas Stiermaier ◽  
Francesco Santoro ◽  
Natale Brunetti ◽  
Ingo Eitel
Keyword(s):  
Clinical Presentation ◽  
Current Knowledge ◽  
Myocardial Dysfunction ◽  
Obstructive Coronary Artery Disease ◽  
Microvascular Dysfunction ◽  
Left Ventricular ◽  
Takotsubo Syndrome ◽  
Adrenergic Stimulation ◽  
Pathophysiological Mechanisms ◽  
Cardiac Condition

First recognized in 1990, takotsubo syndrome (TTS) constitutes an acute cardiac condition that mimics acute myocardial infarction commonly in the absence of obstructive coronary artery disease; it is characterized by temporary left ventricular dysfunction, regularly in a circumferential apical, midventricular, or basal distribution. Considering its acute clinical presentation, coronary angiography with left ventriculography constitutes the gold standard diagnostic tool to exclude or confirm TTS. Frequently, TTS is related to severe emotional or physical stress and a subsequent increased adrenergic stimulation affecting cardiac function. Beyond clinical presentation, epidemiology, and novel diagnostic biomarkers, this review draws attention to potential pathophysiological mechanisms for the observed reversible myocardial dysfunction such as sympathetic overdrive-mediated multi-vessel epicardial spasms, microvascular dysfunction, the direct toxicity of catecholamines, lipotoxicity, and inflammation. Considering the long-term prognosis, further experimental and clinical research is indispensable to elucidate further pathophysiological mechanisms underlying TTS before randomized control trials with evidence-based therapeutic management can be performed.

scholarly journals Association of Serum Uric Acid with Biventricular Myocardial Dysfunction in Patients with type 2 Diabetes Mellitus: A Cross-sectional Study

2020 ◽  
Author(s):  
Ju-Hua Liu ◽  
Mei-Zhen Wu ◽  
Si-Min Li ◽  
Yan Chen ◽  
Qing-Wen Ren ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
Uric Acid ◽  
Serum Uric Acid ◽  
Myocardial Dysfunction ◽  
Global Longitudinal Strain ◽  
Myocardial Strain ◽  
Left Ventricular

Abstract BackgroundIncreased serum uric acid (SUA) is common in patients with type 2 diabetes mellitus (T2DM) and is associated with left ventricular (LV) myocardial dysfunction. Nonetheless the association of SUA with right ventricular (RV) function in patients with T2DM has not been studied. This study aimed to investigate the association of SUA with biventricular myocardial function in patients with T2DM.MethodsA total of 560 patients with T2DM were enrolled and divided into four groups according to quartile of SUA. Transthoracic echocardiography was performed and two-dimensional speckle tracking used to measure biventricular myocardial strain, including LV global longitudinal strain (GLS), circumferential strain (CS), radial strain (RS), and RV free wall longitudinal stra in (RV-FWLS).Results The absolute value of all biventricular strain parameters showed a stepwise decrease across SUA quartiles (all P<0.01). In particular, LV assessment by GLS, CS and RS demonstrated that those in the 4th quartile were impaired compared with the other quartiles (all P<0.05). Similarly, RV-FWLS of the 4th quartile was significantly impaired compared with the 1st and 2nd quartiles (all P<0.05). The same reduction in biventricular strain across SUA quartiles was observed in patients with estimated glomerular filtration rate＜or ≥60 ml/min/1.73 m2, and glycated hemoglobin < or ≥7.0% (all P<0.05). Multivariable linear regression analysis demonstrated that higher quartile of SUA was independently associated with impaired biventricular myocardial strain (all P<0.05). ConclusionsSUA was independently associated with biventricular myocardial dysfunction in asymptomatic T2DM patients, regardless of renal function or diabetic control.

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