Prevalence and Impact of Takotsubo Syndrome in Hospitalizations for Acute Ischemic Stroke

Background: Takotsubo Syndrome (TTS) is characterized by acute and reversible left ventricular dysfunction with apical ballooning arising during acute stress situations. Acute Ischemic Stroke (AIS) is one of the known triggers to TTS, however, the impact of TTS on in-hospital outcomes of AIS remains unexplored. Methods: We utilized data from the National Inpatient Sample (2007-2014) and using ICD-9-CM diagnosis codes to identify admissions for AIS with TTS and evaluated the temporal trends, baseline characteristics, in-hospital complications, length of stay (LOS) and all-cause mortality. Survey multivariable logistic regression was used to compute adjusted Odds Ratios (OR and 95% confidence intervals (CI). Results: An estimated 2,242 (0.4%) TTS cases were identified among AIS hospitalizations (N=43,92,471). The frequency of TTS was higher in elderly, whites and females (82.2%). After adjustment for confounders, TTS incidence in AIS was associated with higher odds of in-hospital complications including cardiogenic shock (OR8.84, CI:4.07-19.17, p<0.001), cardiac arrest (OR3.17, CI:1.57-6.42, p=0.001), and venous thromboembolism (OR1.68, CI:1.14-2.47, p=0.008). Moreover, AIS hospitalizations with TTS showed higher odds of developing respiratory failure (OR3.13, CI:2.42-4.05, p<0.001) and required mechanical ventilation/intubation (OR4.09, CI:3.14-5.32, p<0.001) more frequently compared to non-TTS cohort. The AIS-TTS cohort had longer LOS (8.59 vs 5.22 days) and the mortality was doubled (10.2% vs 5.1% p<0.001) compared to those without TTS. Conclusion: The prevalence of TTS in AIS remained ~20 times higher than the general inpatient population and it predisposed AIS patients to worse inpatient outcomes. Further studies are needed to evaluate the impact of TTS on long-term outcomes in AIS.

Postpartum pheochromocytoma-induced takotsubo syndrome

A postpartum patient with acute-onset dyspnoea and hypotention, associated with reduced left ventricular function requiring intensive blood pressure control, was initially misdiagnosed as having peripartum cardiomyopathy. Her clinical symptoms rapidly resolved. Echocardiography revealed reversible left ventricular dysfunction with apical ballooning and coronary angiography was normal. Based on these findings, we diagnosed takotsubo syndrome. Over the next two months, the patient experienced repeated bouts of elevated sympathetic activity. On workup, we found an adrenal mass and elevated urine metanephrines. After adrenalectomy, histology confirmed pheochromocytoma. Our patient had the rare diagnosis of postpartum pheochromocytoma-induced takotsubo syndrome.

Premature ventricular complexes : Systematic review, evaluation and management

Premature ventricular complexes (PVCs) are a common finding in general population and can be even considered physiologic in most cases. Nevertheless, very frequent isolated PVCs may lead to the development of a usually reversible left ventricular dysfunction or be a manifestation of an underlying cardiac condition that could be associated with more severe ventricular arrhythmias, heart failure or cardiac death. Three causative mechanisms of the PVCs have been proposed: abnormal automaticity, triggered activity and reentry supposing different diagnostic and therapeutic implications. Although many patients with PVCs remain completely asymptomatic, others may suffer from a wide range of symptoms like palpitations, fatigue, dyspnoea or dizziness of a variable degree. Proper characterisation of the PVCs, their burden and features, as well as the identification of their sites of origin and mechanisms should be pursued to establish the convenience of a conservative or therapeutic approach. Specific treatment with medical therapy or catheter ablation must be contemplated in symptomatic patients or in those who develop related systolic dysfunction or other kind of complications.

Curious case of reversible left ventricular dysfunction in a young woman

A 27-year-old woman presented with breathlessness on exertion of 3 months duration and was treated as dilated cardiomyopathy elsewhere. On evaluation, she was found to have left ventricular hypertrophy with ventricular dysfunction. CT angiogram revealed a peripheral-enhancing mass with central necrosis in the aortocaval region. Elevated serum metanephrine and uptake in 131iodine metaiodobenzylguanidine scan lead to the diagnosis of paraganglioma. Patient underwent open surgical excision of the tumour. Left ventricular function became normal and left ventricular hypertrophy resolved after surgery.

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

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.