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Clinical Characteristics and Cardiovascular Magnetic Resonance Findings in Stress (Takotsubo) Cardiomyopathy
Study Questions:
What are the clinical characteristics and cardiovascular magnetic resonance (CMR) imaging findings in patients with stress cardiomyopathy (Takotsubo) syndrome?
Methods:
This was a prospective study conducted at seven European and North American tertiary care centers between January 2005 and October 2010. A total of 256 consecutive patients were identified at the time of presentation, and follow-up was accomplished 1-6 months after the acute event. CMR was performed in 239 (93%) for left ventricular (LV) cavity geometry and wall motion abnormalities, as well as detection of late gadolinium enhancement (LGE) and myocardial edema. All patients underwent serial electrocardiography (ECG), cardiac enzyme analysis, and coronary angiography to exclude underlying obstructive coronary disease.
Results:
Mean age was 69 ± 12 years and 227 (89%) were female, of whom 207 (81% of total patients) were postmenopausal women. Only 29 (11%) were men. Stressful triggers were identified in 182 patients (71%). Emotional stressors were identified in 77 (30%), including 20 patients with recent death of a relative/friend/pet; 15 experiencing severe interpersonal conflict; 16 experiencing panic, anxiety, or anger; and miscellaneous adverse events in the remainder. A physical stressor could be identified in 105 (41%), including perisurgical phenomena in 23, acute respiratory failure in 19, malignancy/chemotherapy in 8, and other significant acute medical illnesses in the remainder. There were four in-hospital deaths, including two with ventricular fibrillation, one with cardiogenic shock, and one with hypoxic brain damage. There was no relationship between hospital outcome and ECG pattern, troponin, or other clinical features. ECG at admission was abnormal in 222 (87%), including 108 with ST elevation and 96 with T-wave inversion. Troponin was elevated in 231 (90%), with a maximum mean of troponin T of 0.4. CMR revealed a ballooning pattern with reduction of LV function in all patients (mean LV ejection fraction [LVEF] 47.7 ± 11.1%). Biventricular ballooning was observed in 81 patients (34%), who had lower LVEF than patients without right ventricular involvement. Ballooning was a typical apical pattern in 197 (82%), midventricular in 40 (17%), isolated basal in two (1%), and biventricular in 81 (34%). LV thrombi were seen in four subjects (2%), all of which resolved on follow-up. On CMR, focal edema corresponding to the region of wall motion abnormality was noted in 162 (81%), and LGE >3 standard deviation (SD) from normal in 22 (9%). LGE >5 SD was noted in none. On follow-up CMR, edema was noted in only two subjects (1%), and mild focal LG in one subject.
Conclusions:
The authors concluded that CMR performed at the time of presentation in patients with stress cardiomyopathy confirms a predominance of anteroapical ballooning, but also identifies subjects with ballooning in other areas. CMR also identified edema in the majority as well as absence of scar.
Perspective:
Stress cardiomyopathy has been known for a number of years, and generally has been the topic of small, isolated single-center case reports. This would appear to be the largest consecutive series of strictly defined patients with stress cardiomyopathy published to date, and demonstrates a somewhat broader range of clinical characteristics. As with other studies, the predominate demographic is a postmenopausal woman, but unlike other studies, a stressful trigger could be identified in only 71%. As with other studies, mild cardiac enzyme elevations were common and the overall prognosis was excellent, with only four in-hospital deaths out of 256 patients. CMR identified myocardial edema in the distribution of the wall motion abnormalities, and whether this is part of the pathophysiology of generation of apical ballooning or a consequence remains to be seen. This study also identified a number of patients with right ventricular or biventricular ballooning, which has not been as well characterized, but which appeared to result in a more significant physiologic abnormality, as witnessed by the greater prevalence of plural effusion and longer hospitalization and lower LVEF in these patients. Because this paper describes a large consecutive series of patients from a multicenter environment using a strict criteria for the definition of stress cardiomyopathy, it provides a significantly broader and more accurate window on this relatively rare disease.
Keywords: Tertiary Care Centers, Takotsubo Cardiomyopathy, Coronary Angiography, Magnetic Resonance Imaging
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