DOI: 10.3724/SP.J.1263.2012.00038

Journal of Geriatric Cardiology 2012/9:1 PP.38-48

Transient stress cardiomyopathies in the elderly: Clinical & Pathophysiologic considerations

Transient stress-induced cardiomyopathies have been increasingly recognized and while rare, they tend to affect elderly women more than other demographic groups. One type, often called tako-tsubo cardiomyopathy (TTC), is typically triggered by significant emotional or physical stress and is associated with chest pain, electrocardiogram (ECG) changes and abnormal cardiac enzymes. Significant left ventricular regional wall motion abnormalities usually include an akinetic “ballooning” apex with normal or hyperdynamic function of the base. A second type, often called neurogenic stunned myocardium, typically associated with subarachnoid hemorrhage, also usually presents with ECG changes and positive enzymes, but the typical wall motion abnormalities seen include normal basal and apical left ventricular contraction with akinesis of the mid-cavity in a circumferential fashion. The pathophysiology, clinical care and typical courses, are reviewed.

Key words:Stress-cardiomyopathy,Tako-tsubo cardiomyopathy,Subarachnoid hemorrhage,Neurogenic stunned myocardium

ReleaseDate:2014-07-21 16:08:59

1 Dote K, Sato H, Tateishi H, et al. Myocardial stunning due to simultaneous multivessel coronary spasms: A review of 5 cases. J Cardiol 1991; 21: 203-214.

2 Akashi YJ, Goldstein DS, Barbaro G, et al. Takotsubo cardiomyopathy: A new form of acute, reversible heart failure. Circulation 2008; 118: 2754-2762.

3 Eitel I, von Knobelsdorff-Brenkenhoff F, Bernhardt P, et al. Clinical characteristics and cardiovascular magnetic resonance findings in stress (takotsubo) cardiomyopathy. JAMA 2011; 306: 277-286.

4 Tsuchihashi K, Ueshima K, Uchida T, 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. J Am Coll Cardiol 2001; 38: 11-18.

5 Abe Y, Kondo M, Matsuoka R, et al. Assessment of clinical features in transient left ventricular apical ballooning. J Am Coll Cardiol 2003; 41: 737-742.

6 Sharkey SW, Lesser JR, Zenovich AG, et al. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation 2005; 111: 472-479

7 Ogura R, Hiasa Y, Takahashi T, et al. Specific findings of the standard 12-lead ECG in patients with 'Takotsubo' cardiomyopathy: Comparison with the findings of acute anterior myocardial infarction. Circ J 2003; 67: 687-690.

8 Gianni M, Dentali F, Grandi AM, et al. Apical ballooning syndrome or takotsubo cardiomyopathy: A systematic review. Eur Heart J 2006; 27: 1523-1529.

9 Sharkey SW, Windenburg DC, Lesser JR, et al. Natural history and expansive clinical profile of stress (tako-tsubo) cardiomyopathy. J Am Coll Cardiol 2010; 55: 333-341.

10 Bybee KA, Kara T, Prasad A, et al. Systematic review: Transient left ventricular apical ballooning: A syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med 2004; 141: 858-865.

11 Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): A mimic of acute myocardial infarction. Am Heart J 2008; 155: 408-417.

12 Haghi D, Athanasiadis A, Papavassiliu T, et al. Right ventricular involvement in takotsubo cardiomyopathy. Eur Heart J 2006; 27: 2433-2439.

13 Kurowski V, Kaiser A, von Hof K, et al. Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): Frequency, mechanisms, and prognosis. Chest 2007; 132: 809-816.

14 Desmet WJ, Adriaenssens BF, Dens JA. Apical ballooning of the left ventricle: First series in white patients. Heart 2003; 89: 1027-1031.

15 Kurisu S, Sato H, Kawagoe T, et al. Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: A novel cardiac syndrome mimicking acute myocardial infarction. Am Heart J 2002; 143: 448-455.

16 Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005; 352: 539-548.

17 Elesber AA, Prasad A, Bybee KA, et al. Transient cardiac apical ballooning syndrome: Prevalence and clinical implications of right ventricular involvement. J Am Coll Cardiol 2006; 47: 1082-1083.

18 Bybee KA, Prasad A, Barsness GW, et al. Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome. Am J Cardiol 2004; 94: 343-346.

19 Ito K, Sugihara H, Kawasaki T, et al. Assessment of ampulla (Takotsubo) cardiomyopathy with coronary angiography, two-dimensional echocardiography and 99m Tc-tetrofosmin myocardial single photon emission computed tomography. Ann Nucl Med 2001; 15: 351-355.

20 Feola M, Chauvie S, Rosso GL, et al. Reversible impairment of coronary flow reserve in takotsubo cardiomyopathy: A myocardial pet study. J Nucl Cardiol 2008; 15: 811-817.

21 Akashi YJ, Koike A, Oikawa K, et al. Relationship between baroreflex sensitivity and oxygen uptake in patients with chronic heart failure. Int J Cardiol 2006; 110: 423-425.

22 Madhavan M, Borlaug BA, Lerman A, et al. Stress hormone and circulating biomarker profile of apical ballooning syndrome (takotsubo cardiomyopathy): Insights into the clinical signifycance of B-type natriuretic peptide and troponin levels. Heart 2009; 95: 1436-1441.

23 Park JH, Kang SJ, Song JK, et al. Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU. Chest 2005; 128: 296-302.

24 Nef HM, Mollmann H, Kostin S, et al. Tako-Tsubo cardiomyopathy: Intraindividual structural analysis in the acute phase and after functional recovery. Eur Heart J 2007; 28: 2456-2464.

25 Frustaci A, Loperfido F, Gentiloni N, et al. Catecholamine induced cardiomyopathy in multiple endocrine neoplasia. A histologic, ultrastructural, and biochemical study. Chest 1991; 99: 382-385.

26 Nef HM, Mollmann H, Troidl C, et al. Abnormalities in intracellular Ca2+ regulation contribute to the pathomechanism of tako-tsubo cardiomyopathy. Eur Heart J 2009; 30: 2155-2164.

27 Ueyama T. Emotional stress-induced tako-tsubo cardiomyopathy: Animal model and molecular mechanism. Ann N Y Acad Sci 2004; 1018: 437-444.

28 Uchida M, Egawa M, Yamaguchi S. Protective effects of emotional stress-induced cardiac dysfunction depend on α/β ratio of adrenoreceptor blocker [abstract]. Circ J 2009; 73: 595.

29 Ibanez B, Navarro F, Cordoba M, et al. Tako-tsubo transient left ventricular apical ballooning: Is intravascular ultrasound the key to resolve the enigma? Heart 2005; 91: 102-104.

30 Haghi D, Roehm S, Hamm K, et al. Takotsubo cardiomyopathy is not due to plaque rupture: An intravascular ultrasound study. Clin Cardiol 2010; 33: 307-310.

31 Villareal RP, Achari A, Wilansky S, et al. Anteroapical stunning and left ventricular outflow tract obstruction. Mayo Clin Proc 2001; 76: 79-83.

32 Avegliano G, Huguet M, Costabel JP, et al. Morphologic pattern of late gadolinium enhancement in takotsubo cardiomyopathy detected by early cardiovascular magnetic resonance. Clin Cardiol 2011; 34: 178-182.

33 Bruder O, Hunold P, Jochims M, et al. Reversible late gadolinium enhancement in a case of takotsubo cardiomyopathy following high-dose dobutamine stress MRI. Int J Cardiol 2008; 127: E22-E24.

34 Simonetti OP, Kim RJ, Fieno DS, et al. An improved MR imaging technique for the visualization of myocardial infarction. Radiology 2001; 218: 215-223.

35 Assomull RG, Lyne JC, Keenan N, et al. The role of cardiovascular magnetic resonance in patients presenting with chest pain, raised troponin, and unobstructed coronary arteries. Eur Heart J 2007; 28: 1242-1249.

36 Mahrholdt H, Wagner A, Deluigi CC, et al. Presentation, patterns of myocardial damage, and clinical course of viral myocarditis. Circulation 2006; 114: 1581-1590.

37 Srichai MB, Junor C, Rodriguez LL, et al. Clinical, imaging, and pathological characteristics of left ventricular thrombus: A comparison of contrast-enhanced magnetic resonance imaging, transthoracic echocardiography, and transesophageal echocardiography with surgical or pathological validation. Am Heart J 2006; 152: 75-84.

38 Siebelink HM, Scholte AJ, Van de Veire NR, et al. Value of contrast echocardiography for left ventricular thrombus detection postinfarction and impact on antithrombotic therapy. Coron Artery Dis 2009; 20: 462-466.

39 Lee VH, Oh JK, Mulvagh SL, et al. Mechanisms in neurogenic stress cardiomyopathy after aneurysmal subarachnoid hemorrhage. Neurocrit Care 2006; 5: 243-249.

40 Mayer SA, LiMandri G, Sherman D, et al. Electrocardiographic markers of abnormal left ventricular wall motion in acute subarachnoid hemorrhage. J Neurosurg 1995; 83: 889-896.

41 Mayer SA, Lin J, Homma S, et al. Myocardial injury and left ventricular performance after subarachnoid hemorrhage. Stroke 1999; 30: 780-786.

42 Zaroff JG, Rordorf GA, Ogilvy CS, et al. Regional patterns of left ventricular systolic dysfunction after subarachnoid hemorrhage: Evidence for neurally mediated cardiac injury. J Am Soc Echocardiogr 2000; 13: 774-779.

43 Pollick C, Cujec B, Parker S, et al. Left ventricular wall motion abnormalities in subarachnoid hemorrhage: An echocardiographic study. J Am Coll Cardiol 1988; 12: 600-605.

44 Lee VH, Connolly HM, Fulgham JR, et al. Tako-tsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage: An underappreciated ventricular dysfunction. J Neurosurg 2006; 105: 264-270.

45 Brouwers PJ, Wijdicks EF, Hasan D, et al. Serial electrocardiographic recording in aneurysmal subarachnoid hemorrhage. Stroke 1989; 20: 1162-1167.

46 Tung PP, Olmsted E, Kopelnik A, et al. Plasma B-type natriuretic peptide levels are associated with early cardiac dysfunction after subarachnoid hemorrhage. Stroke 2005; 36: 1567-1569.

47 Mayer SA, Fink ME, Homma S, et al. Cardiac injury associated with neurogenic pulmonary edema following subarachnoid hemorrhage. Neurology 1994; 44: 815-820.

48 Fontes RB, Aguiar PH, Zanetti MV, et al. Acute neurogenic pulmonary edema: Case reports and literature review. J Neurosurg Anesthesiol 2003; 15: 144-150.

49 Zaroff JG, Rordorf GA, Titus JS, et al. Regional myocardial perfusion after experimental subarachnoid hemorrhage. Stroke 2000; 31: 1136-1143.

50 Kawahara E, Ikeda S, Miyahara Y, et al. Role of autonomic nervous dysfunction in electrocardio-graphic abnormalities and cardiac injury in patients with acute subarachnoid hemorrhage. Circ J 2003; 67: 753-756.

51 Masuda T, Sato K, Yamamoto S, et al. Sympathetic nervous activity and myocardial damage immediately after subarachnoid hemorrhage in a unique animal model. Stroke 2002; 33: 1671-1676.

52 Naredi S, Lambert G, Eden E, et al. Increased sympathetic nervous activity in patients with nontraumatic subarachnoid hemorrhage. Stroke 2000; 31: 901-906.

53 Elrifai AM, Bailes JE, Shih SR, et al. Characterization of the cardiac effects of acute subarachnoid hemorrhage in dogs. Stroke 1996; 27: 737-741; discussion 741-742.

54 Karch SB, Billingham ME. Myocardial contraction bands revisited. Hum Pathol 1986; 17: 9-13.

55 Novitzky D, Wicomb WN, Cooper DK, et al. Prevention of myocardial injury during brain death by total cardiac sympathectomy in the chacma baboon. Ann Thorac Surg 1986; 41: 520-524.

56 Shivalkar B, Van Loon J, Wieland W, et al. Variable effects of explosive or gradual increase of intracranial pressure on myocardial structure and function. Circulation 1993; 87: 230-239.

57 Friedman JA, Pichelmann MA, Piepgras DG, et al. Pulmonary complications of aneurysmal subarachnoid hemorrhage. Neurosurgery 2003; 52: 1025-1031; discussion 1031-1022.

58 Cruickshank JM, Neil-Dwyer G, Lane J. The effect of oral propranolol upon the ECG changes occurring in subarachnoid haemorrhage. Cardiovasc Res 1975; 9: 236-245.

59 Neil-Dwyer G, Walter P, Cruickshank JM, et al. Effect of propranolol and phentolamine on myocardial necrosis after subarachnoid haemorrhage. Br Med J 1978; 2: 990-992.

60 Tung P, Kopelnik A, Banki N, et al. Predictors of neurocardiogenic injury after subarachnoid hemorrhage. Stroke 2004; 35: 548-551.

61 Guglin M, Novotorova I. Neurogenic stunned myocardium and takotsubo cardiomyopathy are the same syndrome: A pooled analysis. Congest Heart Fail 2011; 17: 127-132.

62 Ako J, Honda Y, Fitzgerald PJ. Tako-tsubo-like left ventricular dysfunction. Circulation 2003; 108: E158; author reply E158.

63 Greco CA, De Rito V, Petracca M, et al. Takotsubo syndrome in a newborn. J Am Soc Echocardiogr 2011; 24: 471.

64 Ueyama T, Hano T, Kasamatsu K, et al. Estrogen attenuates the emotional stress-induced cardiac responses in the animal model of tako-tsubo (ampulla) cardiomyopathy. J Cardiovasc Pharmacol 2003; 42 (Suppl 1): S117-S119.

65 Akashi YJ, Nef HM, Mollmann H, et al. Stress cardiomyopathy. Annu Rev Med 2011; 61: 271-286.

66 de Rooij NK, Linn FH, van der Plas JA, et al. Incidence of subarachnoid haemorrhage: A systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry 2007; 78: 1365-1372.

67 Kurisu S, Inoue I, Kawagoe T, et al. Presentation of tako-tsubo cardiomyopathy in men and women. Clin Cardiol 2010; 33: 42-45.

68 Hurst RT, Askew JW, Reuss CS, et al. Transient midventricular ballooning syndrome: A new variant. J Am Coll Cardiol 2006; 48: 579-583.

69 Reuss CS, Lester SJ, Hurst RT, et al. Isolated left ventricular basal ballooning phenotype of transient cardiomyopathy in young women. Am J Cardiol 2007; 99: 1451-1453.

70 Mansencal N, El Mahmoud R, Pilliere R, et al. Relationship between pattern of tako-tsubo cardiomyopathy and age: From midventricular to apical ballooning syndrome. Int J Cardiol 2010; 138: E18-E20.

71 From AM, Sandhu GS, Nkomo VT, et al. Apical ballooning syndrome (takotsubo cardiomyopathy) presenting with typical left ventricular morphology at initial presentation and mid-ventricular variant during a recurrence. J Am Coll Cardiol 2011; 58: E1.

72 He XR, Wang W, Crofton JT, et al. Effects of 17 beta-estradiol on the baroreflex control of sympathetic activity in conscious ovariectomized rats. Am J Physiol 1999; 277: R493-R498.

73 Komesaroff PA, Esler MD, Sudhir K. Estrogen supplementation attenuates glucocorticoid and catecholamine responses to mental stress in perimenopausal women. J Clin Endocrinol Metab 1999; 84: 606-610.

74 Vongpatanasin W, Tuncel M, Mansour Y, et al. Transdermal estrogen replacement therapy decreases sympathetic activity in postmenopausal women. Circulation 2001; 103: 2903-2908.

75 Ueyama T, Kasamatsu K, Hano T, et al. Catecholamines and estrogen are involved in the pathogenesis of emotional stress-induced acute heart attack. Ann N Y Acad Sci 2008; 1148: 479-485.

76 Chambliss KL, Shaul PW. Estrogen modulation of endothelial nitric oxide synthase. Endocr Rev 2002; 23: 665-686.