Stress cardiomyopathy overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2] Arzu Kalayci, M.D. [3]
Overview
Stress cardiomyopathy is a relatively new disease, with the first case documented in literature under the name of Takotsobu Cardiomyopathy in Japan in 1991. It is not very well understood, but the disease is thought to arise following intense emotional or physical stress. Stress cardiomyopathy mostly affects post-menopausal women. The clinical presentation, laboratory findings and imaging studies largely mimic that of anterior MI. However, the absence of significant coronary artery stenosis supports the diagnosis of stress cardiomyopathy. It is generally a self-limiting disease and the majority of patients have a restored cardiac function within a matter of weeks. Complications and death are relatively rare, but they are mostly related to the development of heart failure and pulmonary edema.
Historical Perspective
Stress cardiomyopathy is a relatively new disease, with the first case documented in literature in Japan in 1991. However, cases of death upon going through severe emotional or psychological stress have been described as early as the biblical times.[1][2]
Classification
Stress cardiomyopathy can be divided into several types, depending on the location of regional wall motion abnormality. The area of motion abnormality (whether hypokinesia, dyskinesia or akinesia) can be detected on echocardiography or left ventriculography. The most common type is the apical type, resulting in apical ballooning.[3][4][5][6]
Pathophysiology
The pathogenesis of stress cardiomyopathy is not completely understood. However, the most accepted theory behind it is thought to be due to catecholamine surge, which are thought to contribute to myocardial necrosis and stunning seen in stress cardiomyopathy.[2][7][8] On biopsy, findings include an inflammatory infiltrate, fibrosis and formation of contraction bands, which may or may not be associated with myocardial necrosis.[9][10] Stress cardiomyopathy is associated with various neurological and psychological conditions.
Causes
The cause of stress cardiomyopathy is largely unknown. However, it is usually triggered by emotional and/or physical stress and may be related to certain medical conditions.
Differentiating Stress Cardiomyopathy from Other Diseases
The clinical presentation, laboratory findings and imaging studies of stress cardiomyopathy resembles that of anterior MI and must be differentiated from it. Also, stress cardiomyopathy must be differentiated from other medical conditions, such as pheochromocytoma, dilated cardiomyopathy and hypertrophic cardiomyopathy.[11][12]
Epidemiology and Demographics
The true incidence and prevalence of stress cardiomyopathy is unknown. However, this disease most commonly affects post-menopausal women, with the mean age of diagnosis ranging between 58-75 years.[2][3][1][13][14]
Risk Factors
Stress cardiomyopathy seems to be triggered by intense emotional or physical stress, mostly the unexpected death of a loved one.[2]
Screening
There are no screening recommendations for stress cardiomyopathy.[15]
Natural History, Complications and Prognosis
The prognosis of stress cardiomyopathy is generally excellent, with most patients making a complete recovery within a matter of weeks. However, death from complications of heart failure and heart rupture may occur.[2][13][16]
Diagnostic Criteria
In 2004, researchers at the Mayo Clinic proposed a criteria for the diagnosis of stress cardiomyopathy. All 4 points of the criteria must be fulfilled, which include ruling out other medical conditions, such as obstructive coronary disease, myocarditis and pheochromocytoma.[13][2]
History and Symptoms
The most common presenting symptoms of stress cardiomyopathy are shortness of breath and chest pain.[2][10][13][14][3][17]
Physical Examination
Physical examination findings in patients with stress cardiomyopathy are non-specific and non-diagnostic. The diagnosis of stress cardiomyopathy is largely based on ECG, echocardiographic findings, as well as cardiac catheterization.[18]
Laboratory Findings
Elevated levels of catecholamines, cardiac enzymes and BNP may be seen in patients with stress cardiomyopathy. However, none of these laboratory findings are specific to stress cardiomyopathy.[2][10][14][17]
ECG
ECG findings in stress cardiomyopathy are similar to those seen in anterior MI. The most common findings include ST elevation in the precordial leads, T wave inversion and the formation of a Q wave.[19][2] Findings on ECG include:[2][10][13][16][14][3][17]
Chest X-Ray
Typical findings on chest x-ray include apical ballooning and narrowing of the neck.
CT Scan
A CT scan may be done in patients with stress cardiomyopathy to asses coronary anatomy, as well as detect the presence of regional wall motion abnormalities.[17]
MRI
Cardiac magnetic resonance (CMR) is a useful imaging modality in distinguishing between stress cardiomyopathy and myocarditis or MI. The most common findings on CMR in patients with stress cardiomyopathy include absence of gadolinium hyper-enhancement, as well as myocardial edema.[13][20][21][22][23][24][25][26][27][5][28]
Echocardiography
Echocardiography is done in patients with stress cardiomyopathy to document apical ballooning, dyskinesia/akinesia and reduced ejection fraction.[10][13][16][17]
Other Imaging Findings
In patients with stress cardiomyopathy, coronary angiography usually shows normal anatomy of the coronary arteries no evidence of coronary artery stenosis.[2][14][17]
Other Diagnostic Studies
Coronary angiography and cardiac catheterization are the diagnostic modalities of choice to distinguish between stress cardiomyopathy and acute anterior MI. Normal anatomy of the coronary arteries, along with a reduced ejection fraction supports the diagnosis of stress cardiomyopathy.[10][16][14]
Medical Therapy
Medical therapy in stress cardiomyopathy is indicated to treat the complications that may arise. The most common complications related to stress cardiomyopathy include heart failure and pulmonary edema. Diuretics and anti-heart failure medications are the treatment of choice in these conditions.[1][10]
Surgery
Treatment of stress cardiomyopathy is mostly supportive and medications are used to treat complications.[1][10] There is no role for surgery in the treatment of stress cardiomyopathy.
Primary Prevention
There are no means of prevention of stress cardiomyopathy.
Secondary Prevention
Stress cardiomyopathy is a self-limiting disease, which usually resolves within a few weeks. However, medical therapy may be necessary during the acute phase of the illness or when complications arise.[1][10]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Omerovic E (2011). "How to think about stress-induced cardiomyopathy?--Think "out of the box"!". Scand. Cardiovasc. J. 45 (2): 67–71. doi:10.3109/14017431.2011.565794. PMID 21401402.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Akashi YJ, Goldstein DS, Barbaro G, Ueyama T (2008). "Takotsubo cardiomyopathy: a new form of acute, reversible heart failure". Circulation. 118 (25): 2754–62. doi:10.1161/CIRCULATIONAHA.108.767012. PMC 4893309. PMID 19106400.
- ↑ 3.0 3.1 3.2 3.3 Templin C, Ghadri JR, Diekmann J, Napp LC, Bataiosu DR, Jaguszewski M, Cammann VL, Sarcon A, Geyer V, Neumann CA, Seifert B, Hellermann J, Schwyzer M, Eisenhardt K, Jenewein J, Franke J, Katus HA, Burgdorf C, Schunkert H, Moeller C, Thiele H, Bauersachs J, Tschöpe C, Schultheiss HP, Laney CA, Rajan L, Michels G, Pfister R, Ukena C, Böhm M, Erbel R, Cuneo A, Kuck KH, Jacobshagen C, Hasenfuss G, Karakas M, Koenig W, Rottbauer W, Said SM, Braun-Dullaeus RC, Cuculi F, Banning A, Fischer TA, Vasankari T, Airaksinen KE, Fijalkowski M, Rynkiewicz A, Pawlak M, Opolski G, Dworakowski R, MacCarthy P, Kaiser C, Osswald S, Galiuto L, Crea F, Dichtl W, Franz WM, Empen K, Felix SB, Delmas C, Lairez O, Erne P, Bax JJ, Ford I, Ruschitzka F, Prasad A, Lüscher TF (2015). "Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy". N. Engl. J. Med. 373 (10): 929–38. doi:10.1056/NEJMoa1406761. PMID 26332547.
- ↑ Kurowski V, Kaiser A, von Hof K, Killermann DP, Mayer B, Hartmann F, Schunkert H, Radke PW (2007). "Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): frequency, mechanisms, and prognosis". Chest. 132 (3): 809–16. doi:10.1378/chest.07-0608. PMID 17573507.
- ↑ 5.0 5.1 Eitel I, von Knobelsdorff-Brenkenhoff F, Bernhardt P, Carbone I, Muellerleile K, Aldrovandi A, Francone M, Desch S, Gutberlet M, Strohm O, Schuler G, Schulz-Menger J, Thiele H, Friedrich MG (2011). "Clinical characteristics and cardiovascular magnetic resonance findings in stress (takotsubo) cardiomyopathy". JAMA. 306 (3): 277–86. doi:10.1001/jama.2011.992. PMID 21771988.
- ↑ Win CM, Pathak A, Guglin M (2011). "Not takotsubo: a different form of stress-induced cardiomyopathy--a case series". Congest Heart Fail. 17 (1): 38–41. doi:10.1111/j.1751-7133.2010.00195.x. PMID 21272226.
- ↑ Goico A, Chandrasekaran M, Herrera CJ (2016). "Novel developments in stress cardiomyopathy: From pathophysiology to prognosis". Int. J. Cardiol. 223: 1053–1058. doi:10.1016/j.ijcard.2016.08.241. PMID 27611570.
- ↑ Testa M, Feola M (2014). "Usefulness of myocardial positron emission tomography/nuclear imaging in Takotsubo cardiomyopathy". World J Radiol. 6 (7): 502–6. doi:10.4329/wjr.v6.i7.502. PMC 4109102. PMID 25071891.
- ↑ Akashi YJ, Goldstein DS, Barbaro G, Ueyama T (2008). "Takotsubo cardiomyopathy: a new form of acute, reversible heart failure". Circulation. 118 (25): 2754–62. doi:10.1161/CIRCULATIONAHA.108.767012. PMC 4893309. PMID 19106400.
- ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 Brenner ZR, Powers J (2008). "Takotsubo cardiomyopathy". Heart Lung. 37 (1): 1–7. doi:10.1016/j.hrtlng.2006.12.003. PMID 18206521.
- ↑ Parodi G, Del Pace S, Carrabba N, Salvadori C, Memisha G, Simonetti I, Antoniucci D, Gensini GF (2007). "Incidence, clinical findings, and outcome of women with left ventricular apical ballooning syndrome". Am. J. Cardiol. 99 (2): 182–5. doi:10.1016/j.amjcard.2006.07.080. PMID 17223415.
- ↑ Mikail N, Hess S, Jesel L, El Ghannudi S, El Husseini Z, Trinh A, Ohlmann P, Morel O, Imperiale A (2013). "Takotsubo and Takotsubo-like syndrome: a common neurogenic myocardial stunning pathway?". Int. J. Cardiol. 166 (1): 248–50. doi:10.1016/j.ijcard.2012.09.116. PMID 23058349.
- ↑ 13.0 13.1 13.2 13.3 13.4 13.5 13.6 Prasad A, Lerman A, Rihal CS (2008). "Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction". Am. Heart J. 155 (3): 408–17. doi:10.1016/j.ahj.2007.11.008. PMID 18294473.
- ↑ 14.0 14.1 14.2 14.3 14.4 14.5 Bybee KA, Prasad A, Barsness GW, Lerman A, Jaffe AS, Murphy JG, Wright RS, Rihal CS (2004). "Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome". Am. J. Cardiol. 94 (3): 343–6. doi:10.1016/j.amjcard.2004.04.030. PMID 15276100.
- ↑ U.S. Preventive Services Task Force https://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=stress+cardiomyopathy. Accessed on Jan 9, 2017.
- ↑ 16.0 16.1 16.2 16.3 Tsai TT, Nallamothu BK, Prasad A, Saint S, Bates ER (2009). "Clinical problem-solving. A change of heart". N. Engl. J. Med. 361 (10): 1010–6. doi:10.1056/NEJMcps0903023. PMID 19726776.
- ↑ 17.0 17.1 17.2 17.3 17.4 17.5 Efferth T, Banerjee M, Paul NW (2016). "Broken heart, tako-tsubo or stress cardiomyopathy? Metaphors, meanings and their medical impact". Int. J. Cardiol. doi:10.1016/j.ijcard.2016.12.129. PMID 28041712.
- ↑ Y-Hassan S, Yamasaki K (2013). "History of takotsubo syndrome: is the syndrome really described as a disease entity first in 1990? Some inaccuracies". Int. J. Cardiol. 166 (3): 736–7. doi:10.1016/j.ijcard.2012.09.183. PMID 23073280.
- ↑ Bybee KA, Motiei A, Syed IS, Kara T, Prasad A, Lennon RJ, Murphy JG, Hammill SC, Rihal CS, Wright RS (2006). "Electrocardiography cannot reliably differentiate transient left ventricular apical ballooning syndrome from anterior ST-segment elevation myocardial infarction". J Electrocardiol. PMID 17067626.
- ↑ Sharkey SW, Lesser JR, Zenovich AG, Maron MS, Lindberg J, Longe TF, Maron BJ (2005). "Acute and reversible cardiomyopathy provoked by stress in women from the United States". Circulation. 111 (4): 472–9. doi:10.1161/01.CIR.0000153801.51470.EB. PMID 15687136.
- ↑ Haghi D, Fluechter S, Suselbeck T, Kaden JJ, Borggrefe M, Papavassiliu T (2007). "Cardiovascular magnetic resonance findings in typical versus atypical forms of the acute apical ballooning syndrome (Takotsubo cardiomyopathy)". Int. J. Cardiol. 120 (2): 205–11. doi:10.1016/j.ijcard.2006.09.019. PMID 17175045.
- ↑ Mitchell JH, Hadden TB, Wilson JM, Achari A, Muthupillai R, Flamm SD (2007). "Clinical features and usefulness of cardiac magnetic resonance imaging in assessing myocardial viability and prognosis in Takotsubo cardiomyopathy (transient left ventricular apical ballooning syndrome)". Am. J. Cardiol. 100 (2): 296–301. doi:10.1016/j.amjcard.2007.02.091. PMID 17631086.
- ↑ Deetjen AG, Conradi G, Mollmann S, Rad A, Hamm CW, Dill T (2006). "Value of gadolinium-enhanced magnetic resonance imaging in patients with Tako-Tsubo-like left ventricular dysfunction". J Cardiovasc Magn Reson. 8 (2): 367–72. PMID 16669180.
- ↑ Abe Y, Kondo M, Matsuoka R, Araki M, Dohyama K, Tanio H (2003). "Assessment of clinical features in transient left ventricular apical ballooning". J. Am. Coll. Cardiol. 41 (5): 737–42. PMID 12628715.
- ↑ Dec GW (2005). "Recognition of the apical ballooning syndrome in the United States". Circulation. 111 (4): 388–90. doi:10.1161/01.CIR.0000155234.69439.E4. PMID 15687123.
- ↑ Handy AD, Prasad A, Olson TM (2009). "Investigating genetic variation of adrenergic receptors in familial stress cardiomyopathy (apical ballooning syndrome)". J Cardiol. 54 (3): 516–7. doi:10.1016/j.jjcc.2009.08.008. PMID 19944334.
- ↑ Sharkey SW, Maron BJ, Nelson P, Parpart M, Maron MS, Bristow MR (2009). "Adrenergic receptor polymorphisms in patients with stress (tako-tsubo) cardiomyopathy". J Cardiol. 53 (1): 53–7. doi:10.1016/j.jjcc.2008.08.006. PMID 19167638.
- ↑ Eitel I, Behrendt F, Schindler K, Kivelitz D, Gutberlet M, Schuler G, Thiele H (2008). "Differential diagnosis of suspected apical ballooning syndrome using contrast-enhanced magnetic resonance imaging". Eur. Heart J. 29 (21): 2651–9. doi:10.1093/eurheartj/ehn433. PMID 18820322.