Study Provides New Insight Into Stress Cardiomyopathy

July 20, 2011

July 19, 2011 (Leipzig, Germany) — A multicenter trial in more than 200 patients provides new insight into stress cardiomyopathy, also known as takotsubo cardiomyopathy or broken-heart syndrome [1].

"We show that the clinical profile is much broader than previously thought, where stress cardiomyopathy was typically described in older, postmenopausal women. We also have a significant portion of male patients and some younger female patients," lead author Dr Ingo Eitel (University of Leipzig Heart Center, Germany) told heartwire . Eitel and colleagues also demonstrate--again in contrast to prior work--that stress cardiomyopathy does not always appear to have an identifiable stressful trigger, in their paper published in the Journal of the American Medical Association.

"If you do an MRI in the acute phase, you can distinguish between other entities with a similar clinical presentation."

They also show that cardiac magnetic resonance imaging (MRI) "is very valuable in patients with suspected stress cardiomyopathy," Eitel says. "If you do an MRI in the acute phase, you can distinguish between other entities with a similar clinical presentation, such as acute myocardial infarction or myocarditis."

Data From Large, Multicenter Population Sheds Light on Condition

Stress cardiomyopathy was first described in the US literature about 10 years ago by Japanese authors who described a novel heart syndrome that mimicks acute myocardial infarction, which they called tako-tsubo cardiomyopathy. Tako-tsubo is Japanese for octopus trap, so-called because of the peculiar appearance of the left ventricle seen on an echocardiogram in these patients, which also led to the name apical ballooning syndrome.

Patients who suffer from stress cardiomyopathy are unusual in that they are previously healthy and generally have no evidence of any coronary heart disease. The condition was thought to be almost exclusively triggered by emotional shocks, with patients going on to develop life-threatening--but thankfully reversible--cardiomyopathies.

However, Eitel and colleagues say that the various aspects of the clinical profile of stress cardiomyopathy have been described from small, single-center populations, and large, multicenter datasets have so far been lacking.

Thus, they set out to comprehensively define the clinical spectrum and evolution of stress cardiomyopathy in a large population; they prospectively studied 256 patients with stress cardiomyopathy at time of presentation at seven tertiary care centers in Europe and North America. The individuals were also evaluated one to six months after the acute event. The main outcome was complete recovery of left ventricular (LV) dysfunction.

Absence of Stressful Trigger Should Not Rule Out Stress Cardiomyopathy

The researchers found that although 81% of patients were postmenopausal women, 8% were younger women and 11% were men, illustrating "a considerably broader clinical profile than previously reported."

And even with careful history taking, just over two-thirds of cases (71%) had a clearly identifiable prior stressful event, say Eitel and colleagues, in contrast to previous reports, in which almost 90% of individuals have been documented as having a preceding emotional or physical trigger.

"It would seem inappropriate to assume a common trigger among all stress cardiomyopathy patients; the absence of an identifiable stressful event does not rule out the diagnosis."

"Thus our large multicenter cohort demonstrates that the absence of an identifiable stressful event does not rule out the diagnosis," they observe. "It would therefore seem inappropriate to assume a common trigger among all stress cardiomyopathy patients."

They note that their study is also the largest cardiovascular MRI imaging series of stress cardiomyopathy to date, and they found that the condition was accurately identified using specific criteria: a typical pattern of LV dysfunction, myocardial edema, absence of significant necrosis/fibrosis, and markers of myocardial inflammation.

However, Eitel cautions that more research is needed to verify this. "Our study is a large one, and multicenter, but the disease is rare and we just need more patients to confirm our data," he observes.

Biventricular Ballooning on MRI May Portend More Serious Disease

Cardiovascular MRI data were available for 239 patients (93%) and revealed four distinct patterns of regional ventricular ballooning: apical (82%), biventricular (34%), midventricular (17%), and basal (1%).

The authors note that those individuals with right ventricular (RV) involvement were more likely to be older, hospitalized for longer, and have markers of heart failure, so they suggest that biventricular ballooning on MRI "may portend a longer and more severe course of disease compared with patients with isolated LV involvement."

Doctors should therefore be aware of the possibility of RV dysfunction "because it might have a significant effect on patient morbidity, treatment, and outcome," they advise.

On follow-up MRI, they found complete normalization of LV ejection fraction (66%) and inflammatory markers in the absence of significant fibrosis in all patients.

Senior author Matthias G Friedrich is a shareholder and consultant to Circle Cardiovascular Imaging Inc. No other disclosures are reported.


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