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Takotsubo Cardiomyopathy: Its Various Triggers

      To the Editor:
      We thank Aggarwal and Krantz
      • Aggarwal V.
      • Krantz M.J.
      Migratory takotsubo cardiomyopathy in the setting of cholecystitis.
      for their article entitled “Migratory Takotsubo Cardiomyopathy in the Setting of Cholecystitis,” which was published in The American Journal of Medicine. The authors discussed a unique trigger that has never been reported. We recently found 2 other interesting cases of takotsubo cardiomyopathy.
      The first case was a 73-year-old woman with hypertension who presented to the emergency department after an episode of choking, and subsequently developed chest discomfort. Serial electrocardiography revealed evolution of biphasic T-wave in leads V1-V2 with elevated troponin-T of 0.37 ng/mL. Cardiac catheterization was performed, which showed mid-anterior wall hypokinesis with left ventricular ejection fraction of 45% but normal coronary arteries. She was medically treated for takotsubo cardiomyopathy. Repeated echocardiogram 3 days after the procedure revealed improved ejection fraction of 55% with normalized left ventricular wall motion.
      The second case was of a 45-year-old healthy man who presented with persistent chest pain that developed after an altercation with his work colleague. Initial electrocardiogram revealed J-point elevation in anterolateral leads. Given those electrocardiographic findings along with unremitting symptoms, the patient underwent cardiac catheterization, which showed completely normal coronary arteries and severe ventricular systolic dysfunction, with only anterobasal and posterobasal contracting, compatible with takotsubo cardiomyopathy.
      Takotsubo cardiomyopathy or stress-induced cardiomyopathy can be precipitated by sudden and unexpected physical or emotional stress. With increased recognition, these cases with various trigger factors have been reported.
      • Akashi Y.J.
      • Goldstein D.S.
      • Barbaro G.
      • Ueyama T.
      Takotsubo cardiomyopathy: a new form of acute, reversible heart failure.
      In real practice, the clinical manifestations of takotsubo cardiomyopathy may mimic acute coronary syndrome or be misdiagnosed as other psychological conditions such as panic attack or hyperventilation syndrome. One should keep this condition in mind because its favorable outcome is likely with proper medical treatment.
      • Akashi Y.J.
      • Goldstein D.S.
      • Barbaro G.
      • Ueyama T.
      Takotsubo cardiomyopathy: a new form of acute, reversible heart failure.

      References

        • Aggarwal V.
        • Krantz M.J.
        Migratory takotsubo cardiomyopathy in the setting of cholecystitis.
        Am J Med. 2012; 125: e5-e6
        • Akashi Y.J.
        • Goldstein D.S.
        • Barbaro G.
        • Ueyama T.
        Takotsubo cardiomyopathy: a new form of acute, reversible heart failure.
        Circulation. 2008; 118: 2754-2762

      Linked Article

      • Migratory Takotsubo Cardiomyopathy in the Setting of Cholecystitis
        The American Journal of MedicineVol. 125Issue 12
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          Stress-related cardiomyopathy is a clinical disorder mimicking an acute coronary syndrome. It is defined by the presence of a focal reversible wall-motion abnormality and the absence of obstructive coronary artery disease.1 Stress-related cardiomyopathy often presents with transient “ballooning” of the left ventricular apex, the so-called takotsubo cardiomyopathy. However, involvement of multiple myocardial regions has never been described. We report a case of stress-related cardiomyopathy associated with cholecystitis, sequentially involving different myocardial territories and resolving after cholecystectomy.
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      • The Reply
        The American Journal of MedicineVol. 126Issue 7
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          We thank Temtanakitpaisan et al for their interest in our article on reversible myocardial dysfunction in acute cholecystitis.1 As mentioned, reversible myocardial dysfunction can be precipitated by a variety of stressors, ranging from acute medical illness to emotional or physical stress (Table 1). Of note, reversible myocardial dysfunction has been described in the literature for more than 4 decades, but its pathogenesis remains poorly understood.2 It is not known why this disorder is more common in postmenopausal women, and only recently has the predilection for specific myocardial territories (eg, the left ventricular apex) been elucidated.
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