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Coronary flow reserve assessment via invasive and noninvasive means in Takotsubo cardiomyopathy
International Journal of Cardiology 202 (2016) 573
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Coronary flow reserve assessment via invasive and noninvasive means in Takotsubo cardiomyopathy☆ Nauman Khalid a,⁎, Sarah Aftab Ahmad b, Affan Umer c a b c
Department of Cardiovascular Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA Department of Cardiovascular Medicine, Texas Tech University Health Science Center, Lubbock, TX, USA Department of Cardiovascular Medicine, Saint Francis Hospital, Hartford, CT, USA
a r t i c l e
i n f o
Article history: Received 5 September 2015 Accepted 24 September 2015 Available online 28 September 2015 Keywords: Takotsubo cardiomyopathy Microvascular dysfunction Microcirculatory disorder TIMI frame count Coronary flow reserve Takotsubo cardiomyopathy and diabetes mellitus
Secondly authors describe a lower incidence of diabetes in TTC patients which has been shown in other studies and in our cohort as well. Since catecholamine surge plays a key role in Takotsubo cardiomyopathy, it may be plausible to expect that the autonomic neuropathy and resultant decreased catecholamine secretion among diabetics may portend a protective effect against the evolution of TTC [9]. Finally authors describe the interrelationship between viral myopericarditis and TTC which is an increasingly recognized phenomenon and merits a review of the outmoded diagnostic criteria of Takotsubo cardiomyopathy [10]. We appreciate the valuable insights provided by Chhabra et al. and hope that a larger prospective study addressing these questions will strengthen our understanding on this subject.
Conflict of interest To the Editor: We acknowledge with great interest the excellent observations by Chhabra et al. [1] regarding our article in the recent issue of International Journal of Cardiology entitled “Thrombolysis in myocardial infarction (TIMI) frame count (TFC) in Takotsubo cardiomyopathy (TTC)” [2,3]. The authors have raised a few important points. Microvascular dysfunction or decreased coronary flow reserve (CFR) is a well described entity especially in the subacute phase of Takotsubo cardiomyopathy [4,5]. Whether it is the causative factor or a consequence of this disorder still remains elusive. Previous studies have shown this by utilizing noninvasive or invasive means such as Doppler transthoracic echocardiography [6] or adenosine testing [7] for assessment of CFR in such patients. These cohorts have demonstrated impairment of microvascular dysfunction early in the course of the disease with recovery noted in few weeks to months. A recent study comprising of 22 patients has shown statistically significant reduction in CFR at a low dose dobutamine (10 μg/kg/min) based stress testing in TTC group when compared with controls [8]. We agree with the authors that the modest reduction in TIMI frame counts may suggest only a small contribution from microcirculatory disorder, nevertheless, it still remains one of the strong contenders and an emerging causative factor in the development of Takotsubo syndrome. ☆ Funding: None ⁎ Corresponding author at: 3660 Vista Ave, St. Louis, MO 63110, USA. E-mail address: [email protected] (N. Khalid).
http://dx.doi.org/10.1016/j.ijcard.2015.09.109 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
None.
References [1] L. Chhabra, P. Sareen, Takotsubo cardiomyopathy and microvascular dysfunction, Int. J. Cardiol. 196 (2015) 107. [2] N. Khalid, I. Iqbal, R. Coram, T. Raza, I. Fahsah, S. Ikram, Thrombolysis in myocardial infarction frame count in Takotsubo cardiomyopathy, Int. J. Cardiol. 191 (2015) 107–108. [3] N. Khalid, I. Iqbal, S. Ikram, Thrombolysis in myocardial infarction frame count in Takotsubo cardiomyopathy, J. Am. Coll. Cardiol. 61 (10_S) (2013). [4] N. Khalid, Microcirculatory disorder hypothesis in Takotsubo cardiomyopathy, Int. J. Cardiol. 195 (2015) 29. [5] N. Khalid, S. Ikram, Coronary flow assessment in Takotsubo cardiomyopathy with TIMI frame count, Int. J. Cardiol. 197 (2015) 208. [6] P. Meimoun, D. Malaquin, S. Sayah, et al., The coronary flow reserve is transiently impaired in tako-tsubo cardiomyopathy: a prospective study using serial Doppler transthoracic echocardiography, J. Am. Soc. Echocardiogr. 21 (2008) 72–77. [7] T. Kume, T. Akasaka, T. Kawamoto, et al., Assessment of coronary microcirculation in patients with takotsubo-like left ventricular dysfunction, Circ. J. 69 (2005) 934–939. [8] O. Collste, P. Tornvall, M. Alam, M. Frick, Coronary flow reserve during dobutamine stress in Takotsubo stress cardiomyopathy, BMJ Open 5 (5) (2015) e007671. [9] N. Khalid, S.A. Ahmad, A. Umer, L. Chhabra, Role of microcirculatory disturbances and diabetic autonomic neuropathy in Takotsubo cardiomyopathy, Crit. Care Med. 43 (11) (2015) e527. [10] L. Chhabra, N. Khalid, J. Kluger, D.H. Spodick, Lupus myopericarditis as a preceding stressor for takotsubo cardiomyopathy, Proc. (Bayl. Univ. Med. Cent.) 27 (2014) 327–330.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Coronary flow reserve assessment via invasive and noninvasive means in Takotsubo cardiomyopathy☆ Nauman Khalid a,⁎, Sarah Aftab Ahmad b, Affan Umer c a b c
Department of Cardiovascular Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA Department of Cardiovascular Medicine, Texas Tech University Health Science Center, Lubbock, TX, USA Department of Cardiovascular Medicine, Saint Francis Hospital, Hartford, CT, USA
a r t i c l e
i n f o
Article history: Received 5 September 2015 Accepted 24 September 2015 Available online 28 September 2015 Keywords: Takotsubo cardiomyopathy Microvascular dysfunction Microcirculatory disorder TIMI frame count Coronary flow reserve Takotsubo cardiomyopathy and diabetes mellitus
Secondly authors describe a lower incidence of diabetes in TTC patients which has been shown in other studies and in our cohort as well. Since catecholamine surge plays a key role in Takotsubo cardiomyopathy, it may be plausible to expect that the autonomic neuropathy and resultant decreased catecholamine secretion among diabetics may portend a protective effect against the evolution of TTC [9]. Finally authors describe the interrelationship between viral myopericarditis and TTC which is an increasingly recognized phenomenon and merits a review of the outmoded diagnostic criteria of Takotsubo cardiomyopathy [10]. We appreciate the valuable insights provided by Chhabra et al. and hope that a larger prospective study addressing these questions will strengthen our understanding on this subject.
Conflict of interest To the Editor: We acknowledge with great interest the excellent observations by Chhabra et al. [1] regarding our article in the recent issue of International Journal of Cardiology entitled “Thrombolysis in myocardial infarction (TIMI) frame count (TFC) in Takotsubo cardiomyopathy (TTC)” [2,3]. The authors have raised a few important points. Microvascular dysfunction or decreased coronary flow reserve (CFR) is a well described entity especially in the subacute phase of Takotsubo cardiomyopathy [4,5]. Whether it is the causative factor or a consequence of this disorder still remains elusive. Previous studies have shown this by utilizing noninvasive or invasive means such as Doppler transthoracic echocardiography [6] or adenosine testing [7] for assessment of CFR in such patients. These cohorts have demonstrated impairment of microvascular dysfunction early in the course of the disease with recovery noted in few weeks to months. A recent study comprising of 22 patients has shown statistically significant reduction in CFR at a low dose dobutamine (10 μg/kg/min) based stress testing in TTC group when compared with controls [8]. We agree with the authors that the modest reduction in TIMI frame counts may suggest only a small contribution from microcirculatory disorder, nevertheless, it still remains one of the strong contenders and an emerging causative factor in the development of Takotsubo syndrome. ☆ Funding: None ⁎ Corresponding author at: 3660 Vista Ave, St. Louis, MO 63110, USA. E-mail address: [email protected] (N. Khalid).
http://dx.doi.org/10.1016/j.ijcard.2015.09.109 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
None.
References [1] L. Chhabra, P. Sareen, Takotsubo cardiomyopathy and microvascular dysfunction, Int. J. Cardiol. 196 (2015) 107. [2] N. Khalid, I. Iqbal, R. Coram, T. Raza, I. Fahsah, S. Ikram, Thrombolysis in myocardial infarction frame count in Takotsubo cardiomyopathy, Int. J. Cardiol. 191 (2015) 107–108. [3] N. Khalid, I. Iqbal, S. Ikram, Thrombolysis in myocardial infarction frame count in Takotsubo cardiomyopathy, J. Am. Coll. Cardiol. 61 (10_S) (2013). [4] N. Khalid, Microcirculatory disorder hypothesis in Takotsubo cardiomyopathy, Int. J. Cardiol. 195 (2015) 29. [5] N. Khalid, S. Ikram, Coronary flow assessment in Takotsubo cardiomyopathy with TIMI frame count, Int. J. Cardiol. 197 (2015) 208. [6] P. Meimoun, D. Malaquin, S. Sayah, et al., The coronary flow reserve is transiently impaired in tako-tsubo cardiomyopathy: a prospective study using serial Doppler transthoracic echocardiography, J. Am. Soc. Echocardiogr. 21 (2008) 72–77. [7] T. Kume, T. Akasaka, T. Kawamoto, et al., Assessment of coronary microcirculation in patients with takotsubo-like left ventricular dysfunction, Circ. J. 69 (2005) 934–939. [8] O. Collste, P. Tornvall, M. Alam, M. Frick, Coronary flow reserve during dobutamine stress in Takotsubo stress cardiomyopathy, BMJ Open 5 (5) (2015) e007671. [9] N. Khalid, S.A. Ahmad, A. Umer, L. Chhabra, Role of microcirculatory disturbances and diabetic autonomic neuropathy in Takotsubo cardiomyopathy, Crit. Care Med. 43 (11) (2015) e527. [10] L. Chhabra, N. Khalid, J. Kluger, D.H. Spodick, Lupus myopericarditis as a preceding stressor for takotsubo cardiomyopathy, Proc. (Bayl. Univ. Med. Cent.) 27 (2014) 327–330.