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Pheochromocytoma: Still an exclusion criterion for Tako-tsubo cardiomyopathy diagnosis?
International Journal of Cardiology 201 (2015) 32
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Pheochromocytoma: Still an exclusion criterion for Tako-tsubo cardiomyopathy diagnosis? Francesco Santoro, Armando Ferraretti, Nicola Tarantino, Matteo Di Biase, Natale Daniele Brunetti ⁎ University of Foggia, Cardiology Department, Foggia, Italy
a r t i c l e
i n f o
Article history: Received 16 July 2015 Accepted 1 August 2015 Available online 5 August 2015 Keywords: Takotsubo cardiomyopathy Pheochromocytoma Catecholamine Exclusion criteria
The evidence not only further confirms the role of catecholamines toxicity in TTC, but also remarks the concept that pheochromocytoma is at least one of the numerous comorbidities described in TTC patients: malignancies (10%), neurologic diseases (7%), chronic kidney disease (7%) and thyroid diseases (6%) [8]. Probably, it's time not only to exclude pheochromocytoma from exclusion criteria of TTC diagnosis, but, furthermore, to include this disease among typical comorbidities in TTC, more common in a specific subset of patients such as, probably, younger and/or male. Further studies, however, are warranted to better address this issue. Conflict of interest The authors have no potential conflict of interest to disclose.
In a recent article by Sharkey et al. [1], two patients with pheochromocytoma developed an episode of Takotsubo cardiomyopathy (TTC); rightly, episodes were related to increased circulating levels of catecholamines characteristic of pheochromocytoma. Although direct catecholamine effect on myocardium is considered as one of the main drivers of TTC onset, the pathophysiology of this cardiomyopathy is still unclear [2]. Several algorithms have been proposed for the diagnosis of TTC, and, exclusion criteria are still matter of debate. According to Prasad et al., a diagnosis of TTC should not be done in the presence of myocarditis and/or pheochromocytoma [3], while the Tako-tsubo Italian Network's included only myocarditis among exclusion criteria [4]. Agarwal et al., however, reported on 38 patients with TTC due to pheochromocytoma; all such patients had increased circulating levels of catecholamines, were younger than other patients with TTC, and were characterized by higher rates of complications as cardiogenic shock and heart failure [5]. In our multicenter registry enrolling 190 consecutive patients with TTC, 2 patients (a 17-year-od girl, and a 23-year-old man) had pheochromocytoma with raised circulating levels of catecholamines. The girl presented with a hypertensive crisis successfully managed by the use of a selective beta-1-adrenergic blocker (esmolol) associated with an alpha-blocker (doxazosin) [6], the other with severe left ventricular dysfunction which recovered after levosimendan infusion [7]. ⁎ Corresponding author at: Viale Pinto 1, 71100 Foggia, Italy. Tel.: +39 3389112358; fax: +39 0881745424. E-mail address: [email protected] (N.D. Brunetti).
http://dx.doi.org/10.1016/j.ijcard.2015.08.011 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
References [1] S.W. Sharkey, N. McAllister, D. Dassenko, D. Lin, K. Han, B.J. Maron, Evidence that high catecholamine levels produced by pheochromocytoma may be responsible for Tako-tsubo cardiomyopathy, Am. J. Cardiol. 115 (2015) 1615–1618. [2] I.S. Wittstein, D.R. Thiemann, J.A. Lima, K.L. Baughman, S.P. Schulman, G. Gerstenblith, K.C. Wu, J.J. Rade, T.J. Bivalacqua, H.C. Champion, Neurohumoral features of myocardial stunning due to sudden emotional stress, N. Engl. J. Med. 352 (2005) 539–548. [3] A. Prasad, A. Lerman, C.S. Rihal, Apical ballooning syndrome (Tako-tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction, Am. Heart J. 155 (2008) 408–417. [4] G. Parodi, R. Citro, B. Bellandi, G. Provenza, M. Marrani, E. Bossone, Revised clinical diagnostic criteria for Tako-tsubo syndrome: the Tako-tsubo Italian Network proposal, Int. J. Cardiol. 172 (2014) 282–283. [5] V. Agarwal, G. Kant, N. Hans, F.H. Messerli, Takotsubo-like cardiomyopathy in pheochromocytoma, Int. J. Cardiol. 153 (2011) 241–248. [6] F. Santoro, R. Ieva, G. Spennati, L. De Gennaro, M. Correale, M. Di Biase, N.D. Brunetti, Tako-tsubo cardiomyopathy in a teen girl with pheochromocytoma, Int. J. Cardiol. 160 (2012) e48–e49. [7] F. Santoro, R. Ieva, A. Ferraretti, V. Ienco, G. Carpagnano, M. Lodispoto, L. Di Biase, M. Di Biase, N.D. Brunetti, Safety and feasibility of levosimendan administration in Takotsubo cardiomyopathy: a case series, Cardiovasc. Ther. 31 (2013) e133–e137. [8] F. Pelliccia, G. Parodi, C. Greco, D. Antoniucci, R. Brenner, E. Bossone, L. Cacciotti, A. Capucci, R. Citro, C. Delmas, F. Guerra, C.N. Ionescu, O. Lairez, M. Larrauri-Reyes, P.H. Lee, N. Mansencal, G. Marazzi, C.G. Mihos, O. Morel, H.M. Nef, I.J. Nunez Gil, I. Passaseo, A.M. Pineda, G. Rosano, O. Santana, F. Schneck, B.G. Song, J.K. Song, A.W. Teh, P. Ungprasert, A. Valbusa, A. Wahl, T. Yoshida, C. Gaudio, J.C. Kaski, Comorbidities frequency in Takotsubo syndrome: an international collaborative systematic review including 1,109 patients, Am. J. Med. 128 (2015) 654 (.e11-9).
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Pheochromocytoma: Still an exclusion criterion for Tako-tsubo cardiomyopathy diagnosis? Francesco Santoro, Armando Ferraretti, Nicola Tarantino, Matteo Di Biase, Natale Daniele Brunetti ⁎ University of Foggia, Cardiology Department, Foggia, Italy
a r t i c l e
i n f o
Article history: Received 16 July 2015 Accepted 1 August 2015 Available online 5 August 2015 Keywords: Takotsubo cardiomyopathy Pheochromocytoma Catecholamine Exclusion criteria
The evidence not only further confirms the role of catecholamines toxicity in TTC, but also remarks the concept that pheochromocytoma is at least one of the numerous comorbidities described in TTC patients: malignancies (10%), neurologic diseases (7%), chronic kidney disease (7%) and thyroid diseases (6%) [8]. Probably, it's time not only to exclude pheochromocytoma from exclusion criteria of TTC diagnosis, but, furthermore, to include this disease among typical comorbidities in TTC, more common in a specific subset of patients such as, probably, younger and/or male. Further studies, however, are warranted to better address this issue. Conflict of interest The authors have no potential conflict of interest to disclose.
In a recent article by Sharkey et al. [1], two patients with pheochromocytoma developed an episode of Takotsubo cardiomyopathy (TTC); rightly, episodes were related to increased circulating levels of catecholamines characteristic of pheochromocytoma. Although direct catecholamine effect on myocardium is considered as one of the main drivers of TTC onset, the pathophysiology of this cardiomyopathy is still unclear [2]. Several algorithms have been proposed for the diagnosis of TTC, and, exclusion criteria are still matter of debate. According to Prasad et al., a diagnosis of TTC should not be done in the presence of myocarditis and/or pheochromocytoma [3], while the Tako-tsubo Italian Network's included only myocarditis among exclusion criteria [4]. Agarwal et al., however, reported on 38 patients with TTC due to pheochromocytoma; all such patients had increased circulating levels of catecholamines, were younger than other patients with TTC, and were characterized by higher rates of complications as cardiogenic shock and heart failure [5]. In our multicenter registry enrolling 190 consecutive patients with TTC, 2 patients (a 17-year-od girl, and a 23-year-old man) had pheochromocytoma with raised circulating levels of catecholamines. The girl presented with a hypertensive crisis successfully managed by the use of a selective beta-1-adrenergic blocker (esmolol) associated with an alpha-blocker (doxazosin) [6], the other with severe left ventricular dysfunction which recovered after levosimendan infusion [7]. ⁎ Corresponding author at: Viale Pinto 1, 71100 Foggia, Italy. Tel.: +39 3389112358; fax: +39 0881745424. E-mail address: [email protected] (N.D. Brunetti).
http://dx.doi.org/10.1016/j.ijcard.2015.08.011 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
References [1] S.W. Sharkey, N. McAllister, D. Dassenko, D. Lin, K. Han, B.J. Maron, Evidence that high catecholamine levels produced by pheochromocytoma may be responsible for Tako-tsubo cardiomyopathy, Am. J. Cardiol. 115 (2015) 1615–1618. [2] I.S. Wittstein, D.R. Thiemann, J.A. Lima, K.L. Baughman, S.P. Schulman, G. Gerstenblith, K.C. Wu, J.J. Rade, T.J. Bivalacqua, H.C. Champion, Neurohumoral features of myocardial stunning due to sudden emotional stress, N. Engl. J. Med. 352 (2005) 539–548. [3] A. Prasad, A. Lerman, C.S. Rihal, Apical ballooning syndrome (Tako-tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction, Am. Heart J. 155 (2008) 408–417. [4] G. Parodi, R. Citro, B. Bellandi, G. Provenza, M. Marrani, E. Bossone, Revised clinical diagnostic criteria for Tako-tsubo syndrome: the Tako-tsubo Italian Network proposal, Int. J. Cardiol. 172 (2014) 282–283. [5] V. Agarwal, G. Kant, N. Hans, F.H. Messerli, Takotsubo-like cardiomyopathy in pheochromocytoma, Int. J. Cardiol. 153 (2011) 241–248. [6] F. Santoro, R. Ieva, G. Spennati, L. De Gennaro, M. Correale, M. Di Biase, N.D. Brunetti, Tako-tsubo cardiomyopathy in a teen girl with pheochromocytoma, Int. J. Cardiol. 160 (2012) e48–e49. [7] F. Santoro, R. Ieva, A. Ferraretti, V. Ienco, G. Carpagnano, M. Lodispoto, L. Di Biase, M. Di Biase, N.D. Brunetti, Safety and feasibility of levosimendan administration in Takotsubo cardiomyopathy: a case series, Cardiovasc. Ther. 31 (2013) e133–e137. [8] F. Pelliccia, G. Parodi, C. Greco, D. Antoniucci, R. Brenner, E. Bossone, L. Cacciotti, A. Capucci, R. Citro, C. Delmas, F. Guerra, C.N. Ionescu, O. Lairez, M. Larrauri-Reyes, P.H. Lee, N. Mansencal, G. Marazzi, C.G. Mihos, O. Morel, H.M. Nef, I.J. Nunez Gil, I. Passaseo, A.M. Pineda, G. Rosano, O. Santana, F. Schneck, B.G. Song, J.K. Song, A.W. Teh, P. Ungprasert, A. Valbusa, A. Wahl, T. Yoshida, C. Gaudio, J.C. Kaski, Comorbidities frequency in Takotsubo syndrome: an international collaborative systematic review including 1,109 patients, Am. J. Med. 128 (2015) 654 (.e11-9).