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Takotsubo cardiomyopathy — A new variant and widening disease spectrum. “Inverted Takotsubo” pattern related to catecholamine-toxicity
Letters to the Editor
437
Takotsubo cardiomyopathy — A new variant and widening disease spectrum. “Inverted Takotsubo” pattern related to catecholamine-toxicity Angel Sanchez-Recalde a,⁎, Cristian Iborra b , Olga Costero c , Raúl Moreno a , Esteban López de Sá a , José A. Sobrino a , José L. López-Sendón a a b c
Cardiology Department, La Paz University Hospital, Madrid, Spain Cardiology Department, Virgen de la Salud Hospital, Toledo, Spain Nephrology Department, La Paz University Hospital, Madrid, Spain Received 8 July 2007; accepted 4 August 2007 Available online 18 December 2007
Keywords: Inverted Takotsubo; Catecholamine; Stress-induced cardiomyopathy
To the Editor:
We have read with great interest the recent article by Nanda et al. [1], in which a 46 year old female presented with transient marked hypokinesia and relative preservation of apical contraction after scalene block and intra-articular anesthesia for shoulder surgery. As the authors pointed this entity probably represents a variant of stress-related cardiomyopathy, which physiopathology is believed to be mediated by catecholamines. The authors state that this case is unique because of the whole ventricle was dyskinetic with apical sparing. A similar pattern of contractility was widely described in different conditions with high levels of catecholamines as pheochromocytoma, acute cerebral disorders, septic shock treated with noradrenaline, delirium tremens, alcoholic pancreatitis, or Guillaume–Barré syndrome in acute respiratory distress [2–5]. A comparable case was recently reported by Bonnemeier et al. [6] in whom a young female suffered an episode of acute pulmonary edema associated with this atypical transient left ventricular dysfunction (inverted Takotsubo) after local skin infiltration anaesthesia using a combination of lidocaine and epinephrine. Unfortunately, Nanda et al. made no mention the hormonal status of the patient, or if pheochromocytoma was excluded with some diagnostic imaging techniques. We have seen 3 patients admitted to our hospital with the
diagnosis of acute coronary syndrome that rapidly developed acute pulmonary edema and cardiogenic shock. The electrocardiograms showed sinus tachycardia and ST segment depression in V2–V6 and inferior leads, and troponins levels were elevated. Transthoracic echocardiography showed left ventricular dysfunction with akinesis of basal and mid-ventricular segments and preserved contractility of apical segments (inverted Takotsubo contractile pattern). Coronary angiograms were normal. One patient died during cardiac catheterization being diagnosed with pheochromocytoma by necropsy, and in the remaining 2 patients a pheochromocytoma was suspected and confirmed by imaging techniques. They underwent uncomplicated adrenalectomy with resolution of wall motion abnormalities within 2 weeks. Also, the authors mention that these patients regain ventricular function fairly quickly and recurrence is rare. If pheochromocytoma is the underlying disease, recurrences could be common until the excision of this neuroendocrine tumor by surgery. One of our patients described above suffered several episodes until the pheochromocytoma was diagnosed and subsequently operated on. For this reason, it seems judicious to include catecholamine levels and diagnostic imaging techniques for excluding pheochromocytoma in the differential diagnosis of patients presenting with transient left ventricular contractility abnormalities, mainly the “inverted Takotsubo pattern”. References
⁎ Corresponding author. Sección de Hemodinamica y Cardiologia Intervencionista, Planta 1 Diagonal, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain. Tel.: +34 91 7277290. E-mail address: [email protected] (A. Sanchez-Recalde).
[1] Nanda S, Pamula J, Bhatt SP, Chan I, Turki MA, Dale TH. Takotsubo cardiomyopathy – A new variant and widening disease spectrum. Int J Cardiol 2008;132:232–3. [2] Sanchez-Recalde A, Costero O, Iborra C, Oliver JM, Ruiz E, Sobrino JA. Pheochromocytoma-related cardiomyopathy: inverted takotsubo contractile pattern. Circulation 2006;113:e738–e3739.
438
Letters to the Editor
[3] Ennezat PV, Pesenti-Rossi D, Aubert JM, et al. Transient left ventricular basal dysfunction without coronary stenosis in acute cerebral disorders: a novel heart syndrome (inverted Takotsubo). Echocardiography 2005;22:599–602. [4] Copetti R, Gonano C, Colombo T, Cattarossi L. “Inverted Takotsubo” pattern. Resuscitation 2007, doi:10.1016/j.resuscitation. 2007.04.009.
[5] Van de Walle SO, Gevaert SA, Gheeraert PJ, De Pauw M, Gillebert TC. Transient stress-induced cardiomyopathy with an “inverted takotsubo” contractile pattern. Mayo Clin Proc 2006;81:1499–502. [6] Bonnemeier H, Ortak J, Burgdorf C, et al. “The artichoke heart”: the inverse counterpart of left ventricular apical ballooning. Resuscitation 2007;72:342–3.
0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.08.069
Takotsubo cardiomyopathy — A new variant and widening disease spectrum. “Inverted takotsubo” pattern related to catecholamine toxicity Sudip Nanda a,⁎, Surya Prakash Bhatt a , Thompson H. Dale b b
a Internal Medicine, St. Luke's Hospital, Bethlehem, PA, United States Department of Cardiology, St. Luke's Hospital, Bethlehem, PA, United States
Received 3 September 2007; accepted 18 November 2007 Available online 24 January 2008
Abstract Diagnosis of takotsubo cardiomyopathy can be made after pheochromocytomas have been ruled out. Catecholamines are currently considered pathogenetic in takotsubo cardiomyopathy. Various types of cardiomyopathy, both dilated and hypertrophic are seen with pheochromocytomas. The proper diagnosis of takotsubo cardiomyopathy will help to identify as yet undefined factors in pathogenesis. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Takotsubo cardiomyopathy; Pheochromocytoma; Pathogenesis
We thank Sanchez-Recalde et al. for their comment on our article [1]. When a patient presents with apical or midventricular variant of takotsubo cardiomyopathy we measure serum catecholamines. This serves two purposes. If a pheochromocytoma is suspected as the precipitator of cardiomyopathy the amount of radiocontrast used is minimized. Radiocontrast media can promote catecholamine release from the adrenal medulla and worsen heart failure [2]. This also gives lead time before angiography to keep agents like labetolol, phentolamine and nitroglycerine ready for rapid administration if a hypertensive crisis develops. Secondly takotsubo cardiomyopathy is associated with higher catecholamine levels compared to myocardial infarction induced heart failure [3]. Sanchez-Recalde et al. [4] describe three patients with pheochromocytoma and ‘inverted takotsubo’ pattern. The proposed Mayo criteria for clinical diagnosis of apical ⁎ Corresponding author. Department of Internal Medicine, St. Luke's Hospital, 801 Ostrum Street, Bethlehem, PA 18015, United States. Tel.: +610 954 4644; fax: +610 954 4920. E-mail addresses: [email protected] (S. Nanda), [email protected] (S.P. Bhatt), [email protected] (T.H. Dale).
ballooning syndrome requires ruling out pheochromocytoma [5]. Pheochromocytomas are associated with both hypertrophic and dilated cardiomyopathy. While ‘inverted takotsubo’ may be one form of dilated cardiomyopathy, other variants like global hypokinesia [6], marked antero-apical involvement [7], and predominant anterior and posterior wall involvement [8] are also well described in pheochromocytomas. Determining relative abundance of various catecholamines like epinephrine, norepinephrine and dopamine in pheochromocytomas may help to understand such varied myocardial involvement. Our patient was transferred from a sister institution and was already on dopamine and norepinephrine on arrival. Angiography was done with minimal amounts of dye with medications for hypertensive crisis kept in the catheterization laboratory. At follow up the patient was evaluated for pheochromocytoma with serum catecholamines and abdominal imaging. A new variant of takotsubo cardiomyopathy was diagnosed after pheochromocytoma was ruled out. Although catecholamines are currently considered pathogenetic in takotsubo cardiomyopathy it cannot account why women in their sixth and seventh decade are most commonly affected. The proper diagnosis of takotsubo
437
Takotsubo cardiomyopathy — A new variant and widening disease spectrum. “Inverted Takotsubo” pattern related to catecholamine-toxicity Angel Sanchez-Recalde a,⁎, Cristian Iborra b , Olga Costero c , Raúl Moreno a , Esteban López de Sá a , José A. Sobrino a , José L. López-Sendón a a b c
Cardiology Department, La Paz University Hospital, Madrid, Spain Cardiology Department, Virgen de la Salud Hospital, Toledo, Spain Nephrology Department, La Paz University Hospital, Madrid, Spain Received 8 July 2007; accepted 4 August 2007 Available online 18 December 2007
Keywords: Inverted Takotsubo; Catecholamine; Stress-induced cardiomyopathy
To the Editor:
We have read with great interest the recent article by Nanda et al. [1], in which a 46 year old female presented with transient marked hypokinesia and relative preservation of apical contraction after scalene block and intra-articular anesthesia for shoulder surgery. As the authors pointed this entity probably represents a variant of stress-related cardiomyopathy, which physiopathology is believed to be mediated by catecholamines. The authors state that this case is unique because of the whole ventricle was dyskinetic with apical sparing. A similar pattern of contractility was widely described in different conditions with high levels of catecholamines as pheochromocytoma, acute cerebral disorders, septic shock treated with noradrenaline, delirium tremens, alcoholic pancreatitis, or Guillaume–Barré syndrome in acute respiratory distress [2–5]. A comparable case was recently reported by Bonnemeier et al. [6] in whom a young female suffered an episode of acute pulmonary edema associated with this atypical transient left ventricular dysfunction (inverted Takotsubo) after local skin infiltration anaesthesia using a combination of lidocaine and epinephrine. Unfortunately, Nanda et al. made no mention the hormonal status of the patient, or if pheochromocytoma was excluded with some diagnostic imaging techniques. We have seen 3 patients admitted to our hospital with the
diagnosis of acute coronary syndrome that rapidly developed acute pulmonary edema and cardiogenic shock. The electrocardiograms showed sinus tachycardia and ST segment depression in V2–V6 and inferior leads, and troponins levels were elevated. Transthoracic echocardiography showed left ventricular dysfunction with akinesis of basal and mid-ventricular segments and preserved contractility of apical segments (inverted Takotsubo contractile pattern). Coronary angiograms were normal. One patient died during cardiac catheterization being diagnosed with pheochromocytoma by necropsy, and in the remaining 2 patients a pheochromocytoma was suspected and confirmed by imaging techniques. They underwent uncomplicated adrenalectomy with resolution of wall motion abnormalities within 2 weeks. Also, the authors mention that these patients regain ventricular function fairly quickly and recurrence is rare. If pheochromocytoma is the underlying disease, recurrences could be common until the excision of this neuroendocrine tumor by surgery. One of our patients described above suffered several episodes until the pheochromocytoma was diagnosed and subsequently operated on. For this reason, it seems judicious to include catecholamine levels and diagnostic imaging techniques for excluding pheochromocytoma in the differential diagnosis of patients presenting with transient left ventricular contractility abnormalities, mainly the “inverted Takotsubo pattern”. References
⁎ Corresponding author. Sección de Hemodinamica y Cardiologia Intervencionista, Planta 1 Diagonal, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain. Tel.: +34 91 7277290. E-mail address: [email protected] (A. Sanchez-Recalde).
[1] Nanda S, Pamula J, Bhatt SP, Chan I, Turki MA, Dale TH. Takotsubo cardiomyopathy – A new variant and widening disease spectrum. Int J Cardiol 2008;132:232–3. [2] Sanchez-Recalde A, Costero O, Iborra C, Oliver JM, Ruiz E, Sobrino JA. Pheochromocytoma-related cardiomyopathy: inverted takotsubo contractile pattern. Circulation 2006;113:e738–e3739.
438
Letters to the Editor
[3] Ennezat PV, Pesenti-Rossi D, Aubert JM, et al. Transient left ventricular basal dysfunction without coronary stenosis in acute cerebral disorders: a novel heart syndrome (inverted Takotsubo). Echocardiography 2005;22:599–602. [4] Copetti R, Gonano C, Colombo T, Cattarossi L. “Inverted Takotsubo” pattern. Resuscitation 2007, doi:10.1016/j.resuscitation. 2007.04.009.
[5] Van de Walle SO, Gevaert SA, Gheeraert PJ, De Pauw M, Gillebert TC. Transient stress-induced cardiomyopathy with an “inverted takotsubo” contractile pattern. Mayo Clin Proc 2006;81:1499–502. [6] Bonnemeier H, Ortak J, Burgdorf C, et al. “The artichoke heart”: the inverse counterpart of left ventricular apical ballooning. Resuscitation 2007;72:342–3.
0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.08.069
Takotsubo cardiomyopathy — A new variant and widening disease spectrum. “Inverted takotsubo” pattern related to catecholamine toxicity Sudip Nanda a,⁎, Surya Prakash Bhatt a , Thompson H. Dale b b
a Internal Medicine, St. Luke's Hospital, Bethlehem, PA, United States Department of Cardiology, St. Luke's Hospital, Bethlehem, PA, United States
Received 3 September 2007; accepted 18 November 2007 Available online 24 January 2008
Abstract Diagnosis of takotsubo cardiomyopathy can be made after pheochromocytomas have been ruled out. Catecholamines are currently considered pathogenetic in takotsubo cardiomyopathy. Various types of cardiomyopathy, both dilated and hypertrophic are seen with pheochromocytomas. The proper diagnosis of takotsubo cardiomyopathy will help to identify as yet undefined factors in pathogenesis. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Takotsubo cardiomyopathy; Pheochromocytoma; Pathogenesis
We thank Sanchez-Recalde et al. for their comment on our article [1]. When a patient presents with apical or midventricular variant of takotsubo cardiomyopathy we measure serum catecholamines. This serves two purposes. If a pheochromocytoma is suspected as the precipitator of cardiomyopathy the amount of radiocontrast used is minimized. Radiocontrast media can promote catecholamine release from the adrenal medulla and worsen heart failure [2]. This also gives lead time before angiography to keep agents like labetolol, phentolamine and nitroglycerine ready for rapid administration if a hypertensive crisis develops. Secondly takotsubo cardiomyopathy is associated with higher catecholamine levels compared to myocardial infarction induced heart failure [3]. Sanchez-Recalde et al. [4] describe three patients with pheochromocytoma and ‘inverted takotsubo’ pattern. The proposed Mayo criteria for clinical diagnosis of apical ⁎ Corresponding author. Department of Internal Medicine, St. Luke's Hospital, 801 Ostrum Street, Bethlehem, PA 18015, United States. Tel.: +610 954 4644; fax: +610 954 4920. E-mail addresses: [email protected] (S. Nanda), [email protected] (S.P. Bhatt), [email protected] (T.H. Dale).
ballooning syndrome requires ruling out pheochromocytoma [5]. Pheochromocytomas are associated with both hypertrophic and dilated cardiomyopathy. While ‘inverted takotsubo’ may be one form of dilated cardiomyopathy, other variants like global hypokinesia [6], marked antero-apical involvement [7], and predominant anterior and posterior wall involvement [8] are also well described in pheochromocytomas. Determining relative abundance of various catecholamines like epinephrine, norepinephrine and dopamine in pheochromocytomas may help to understand such varied myocardial involvement. Our patient was transferred from a sister institution and was already on dopamine and norepinephrine on arrival. Angiography was done with minimal amounts of dye with medications for hypertensive crisis kept in the catheterization laboratory. At follow up the patient was evaluated for pheochromocytoma with serum catecholamines and abdominal imaging. A new variant of takotsubo cardiomyopathy was diagnosed after pheochromocytoma was ruled out. Although catecholamines are currently considered pathogenetic in takotsubo cardiomyopathy it cannot account why women in their sixth and seventh decade are most commonly affected. The proper diagnosis of takotsubo