Seventy-two of the patients were women and 3 were men with a mean age of 71.9±9.6 years; 53 (70.6%) presented a history of hypertension, 20 (26.6%) of hypercholesterolaemia, 22 (29.3%) of disthyroidism, 12 (16%) of diabetes mellitus and 14 (18.6%) of tobacco use. No patient had previous or a family history suggestive of TC.
The most common presenting cardiovascular symptoms were substantial chest pain (n=48; 64%), in these patients the ECG, on admission, showed: ST-segment elevation (n=28), diffuse ST-segment depression (n=4), T-wave inversion (n=11), left bundle brunch block (n=1) and non-specific abnormality (n=4). In the patients who went with exertional dyspnoea (n=11; 14.6%), the ECG showed an ST-segment elevation (n=6), a diffuse ST-segment depression (n=1), T-wave inversion (n=2) and non-specific abnormality (n=2). The remaining 16 (21.3%) patients were identified during the management or monitoring of non-cardiac conditions.
Based on the presentation suggestive of TC, patients were asked whether a stressful event had preceded the admission. There were identifiable precipitating events in 62 (82.6%) of them (), but 13 patients (17.3%) did not have any identifiable stressor at time of presentation.
Emotional and physical stressors triggering TC
In the acute phase, the patients had a QTc interval of 503.8±61.7 (range 378–680 ms). In 64 patients, QTc interval was ≥450 ms (); the prolongation occurred within 48 h after the onset of symptoms and was associated with deep and symmetric T-wave inversion in most leads. In 10 patients, deep and symmetric T-wave inversion appeared, but QTc interval was normal. Only in one patient with the basal ballooning, variant broad upright T waves and normal QTc in subacute phase were observed. Despite significant prolongation of the QTc, no patient developed torsades de pointes (TdP), ventricular tachycardia (VT) and/or ventricular fibrillation (VF). Therefore, long QT triggering ventricular arrhythmias appear to be highly infrequent, although VT/VF have been reported at the time of presentation as well as delayed complications of this syndrome.
ECG at the second day showing widespread repolarisation abnormalities with QT interval prolongation and marked negative T wave.
In acute phase, four patients had life-threatening arrhythmias: one patient presented with a cardiac arrest during non-cardiac surgery; three patients presented with second-degree atrioventricular block (); these patients subsequently required permanent pacemaker implantation. Eight patients had atrial fibrillation during hospitalisation ().
Figure 2 ECG showing atrioventricular block 2:1 with deep T-wave inversion and QTc interval prolongation.
Mean echocardiographic left ventricle ejection fraction, assessed in the acute phase, was 37.2%±9.05%. The prevalent regional wall motion abnormalities involved hypokinesis or akinesis of the mid and apical segments of the left ventricle; also one patient with situs viscerum inversus had this features.19
In five patients, there was preserved function of the apex and basal segments with wall motion abnormality that involved the mid-segments. In only one patient, there was a rare variant present with hypokinesis or akinesis of the mid and basal segments of the LV with preserved apical function. Also, the variant with biventricular involvement were present in one patient.20
Importantly, the wall motion abnormality typically extends beyond the distribution of any single coronary artery. Intraventricular apical thrombosis was identified in one patient ().22–24
Cardiac MR in the early phase of takotsubo-like cardiomyopathy showing apical akinesis with thrombosis (arrow).
In the acute period, only 1 of 75 patients developed dynamic obstruction to LV outflow (gradient >30 mm Hg) owing to systolic anterior motion of the mitral valve leaflets with chordal apparatus and mitral–septal contact. This outflow obstruction resolved in the subacute period.25
The interval between the door of the hospital and coronary angiography was 90 min in 32 patients and 36 h in 43 patients. Coronary angiography at initial evaluation indicated normal coronary arteries in 61 patients and mild stenoses (<50%) in 24 patients. Concomitant LV angiogram was performed in 42 patients (56%) (). Congestive heart failure occurred in nine patients and cardiogenic shock in 1, intra-aortic balloon pumping was required in one patient, while the dopamine was used in only two patients.
End-diastolic and end-systolic frame of left ventriculography showing anterolateral, anteroapical and inferior apical wall dyskinesia with hypercontractility of the basal segments.
Cardiac MR was performed in only 21 patients within 10 days after their admission. Delayed gadolinium hyperenhancement was absent in all patients.27
None of the 75 patients died; all patients were promptly discharged (8.4±4.4 days), since they recovered their normal functional status without symptoms, echocardiographic left ventricle ejection fraction, on discharge, was 50.5%±7.76%. On discharge, all patients had the QTc interval ≤450 ms.
At discharge, 73 patients (97.3%) received aspirin, 71 (94.6%) ACE inhibitors/angiotensin receptor blockers, 67 (89.3%) β-blockers, 42 (56%) diuretic and 51 (68%) received statins.
Follow-up information was available for 56 patients. The frequency of returns was variable. After a mean of 6 months of follow-up, in all 56 patients, the ECG had normalised and mean echocardiographic left ventricle ejection fraction was 58%±4. At a mean follow-up time of 2.2±2 years (range 0.1–6.8 years), two patients (2.6%) died because of sudden cardiac death and pulmonary embolism, respectively, 2 years after the episode of cardiomyopathy. These patients used aspirin, ACE inhibitors and β-blockers.
In follow-up, 47 patients (83.9%) received aspirin, 50 patients (89.2%) ACE inhibitors/angiotensin receptor blockers, 42 patients (75%) β-blockers, 8 (14.2%) diuretic and 36 (64.2%) statins.
The TC recurred in one patient after 1 month from the first episode. This patient at the moment of the second episode used only aspirin and did not use β-blockers and ACE inhibitors/angiotensin receptor blockers.
Antihypertensive therapy required to be increased in seven patients. A new episode of atrial fibrillation was observed in one patient.