Korean Circ J.  2010 Jun;40(6):277-282. 10.4070/kcj.2010.40.6.277.

Clinical Characteristics and Prognostic Factors of Stress-Induced Cardiomyopathy

• Lee JW
• Kim JY
• Youn YJ
• Sung JK
• Lee NS
• Lee KH
• Yoo BS
• Lee SH
• Yoon J
• Choe KH

• KMID: 2225188
• DOI: http://doi.org/10.4070/kcj.2010.40.6.277

Abstract

BACKGROUND AND OBJECTIVES
Stress-induced cardiomyopathy (SCM) is characterized by a transient left ventricular (LV) dysfunction due to emotional and physical stress. There are limited data about the clinical characteristics in Korean patients. We sought to clarify the clinical features and prognosis in patients with SCM.
SUBJECTS AND METHODS
We reviewed 39 cases diagnosed with SCM in a tertiary hospital. The SCM was diagnosed as: 1) no previous history of cardiac disease, 2) acute onset, 3) regional wall motion abnormality, typically in the takotsubo or inverted takotsubo shape by echocardiography, and 4) no significant stenosis in the coronary angiogram. We evaluated clinical characteristics, biomarkers, and prognosis.
RESULTS
Mean age was 61.3+/-16.1 years (female 69%). The triggering factors were physical stress in 32 patients (82%) and emotional stress in 5 patients (13%). The initial symptom was dyspnea (n=18, 46%) rather than chest pain (n=10, 26%). An initial electrocardiogram (EKG) presented T-wave inversion (n=18, 46%), ST-elevation (n=11, 28%), and ST-depression (n=2, 5%). Multivariate logistic regression analysis showed that initial high sensitive C-reactive protein (hs-CRP) {odds ratio (OR) 1.41, 95% confidence interval (CI); 1.02-1.97} and initial left ventricular ejection fraction (LVEF) (OR 0.89, 95% CI; 0.80-0.98) were significantly associated with death or cardiogenic shock, respectively.
CONCLUSION
The major triggering factor of SCM is physical stress due to illness or surgical procedures, and the first manifestation is dyspnea rather than chest pain. Elevated hs-CRP and decreased LVEF at admission were independent risk factors for death or cardiogenic shock.

Keyword

Takotsubo cardiomyopathy; Inflammatory response

MeSH Terms

Biomarkers
C-Reactive Protein
Cardiomyopathies
Chest Pain
Constriction, Pathologic
Dyspnea
Echocardiography
Electrocardiography
Heart Diseases
Humans
Logistic Models
Prognosis
Risk Factors
Shock, Cardiogenic
Stress, Psychological
Stroke Volume
Takotsubo Cardiomyopathy
Tertiary Care Centers
C-Reactive Protein

Figure

• 

  Fig. 1 An apical thrombus of the left ventricle due to stress-induced cardiomyopathy. Two dimensional echocardiography shows an apical LV thrombus (A and B) and disappeared apical thrombus (C and D) after anticoagulant therapy.

• 

  Fig. 2 A case of inverted stress-induced cardiomyopathy {systolic (A) and diastolic (B) phase}. Left ventriculogram (right anterior oblique view) shows hyper-contractility of the basal and apical segments and ballooning of the mid-segments.

Reference

1. Bybee KA, Kara T, Prasad A, et al. Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med. 2004. 141:858–865.

2. Grawe H, Katoh M, Kuhl HP. Stress cardiomyopathy mimicking acute coronary syndrome: case presentation and review of the literature. Clin Res Cardiol. 2006. 95:179–185.

3. Dote K, Sato H, Tateishi H, Uchida T, Ishihara M. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases. J Cardiol. 1991. 21:203–214.

4. Abe Y, Kondo M, Matsuoka R, Araki M, Dohyama K, Tanio H. Assessment of clinical features in transient left ventricular apical ballooning. J Am Coll Cardiol. 2003. 41:737–742.

5. Lee HH, Gwon HC, Kim BJ, et al. Clinical manifestation of novel stress-induced cardiomyopathy mimicking acute myocardial infarction: single center prospective registry. Korean Circ J. 2002. 32:1054–1063.

6. Chang KY, Jeon HK, Chae JS, et al. A novel cardiomyopathy mimicking acute myocardial infarction. Korean Circ J. 2002. 32:608–612.

7. Morel O, Sauer F, Imperiale A, et al. Importance of inflammation and neurohumoral activation in Takotsubo cardiomyopathy. J Card Fail. 2009. 15:206–213.

8. Zelinka T, Petrak O, Strauch B, et al. Elevated inflammatory markers in pheochromocytoma compared to other forms of hypertension. Neuroimmunomodulation. 2007. 14:57–64.

9. Kurisu S, Sato H, Kawagoe T, et al. Tako-tsubo-like left ventricular dysfunction with ST segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction. Am Heart J. 2002. 143:448–455.

10. Tsuchihashi K, Ueshima K, Uchida T, et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. J Am Coll Cardiol. 2001. 38:11–18.

11. Desmet WJ, Adriaenssens BF, Dens JA. Apical ballooning of the left ventricle: first series in white patients. Heart. 2003. 89:1027–1031.

12. Bybee KA, Prasad A, Barsness GW, et al. Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome. Am J Cardiol. 2004. 94:343–346.

13. Sharkey SW, Lesser JR, Zenovich AG, et al. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation. 2005. 111:472–479.

14. Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005. 352:539–548.

15. Regnante RA, Zuzek RW, Weinsier SB, et al. Clinical characteristics and four-year outcomes of patients in the Rhode Island Takotsubo Cardiomyopathy Registry. Am J Cardiol. 2009. 103:1015–1019.

16. Lambert G, Naredi S, Eden E, Rydenhag B, Friberg P. Monoamine metabolism and sympathetic nervous activation following subarachnoid haemorrhage: influence of gender and hydrocephalus. Brain Res Bull. 2002. 58:77–82.

17. Ueyama T, Hano T, Kasamatsu K, Yamamoto K, Tsuruo Y, Nishio I. Estrogen attenuates the emotional stress-induced cardiac responses in the animal model of Tako-tsubo (Ampulla) cardiomyopathy. J Cardiovasc Pharmacol. 2003. 42:Suppl 1. S117–S119.

18. Ueyama T, Kasamatsu K, Hano T, Tsuruo Y, Ishikura F. Catecholamines and estrogen are involved in the pathogenesis of emotional stress-induced acute heart attack. Ann N Y Acad Sci. 2008. 1148:479–485.

19. Park JH, Kang SJ, Song JK, et al. Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU. Chest. 2005. 128:296–302.

20. Hahn JY, Gwon HC, Park SW, et al. The clinical features of transient left ventricular nonapical ballooning syndrome: comparison with apical ballooning syndrome. Am Heart J. 2007. 154:1166–1173.

21. Hurst RT, Askew JW, Reuss CS, et al. Transient midventricular ballooning syndrome: a new variant. J Am Coll Cardiol. 2006. 48:579–583.