Due to acute refractory heart failure, intraortic balloon pump was used in 2 patients. At ventriculography all of the patients showed apical akinesis and normokinesis of middle and basal segments. All patients were uneventfully discharged and remained asymptomatic at follow – up (median 44, range 12–68 months). At follow-up echocardiogram, normal regional and global left ventricular systolic and diastolic function were restored (Table 2).├é┬á
EDV = end-diastolic volume; ESV = end-systolic volume; PAPS = Pulmonary artery arterial pressure; WMSI = Wall Motion Score Index * p < .05 vs. baseline; ** p < 0.01 vs. baseline
We described 6 cases of tako-tsubo cardiomyopathy in a region of Southern Italy close to Naples. In the contemporary definition and classification of the Cardiomyopathies proposed in 2006 by the American Heart Association, stress ("Tako-Tsubo") cardiomyopathy is classified among acquired forms of cardiomyopathy 6. A recent systematic review on apical ballooning syndrome identified 14 case series published on international peer-reviewed literature, totalling about 200 patients 7. Our data are broadly consistent with these previous reports, regarding epidemiological profile, clinical presentation and long-term follow-up. ABS accounts 2% of acute coronary syndromes, with most cases occurring in post-menopausal women. Ischemic-like ST-T changes most frequently occur with mild elevation of cardiac biomarkers. The acute left ventricular dysfunction typically involves the apex, although recently some apex-sparing variants of the syndrome have been described 8. The acute left ventricular dysfunction usually recovers in a few days or weeks, and long-term follow-up is usually uneventful. Of note, the geographic origin of published reports originates from Japan (9 studies), USA (3 studies), Belgium and Spain (1 study each) 9. In the present case series, we describe 6 cases all originating from Irpinia, a region of Southern Italy, near Naples but with different ethnic origin and lifestyles (Figure 3). This report again emphasizes that ABS can be much more diffuse than previously thought, and it can be easily recognized, if one thinks of it and applies clearly pre-defined criteria.
Figure 3 - Geographic origin of published reports and spotlight on Tako-Tsubo in Mercogliano, Southern Italy.
Clinicians should consider this syndrome in the differential diagnosis of acute coronary syndromes, especially in post-menopausal women with a recent history of acute emotional or physical stress. The non-invasive suspicion rests on the typical echocardiographic appearance apical ballooning – usually reversible within a few days or weeks. The angiographic documentation of normal coronary arteries is necessary to substantiate the diagnosis."
- Sharkey SW, Lesser JR, Zenovich AG, Maron MS, Lindberg J, Longe FT, Maron BJ: Acute and Reversible Cardiomyopathy Provoked by Stress in Women from the United States. Circulation 2005, 111:472-479.
- Prasad A: Apical ballooning syndrome: an important differential diagnosis of acute myocardial infarction. Circulation 2007, 115(5):e56-e59.
- Wittstein IS, Thiemann DR, Lima JAC, Baughman KL, Schulman SP, Gerstenblith G, Wu KC, Rade JJ, Bivalacqua TJ, Champion C: Neurohumoral features of Myocardial Stunning due to Sudden Emotional Stress. N Engl J Med 2005, 352(6):539-48.
- Mori H, Ishikawa S, Kojima S, Hayashi J, Watanabe Y, Hoffman JI, Okino H, et al.: Increased responsiveness of left ventricular apical myocardium to adrenergic stimuli. Cardiovasc Res 1993, 27(2):192-198.
- Quinones MA, Otto CM, Stoddard M, Waggoner A, Zoghbi WA: Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr 2002, 15(2):167-84.
- Maron BJ, Towbin A, Thiene G, Antzelevitch C, Corrado D, Arnett D, Moss JA, Seidman E, Young JB: Contemporary definitions and classification of the cardiomyopathies: an American Heart Association Scientific Statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention. Circulation 113(14):1807-16. 2006; Apr 11
- Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E: Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J 2006, 27(13):1523-1529.
- Hurst RT, Askew JW, Reuss CS, Lee RW, Sweeney JP, Fortuin FD, Oh JK, Tajik AJ: Transient midventricular ballooning syndrome: a new variant. J Am Coll Cardiol 2006, 48:579-583.
- Dec WG: Recognition of the Apical Ballooning Syndrome in the United States. Circulation 2005, 111:388-390.