Stress induced cardiomyopathy presenting as acute coronary syndrome: Tako-Tsubo in Mercogliano, Southern Italy

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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

Table 2: Echocardiographic findings

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."


























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