Stress Cardiomyopathy (SC), originally described as takotsubo, is characterised by severe – but reversible – impairment of left ventricular function in the absence of significant coronary artery disease. The vast majority of patients present with symptoms similar to those of an acute coronary syndrome, and tend to have good outcomes despite the initial severity of presentation. Although SC is now well recognised, no study to date has comprehensively defined the clinical spectrum and evolution of SC, including tissue characteristics, in a large, multicenter population from Europe and North America using a comprehensive, state-of-the-art CMR imaging protocol.
In this prospective study conducted at seven centres in Europe and North America between 2005 and 2010, 256 patients presenting with SC were assessed both at presentation and between 1 to 6 months later using cardiac MRI. The main outcome measure was complete recovery of LV function. Of note, the vast majority of patients (89%) were women: eighty-one percent (n = 207) were postmenopausal, 8% (n = 20) were younger women (aged ≤50 years), and 11% (n = 29) were men. Characteristically, SC is said to be triggered by a stressful event, and in this cohort a stressful trigger could be identified in 182 patients (71%). Cardiovascular magnetic resonance imaging data (available for 239 patients [93%]) revealed 4 distinct patterns of regional ventricular ballooning: apical (n = 197 [82%]), biventricular (n = 81 [34%]), midventricular (n = 40 [17%]), and basal (n = 2 [1%]). Left ventricular ejection fraction was reduced (48% [SD, 11%]; 95% confidence interval [CI], 47%-50%) in all patients. Stress cardiomyopathy was accurately identified by CMR using specific criteria: a typical pattern of LV dysfunction, myocardial edema, absence of significant necrosis/fibrosis, and markers for myocardial inflammation. Follow-up CMR imaging showed complete normalization of LV ejection fraction (66% [SD, 7%]; 95% CI, 64%-68%) and inflammatory markers in the absence of significant fibrosis in all patients.
The novel insights from this study demonstrate that the clinical profile of SC is far broader than previously thought. Cardiovascular MRI is able to provide accurate functional information that can aid in the diagnosis of SC.
- Eitel I, von Knobelsdorff-Brenkenhoof F, Bernhardt P et al. Clinical Characteristics and Cardiovascular Magnetic Resonance Findings in Stress (Takotsubo) Cardiomyopathy. JAMA 2011;306(3):277-286. doi:10.1001/jama.2011.992