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Article history:
Received 11 August 2014
Accepted 14 August 2014
Available online 23 August 2014
Keywords:
Catecholamine
Echocardiography
Electrocardiogram
Neurogenic stunned myocardium
Takotsubo cardiomyopathy
Many similarities have been noted between Takotsubo cardiomyopathy (TCM) and neurogenic stunned myocardium (NSM): both exhibit
characteristic echocardiographic/electrocardiographic ndings, and
sympathetic over-activity is implicated as a common etiological mechanism [1,2]. In this single-center, prospective observational study, we
aimed to clarify the potential differences between TCM and NSM by
http://dx.doi.org/10.1016/j.ijcard.2014.08.084
0167-5273/ 2014 Elsevier Ireland Ltd. All rights reserved.
Age (y)
Male:Female
Presenting symptoms
Aneurysm locations
Admission GCS scores
Prior cardiac events
Hypertension
Hyperlipidemia
Diabetes mellitus
Psychiatric history
Systolic BP (mm Hg)
Diastolic BP (mm Hg)
Heart rate (bpm)
Pulmonary edema
Troponin I (ng/mL)
BNP (pg/mL)
CK-MB (ng/mL)
TCM (n = 19)
NSM (n = 12)
p-Value
71.7 7.6
8:11
Chest pain 8
Dyspnea 7
Dizziness 4
N/A
14.7 0.7
8 (42%)
10 (53%)
6 (32%)
8 (42%)
2 (11%)
149 32
83 19
103 31
4/19 (21%)
2.92 4.61
460.2 575.1
33.8 46.1
57.5 13.7
6:6
Headache 5
Altered mental status 7
b0.01*
0.95
N/A
N/A
b0.001**
0.03***
0.82
0.67
0.25
0.51
0.31
0.37
0.39
0.20
0.40
0.30
0.59
ACoA: anterior communicating artery; BNP: B-type natriuretic peptide; BP: blood pressure; CK-MB: creatine kinase MB isozyme; GCS: Glasgow Coma Scale; ICA: internal carotid
artery; MCA: middle cerebral artery; NA: not applicable; NSM: neurogenic stunned myocardium; TCM: Takotsubo cardiomyopathy; VA: vertebral artery.
*, **, ***: statistically signicant.
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Table 2
Comparison of echocardiographic and electrocardiographic parameters between
Takotsubo cardiomyopathy and neurogenic stunned myocardium patients.
LVEF (%)
LVIDd (mm)
LVIDs (mm)
LVMI (g/m2)
E (m/s)
A (m/s)
E/A
E (m/s)
E/E
DcT (ms)
RWMSI
ST-segment elevation
T-wave inversion
QTc (ms)
TCM (n = 19)
NSM (n = 12)
p-Value
42.6 9.2
45.9 7.7
34.2 8.4
126.1 37.7
78.2 26.7
86.2 29.3
1.02 0.60
4.89 1.91
17.7 7.5
173.6 47.5
1.67 0.31
12/19 (63%)
13/19 (68%)
479 4
44.2 9.1
45.0 7.9
37.0 8.1
108.5 46.3
59.8 20.6
73.5 22.0
0.88 0.39
5.30 1.95
12.2 4.6
172.7 40.2
1.71 0.34
6/12 (50%)
3/12 (25%)
468 4
0.65
0.74
0.30
0.33
0.07
0.26
0.53
0.58
0.04*
0.96
0.67
0.73
0.03**
0.50
DcT: deceleration time; LVEF: left ventricular ejection fraction; LVIDd: left ventricular internal dimension, diastole; LVIDs: left ventricular internal dimension, systole; LVMI: left
ventricular mass index; NSM: neurogenic stunned myocardium; RWMSI: Regional Wall
Motion Score Index; TCM: Takotsubo cardiomyopathy.
*, **: statistically signicant.
Fig. 1. The plasma epinephrine levels (pg/mL) were 96 72 for Takotsubo cardiomyopathy (TCM) and 392 331 for neurogenic stunned myocardium (NSM) group (A). The difference
was statistically signicant (p = 0.007*). The plasma norepinephrine levels (pg/mL) were 1015 1038 for TCM and 2028 1216 for NSM (B). The difference was statistically signicant
(p = 0.01**). Linear regression analysis revealing that the plasma epinephrine and norepinephrine levels were positively correlated in TCM group (R = 0.70, p = 0.0007) (C). The plasma
epinephrine and norepinephrine levels were also positively correlated in NSM group (R = 0.64, p = 0.03) (D).
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was signicantly more likely to induce typical TCM-like cardiac dysfunction [8].
Most echocardiographic parameters were comparable except the E/
E ratio (Table 2). The higher E/E ratio in TCM group indicates the presence of more severe diastolic dysfunction [9]. That difference could be
explained by differences in demographics: TCM patients were signicantly older and more likely to have had prior cardiac events, and stiffened myocardium in that group might have resulted in worse diastolic
dysfunction and a higher E/E ratio. On the other hand, the degree of systolic dysfunction, the degree of myocardial injury, and spatial RWMA
distribution were similar between the two groups. The lower frequency
of T-wave inversion in NSM group without signicant difference in STsegment elevation may be explained by the general propensity for SAH
patients to present earlier after onset: conversion from ST-segment elevation to T-wave inversion might have not occurred in most NSM patients by the time of their arrival [10].
There are several limitations to this study. First, timing of follow-up
examinations was not standardized and we were unable to perform a
chronological evaluation. Second, the number of patients was small:
given that both disorders have low incidences making it difcult to accumulating adequate samples, it is important to establish national/
international registries. Finally, because of the short half-life of epinephrine, the epinephrine/norepinephrine coefcient may vary substantially
with the timing of blood collection [7].
In conclusion, more prominent diastolic dysfunction and more frequent T-wave inversion in TCM group may have resulted from demographic differences. While plasma catecholamine levels were raised in
greater magnitudes in NSM group, it remains unclear whether that difference explains the echocardiographic/electrocardiographic differences. The authors certify that they comply with the principles of
Ethical Publishing in the International Journal of Cardiology.
Disclosure
The rst author (JI) received a research grant from the Japan Brain
Foundation.
References
Fig. 2. Comparison of the 16 segment model between Takotsubo cardiomyopathy (A) and
neurogenic stunned myocardium group (B) revealing that there were no signicant differences in the frequency of regional wall motion abnormality in any of the corresponding
segments.
[1] Pilgrim TM, Wyss TR. Takotsubo cardiomyopathy or transient left ventricular apical
ballooning syndrome: A systematic review. Int J Cardiol 2008;124:28392.
[2] Bielecka-Dabrowa A, Mikhailidis DP, Hannam S, et al. Takotsubo cardiomyopathy:
the current state of knowledge. Int J Cardiol 2010;142:1205.
[3] Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J 2008;155:
40817.
[4] Tanabe M, Crago EA, Suffoletto MS, et al. Relation of elevation in cardiac troponin I to
clinical severity, cardiac dysfunction, and pulmonary congestion in patients with
subarachnoid hemorrhage. Am J Cardiol 2008;102:154550.
[5] Sugimoto K, Inamasu J, Hirose Y, et al. The role of norepinephrine and estradiol in
the pathogenesis of cardiac wall motion abnormality associated with subarachnoid
hemorrhage. Stroke 2012;43:1897903.
[6] Goldstein DS, Eisenhofer G, Kopin IJ. Sources and signicance of plasma levels of catechols and their metabolites in humans. J Pharmacol Exp Ther 2003;305:80011.
[7] Lyon AR, Rees PS, Prasad S, Poole-Wilson PA, Harding SE. Stress (Takotsubo) cardiomyopathy: a novel pathophysiological hypothesis to explain catecholamine-induced
acute myocardial stunning. Nat Clin Pract Cardiovasc Med 2008;5:229.
[8] Redfors B, Ali A, Shao Y, Lundgren J, Gan LM, Omerovic E. Different catecholamines
induce different patterns of takotsubo-like cardiac dysfunction in an apparently
afterload dependent manner. Int J Cardiol 2014;174:3306.
[9] Medeiros K, O'Connor MJ, Baicu CF, et al. Systolic and diastolic mechanics in stress
cardiomyopathy. Circulation 2014;129:165967.
[10] Madias JE. Plausible mechanisms of the rapid conversion of ST-segment elevation to
T-wave inversion in Takotsubo syndrome. Int J Cardiol 2013;168:45935.