Stress induced cardiomyopathy presenting as acute coronary syndrome: Tako-Tsubo in Mercogliano, Southern Italy.
BACKGROUND
Tako-tsubo syndrome (TTS) in its typical (apical) and atypical (non-apical) forms is being increasingly recognized in the West owing to early systematic coronary angiography in acute coronary syndromes (ACS).


OBJECTIVE
To assess the incidence, the clinical characteristics and the outcome of TTS in a single high volume cath lab in Southern Italy over the last 6 years.


METHODS
Among 1674 consecutive patients (pts) referred to our coronary care units in the last 6 years (2001-2006) for ACS we selected 6 (0.5%) pts (6 women; age 57 +/- 6 years) who fulfilled the following 4 criteria: 1) transient left ventricular wall motion abnormalities resulting in ballooning at contrast ventricolographic or echocardiographic evaluation; 2) normal coronary artery on coronary angiography performed 5 +/- 9 hours from hospitalization; 3) new electrocardiographic ischemic-like abnormalities (either ST-segment elevation or T-wave inversion) and 4) emotional or physical trigger event.


RESULTS
At admission all pts had presumptive diagnosis of ACS and ECG revealed ST elevation in 3 (50%) and T wave inversion with QT elongation in 3 (50%). In the acute phase cardiogenic shock occurred in 2 (33%) and heart failure in 1(16%). Presenting symptoms were chest pain in 6 (100%), dyspnoea in 2 (33%) and lipotimia in 1 (16%). At echocardiographic-ventricolographic assessment, the mechanical dysfunction (ballooning) was apical in all 6 pts ("classic" TTS). In all patients wall motion abnormalities completely reversed within 4.5 +/- 1.5 days. The region of initial recovery was the anterior and lateral wall in 4 cases and the lateral wall in 2 cases. Ejection fraction was 35 +/- 8% in the acute phase and increased progressively at discharge (55 +/- 6%) and at 41 +/- 20 months follow-up (60 +/- 4%, p < 0.001 vs. baseline). All patients remained asymptomatic with minimal (aspirin, beta blockers, antihypertensive and antidislipidemic therapy) treatment.


CONCLUSIONS
Classic TTS is a frequent serendipitous diagnosis after coronary angiography showed "surprisingly" normal findings in a clinical setting mimicking an ACS. Despite its long-term good prognosis life threatening complications in the acute phase can occur.
Cangella
F
F
Cardiology Department, Montevergine Cardilogy Clinic, Mercogliano, Italy. f.cangella@libero.it
Medolla
A
A
De Fazio
G
G
Iuliano
C
C
Curcio
N
N
Salemme
L
L
Mottola
G
G
Agrusta
Marco
M
D000704:Analysis of Variance; D003287:Contrast Media; D017023:Coronary Angiography; D004452:Echocardiography; D004562:Electrocardiography; D006801:Humans; D015994:Incidence; D007558:Italy / Q000453:epidemiology; D008875:Middle Aged; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D013312:Stress, Physiological / Q000150:complications* / Q000503:physiopathology; D054549:Takotsubo Cardiomyopathy / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000532:radiotherapy; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology
D003287:Contrast Media