title: Recurrent Tako-Tsubo cardiomyopathy (TTC) in a pre-menopausal woman: late sequelae of a traumatic event?
abstract: BACKGROUND
  "Tako-Tsubo cardiomyopathy" (TTC) is a syndrome characterized by left ventricular (LV) wall motion abnormalities, usually without coronary artery disease, mimicking the diagnosis of acute coronary syndrome. It most often affects post-menopausal women and TTC tends to run a benign course with very low rates of recurrence, complications or mortality. The condition is also called "stress-induced cardiomyopathy" because acute physical or emotional stress appears to be frequently related to its onset. The pathogenic role of premorbid or comorbid psychiatric illnesses has been discussed controversially. For the first time, we present a case of fourfold recurrent TTC with severe complications in a pre-menopausal woman. Furthermore, a long history of flaring posttraumatic stress symptoms anteceded the first event.
  
  
  METHODS
  A 43-year old, pre-menopausal Caucasian woman was hospitalized with symptoms of acute coronary syndrome. Clinical examination revealed hypokinetic wall motion in the apical ventricular region with no signs of coronary artery disease and diagnosis of TTC was established. She experienced recurrence three times within the following ten months, which led to thrombembolism and myocardial scarring among others. The circumstances of chronic distress were striking. 16 years ago she miscarried after having removed a myoma according to her doctor's suggestion. Since then, she has suffered from symptoms of posttraumatic distress which peaked annually at the day of abortion. Chronic distress became even more pronounced after the premature birth of a daughter some years later. The first event of TTC occurred after a family dispute about parenting.
  
  
  CONCLUSIONS
  This is the first case report of fourfold TTC in a pre-menopausal woman. From somatic perspectives, the course of the disease with recurrences and complications underlines the fact that TTC is not entirely benign. Furthermore, it is the first case report of long lasting symptoms of traumatic stress anteceding TTC. Close connections between adrenergic signaling and late onset of clinical stress symptoms are well known in the psychopathology of traumatization. Although larger clinical trials are needed to elucidate possible interactions of premorbid psychiatric illnesses and TTC, cardiologists should be vigilant especially in cases of recurrent TTC.
authors.affiliation: Section of Psychosomatic Medicine and Psychotherapy, Department of Internal Medicine II, Julius-Maximilian-University of Wuerzburg, Oberduerrbacher Str, 6, D- 97080 Wuerzburg, Germany. hefner_j@ukw.de.
authors.forename: Jochen
authors.initials: J
authors.lastname: Hefner
authors.forename: Herbert
authors.initials: H
authors.lastname: Csef
authors.forename: Stefan
authors.initials: S
authors.lastname: Frantz
authors.forename: Nina
authors.initials: N
authors.lastname: Glatter
authors.forename: Bodo
authors.initials: B
authors.lastname: Warrings
mesh_terms: D000328:Adult; D002908:Chronic Disease; D005260:Female; D006801:Humans; D017697:Premenopause; D013313:Stress Disorders, Post-Traumatic / Q000150:complications*; D013315:Stress, Psychological / Q000150:complications; D054549:Takotsubo Cardiomyopathy / Q000523:psychology*