This review describes and evaluates the representation of women in cardiovascular randomized controlled trials (RCT), it reports significant under-representation of women in clinical trials both as participants and researchers and discusses the ethical implications of under-representation. The under-representation of women as participants in cardiovascular RCTs is evident in trials investigating cardiovascular drugs, acute coronary syndrome, heart failure and interventional procedures and devices. Under-representation of women is also evident in the authorship of cardiovascular clinical trials and in trial leadership roles, and under-representation of women as trial investigators is independently associated with under- recruitment of women as trial participants. A notable lack of RCTs investigating conditions that disproportionately affect women is also evident, this triad of underrepresentation for women as participants, and investigators, and the lack of RCTs into conditions predominantly experienced by women, all contribute to the gender gap in cardiovascular outcomes. Better representation of women in clinical trials, in trial leadership and authorship is a key factor to address to equity, distributive justice and improve outcomes for women with cardiovascular disease.

Takotsubo syndrome (TTS) is an acute condition characterized by a reversible left ventricular (LV) systolic dysfunction leading to serious in-hospital complications (IHC). The aim of our study is to investigate the prognostic impact of right ventricular-to-pulmonary artery (RV-PA) coupling in patients with TTS.

Consecutive TTS patients were prospectively enrolled. In all patients, standard and speckle tracking transthoracic echocardiography was performed within 48 h from hospital admission. RV function was evaluated by RV global longitudinal strain (RV-GLS) and RV free wall strain (RV-FWS) and RV-PA coupling was measured as the ratio of either tricuspid annular plane systolic excursion (TAPSE), RV-GLS or RV-FWS to pulmonary artery systolic pressure (PASP). Data about IHC (acute heart failure, life-threatening arrhythmias and death) were collected.

A total of 80 patients were analyzed (71 ± 11 years, female 77.5 %) and IHC occurred in 33 (41 %). Patients who experienced IHC had lower LV ejection fraction (LVEF), lower left atrial (LA) reservoir strain, TAPSE/PASP, RV-FWS/PASP and RV-GLS/PASP and higher left atrial volume indexed (LAVi) values. At multivariate analysis, only LVEF (OR 0.913, 95 % CI [0.858-0.971], p = 0.004) was an independent predictor of IHC. Receiver operating characteristics (ROC) curve analysis showed an additional prognostic value of a combined model including RV-GLS/PASP and LVEF compared to LVEF alone in the prediction of IHC (AUC of 0.756 vs 0.736, differences between AUCs: 0.02 [p = 0.73]).

RV-PA coupling assessed by RV-GLS/PASP may help in identifying TTS patients at higher risk of cardiovascular complications with an additional prognostic value to LVEF alone.

Background: Pheochromocytoma and paraganglioma are catecholamine-secreting tumors, rarely presenting with pheochromocytoma multisystem crisis (PMC), a life-threatening endocrine emergency. The severity of the condition includes a refractory cardiogenic shock and may therefore require the use of temporary mechanical circulatory support. The aim of this review is to describe the incidence of pheochromocytoma and paraganglioma crises associated with refractory cardiogenic shock, the physiopathological impact of this condition on the myocardial function, the role of temporary mechanical circulatory support (tMCS) in its management, and the outcomes of this specific population. Methods: For the purpose of this narrative review, a literature search of PubMed was conducted as of 16 November 2024. Medical Subject Headings (MeSH) terms used included extracorporeal circulation", "Impella", "pheochromocytoma", "paraganglioma", and "cardiogenic shock", combined with Boolean "OR" and "AND". Data from case series, retrospective studies, and systematic reviews were considered. Seven studies reporting on 45 patients who developed PMC with cardiogenic shock requiring tMCS were included. Patients were young, with a median age of 43 years (range 25-65) at presentation. Most cases presented with severe hemodynamic instability, blood pressure lability, and rapid progression to severe left ventricular dysfunction. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was the most common tMCS used to stabilize patients, initiate specific pheochromocytoma treatments, and, in some cases, provide circulatory support during emergent surgery. The median duration of VA-ECMO support was 4 days (range 1-7) and the reported mean in-hospital survival rate was 93.5%. Following VA-ECMO weaning, survivors showed full recovery of the left ventricular ejection fraction (LVEF). Conclusions: The cardiac dysfunction observed in PMC-associated cardiogenic shock may be severe and life-threatening but appears reversible. tMCS should therefore be considered in eligible cases, as a bridge to recovery, treatment, or surgery. The reported survival rates are impressively high, suggesting possibly a substantial risk of publication bias.

Negative emotions can have a significant impact on individuals, which then influences their cardiovascular system. However, the underlying pathophysiological mechanisms and clinical implications of this association remain inadequately defined. A narrative review of pertinent literature was conducted to examine the pathophysiology, clinical manifestations, and treatment related to the interplay between emotions and conditions such as takotsubo cardiomyopathy, atherosclerosis, acute plaque rupture, and cardiac arrhythmias. Negative emotions can instigate a chronic stress response, which in turn heightens sympathetic nervous system activity and increases vulnerability to cardiovascular diseases. This intricate relationship between emotional states and cardiovascular health underscores the necessity for targeted lifestyle interventions and clinical strategies aimed at mitigating the adverse effects of negative emotions.

Secondary Takotsubo syndrome (TTS) differs from primary TTS in terms of clinical characteristics, management, and prognosis. COPD exacerbation has been recognized as a physical trigger for TTS, but its prognostic implications for secondary TTS are poorly understood.

The purpose of this study was to examine the effects of COPD on in-hospital outcomes in TTS patients.

Using data from the National Inpatient Sample, patients with a primary diagnosis of COPD and a secondary diagnosis of TTS were identified (COPD-TTS group). Patients with a primary diagnosis of TTS and comorbid COPD were selected as a control group (TTS-COPD group). Then, we compared the in-hospital mortality and the incidence of adverse events before and after propensity score matching.

603 patients were included in each of the TTS-COPD and COPD-TTS groups after matching. In both groups, the average age of included patients was about 68 years, and more than 85 percent of them were female. There were no statistically significant differences in the in-hospital mortality or the incident of cardiac arrest, ventricular arrhythmias, and AKI, between the two groups (All, p > 0.05). Patients with COPD-TTS had a higher rate of acute respiratory failure (ARF) (p < 0.001), a lower rate of cardiogenic shock (p = 0.001), and a longer length of hospital stay (LOS) (p < 0.001) compared to patients with TTS-COPD.

Patients with COPD-TTS had a higher rate of ARF and a longer LOS but a lower risk of cardiogenic shock compared to patients with TTS-COPD.

This study investigated the occurrence of left ventricular thrombus formation and subsequent embolic stroke in patients with Takotsubo syndrome. Through the case analysis of an 80-year-old Chinese elderly female patient, it was found that although Takotsubo syndrome is generally considered a self-limiting disease, it can lead to severe complications such as left ventricular thrombus and cerebral stroke. The patient experienced a cardioembolic stroke during hospitalization, and magnetic resonance imaging revealed acute cerebral vascular occlusion. This case highlights the importance of anticoagulation therapy, especially in the prevention of thromboembolic events in patients with Takotsubo syndrome complicated with intracardiac thrombosis.

The intricate role of the autonomic nervous system (ANS) in regulating cardiac physiology has long been recognized. Aberrant function of the ANS is central to the pathophysiology of cardiovascular diseases. It stands to reason, therefore, that neuroscience-based cardiovascular therapeutics hold great promise in the treatment of cardiovascular diseases in humans. A decade after the inaugural edition, this White Paper reviews the current state of understanding of human cardiac neuroanatomy, neurophysiology and pathophysiology in specific disease conditions, autonomic testing, risk stratification, and neuromodulatory strategies to mitigate the progression of cardiovascular diseases.

The purpose of this review is to highlight the utility of echocardiography in the diagnosis and management of cardiomyopathies.

Echocardiographic parameters function synergistically to guide decision-making ranging from early detection of disease and screening to risk stratification of complex disease. The collective wealth of information available from 2D/3D assessment, Doppler, diastology and strain makes echocardiography an invaluable decision aid.

Approximately 20% of patients with Takotsubo syndrome (TTS) develop complications such as left ventricular outflow tract obstruction (LVOTO). The published data suggest that a significant proportion of these patients have predisposing septal hypertrophy or sigmoid septum. However, the pathophysiology regarding this connection has not yet been fully elucidated. We herein present the case of a 75-year-old female patient with TTS complicated by LVOTO, which was successfully managed. During the follow-up, mild basal septal hypertrophy was observed. Subsequent exercise and dobutamine stress echocardiography were performed to reveal the mechanism of LVOTO in TTS.

Takotsubo syndrome (TTS) is identified by its acute and transient impairment of left ventricular systolic function. Although recent research has highlighted occurrences of TTS among individuals with gastrointestinal diseases (GI diseases), comprehensive and systematic investigations focusing on this patient demographic are still scarce.

This retrospective study analyzed case reports and series that documented an association between gastrointestinal diseases (GI diseases) and Takotsubo syndrome (TTS). We conducted comprehensive searches across PubMed, Embase, and the Cochrane Database to identify relevant cases.

In patients with gastrointestinal-induced Takotsubo syndrome (GI-TTS), the primary reasons for admission were pancreatitis (15.48 %), liver failure (10.71 %), bowel obstruction (5.95 %) and liver cirrhosis (5.95 %). It is noteworthy that the main triggers for Takotsubo syndrome are surgeries related to gastrointestinal diseases (29.76 %), including liver transplantation (15.48 %) and cholecystectomy (2.38 %). Dyspnea (45.71 %) was the most common symptom, followed by abdominal pain (35.71 %) and chest pain (34.29 %). The apical type was the most frequent TTS variant (81.25 %). Compared with the All-TTS cohort, GI-TTS patients were younger, and had a lower proportion of women (69.05 % vs. 89.77 %, P < 0.001). GI-TTS patients had higher ventilation use and lower usage of β-blockers, ACEI/ARBs, aspirin, and statins, while catecholamine use was more prevalent.

The study underscores the potential of gastrointestinal diseases and their treatments to trigger TTS, often presenting atypical clinical features compared to TTS of all types. Given these differences, an elevated level of clinical vigilance is imperative for the timely diagnosis of TTS in patients with gastrointestinal conditions.

Ischemic heart disease is the most common cardiovascular cause of death in women worldwide. Obstructive coronary atherosclerosis is the primary cause of myocardial infarction (MI), however, non-atherosclerotic mechanisms of MI, such as spontaneous coronary artery dissection, vasospasm, microvascular dysfunction, embolization, inflammation, coronary anomalies, infectious and infiltrative causes are increasingly being recognized. Emerging data suggest that women are two to five times more likely to have an MI in the absence of coronary atherosclerosis compared to men, but they continue to remain underdiagnosed and undertreated, partly due to underdiagnosis and limited understanding of these mechanisms. Recent advancements in invasive and noninvasive imaging techniques and physiological testing allow for distinguishing these mechanisms from each other, providing a definitive diagnosis and tailored treatment. This review summarizes the existing literature on the non-atherosclerotic coronary causes of MI with a focus on evidence pertaining to women, offering a basis for future studies.

Takotsubo syndrome (TTS) is a transient form of left ventricular dysfunction, typically affecting post-menopausal females, often preceded by emotional or physical stressful events that act as triggers. Initially believed to be a rare and benign condition for its reversible nature, TTS has recently emerged as a complex multifaceted clinical entity, with heterogenous clinical presentations and a non-negligible risk of serious in-hospital complications, including acute heart failure, arrhythmias and death.

Emerging pathophysiological hypotheses, ranging from microvascular dysfunction to systemic inflammation, offer new insights into the underlying mechanisms of TTS. Moreover, increasing awareness of potential complications during the acute phase of the disease underscores its significant prognostic implications and emphasizes the need for randomized clinical trials to guide the therapeutic management of TTS. In this narrative review article, we aim to discuss the recent insights on the epidemiology, pathophysiology, treatment and prognosis of patients affected by TTS discussing the emerging evidence and the remaining knowledge gap in the field.

Extensive myocardial edema is a key feature of acute takotsubo syndrome (TTS) and it can be quantitatively assessed by T2 mapping cardiac magnetic resonance (CMR) imaging. Clinical correlates of myocardial edema in TTS are not well characterized.

Sixty patients with acute TTS underwent CMR with T2 mapping within one week of hospitalization. Disease severity was assessed by a validated risk score (GEIST-score).

Mean age of the study population was 71 ± 12 years (92 % females). Mean mid-septal T2 time was 58 ± 6 ms. Higher T2 mapping values were found in patients with left ventricular ejection fraction (LVEF) ≤40 % (60 ± 6 ms vs 56 ± 5 ms; p = 0.006), male sex (66 ± 7 ms vs 58 ± 6 ms; p = 0.010), dyspnea on admission (63 ± 7 ms vs 58 ± 6 ms; p = 0.006), absence of an emotional trigger (60 ± 7 ms vs 57 ± 5 ms; p = 0.039), intermediate-to-severe GEIST-score (63 ± 7 ms vs 58 ± 6 ms; p = 0.045) and in-hospital complications (61 ± 1 ms vs 58 ± 6 ms; p = 0.009). A trend towards higher values was observed in patients who died at follow-up (62 ± 8 ms vs 58 ± 6 ms; p = 0.098). On linear regression analysis, T2 mapping did not correlate with the timing of CMR (Beta -0.182, p = 0.170), whereas after multivariable correction, lack of emotional trigger (Beta 0.262, p = 0.031), decreasing LVEF (Beta -0.254, p = 0.024) and increasing GEIST score (Beta 0.282, p = 0.024) remained independently associated with T2 mapping.

In patients with acute TTS undergoing a timely CMR within the first week after admission, T2 mapping was not affected by timing of the examination, was higher in patients displaying high-risk features, and independently associated with the GEIST risk score.

Takotsubo syndrome or broken-heart syndrome is a rare form of nonischemic cardiomyopathy characterized by regional systolic dysfunction of the left ventricle without evidence of coronary artery disease or acute plaque rupture. This transient impairment in myocardial contractility leads to symptoms and signs that can mimic a myocardial infarction. We present a case of Takotsubo syndrome in a 47-year-old premenopausal woman with complex congenital heart disease who initially presented with acute onset of shortness of breath and chest tightness after a verbal altercation. Extremely rare cases of Takotsubo syndrome have been described in the congenital heart disease population in premenopausal women. This case emphasizes the need to highlight acquired cardiac disease in patients with adult congenital heart disease as this cohort continues to age.

Sepsis often leads to vasoplegia and a hyperdynamic cardiac state, with treatment focused on restoring vascular tone. However, sepsis can also cause reversible myocardial dysfunction, particularly in the elderly with pre-existing heart conditions. The Surviving Sepsis Campaign Guidelines recommend using dobutamine with norepinephrine or epinephrine alone for patients with septic shock with cardiac dysfunction and persistent hypoperfusion despite adequate fluid resuscitation and stable blood pressure. However, the definition of cardiac dysfunction and hypoperfusion in these guidelines remains controversial, leading to varied clinical interpretations. Cardiac dysfunction with persistent hypoperfusion despite restoring adequate preload and afterload is often considered a cardiogenic shock. Therefore, sepsis complicated by new-onset myocardial dysfunction or worsening of underlying myocardial dysfunction due to sepsis-induced cardiomyopathy, resulting in cardiogenic shock, can be defined as "Sepsis-induced cardiogenic shock (SICS)". SICS is known to be associated with significantly higher mortality. A history of cardiac dysfunction is a strong predictor of SICS, highlighting the need for precise diagnosis and management given the aging population and rising cardiovascular disease prevalence. Therefore, SICS might benefit from early invasive hemodynamic monitoring with a pulmonary artery catheter (PAC), unlike those with septic shock alone. While routine PAC monitoring for all septic patients is impractical, echocardiography could be a useful screening tool for high-risk individuals. If echocardiography indicates cardiogenic shock, PAC might be warranted for continuous monitoring. The role of inotropes in SICS remains uncertain. Mechanical circulatory support (MCS) might be considered for severe cases, as high-dose vasopressors and inotropes are associated with worse outcomes. Correct patient selection is the key to improving outcomes with MCS. Engaging a cardiogenic shock team for a multidisciplinary approach can be beneficial. In summary, addressing the evidence gaps in SICS diagnosis and management is crucial. Echocardiography for screening, advanced monitoring with PAC, and careful patient selection for MCS are important for optimal patient care.

Despite the frequent and often severe repolarization abnormalities seen in Takotsubo syndrome (TTS), the underlying mechanism of life-threatening arrhythmias is incompletely understood, and the risk remains uncertain. TTS is considered a potential cause of acquired long QT syndrome; however, there is no robust evidence that QT prolongation has a major prognostic impact on these patients' outcomes. Our aim was to assess the prevalence and clinical implications of acquired long QT during TTS events and compare in-hospital and long-term outcomes between patients with and without corrected QT interval (QTc) prolongation. This is a retrospective cohort study that included 113 patients admitted to our tertiary care hospital with a diagnosis of TTS. The cohort was divided into two groups: a long QTc group (QTc≥460 milliseconds in any electrocardiogram at admission or during hospitalization) and a normal QTc group. Baseline characteristics, occurrences during hospitalization, and outcome data were obtained from the revision of medical registries and hospital visits. Of the 113 patients, 107 (94.7%) were female. The mean age was 67.6±11.7 years. QTc prolongation was found in 38%. Demographic characteristics, relevant chronic medication, prevalence of cardiovascular risk factors, and other comorbidities were similar between the groups, except for a history of atrial fibrillation, which was more common in the long QTc group. Syncope was more prevalent in the long QTc group. In-hospital complications were not statistically different between patients with long and normal QTc (48.8% vs. 44.2%, p=0.637), including ventricular arrhythmias and complete atrioventricular block (both 4.7% vs. 1.4%, p=0.556). In-hospital mortality was 0.9%, corresponding to one patient in the long QTc group. The mean follow-up time was 4.8±3.8 years. 5-year all-cause mortality and the occurrence of the composite endpoint of major adverse cardiac and cerebrovascular events did not differ between the groups (p=0.511 and p=0.538, respectively). Our study found no association between prolonged QTc interval during TTS events and adverse prognosis since in-hospital and long-term outcomes were similar between the groups. Our findings suggest that, although QT prolongation is usually a frightening feature on ECG, this repolarization abnormality during the acute phase has no major prognostic implications in the TTS population.

Stress cardiomyopathy (SCM) currently has a high incidence in older adults, and the theories regarding its causes include "catecholamine myocardial toxicity" and "sympathetic hyperactivation". However, the role of the central nervous system in the pathogenesis of SCM remains unknown. We investigated the role of microglia activation in the paraventricular hypothalamic nucleus (PVN) in the development of SCM.

An SCM model was created using male Sprague-Dawley (SD) rats, immobilized for 6 h every day for a week. Electrocardiogram, cardiac electrophysiology, and echocardiography examinations were performed to verify the changes in cardiac structure and function in rats with SCM. RNA sequencing was used to explore the changes in the hypothalamus during SCM. In addition, brain and heart tissues were collected to detect microglial activation and sympathetic activity.

The main findings were as follows: (1) immobilization stress successfully induced SCM in SD rats; (2) microglia were significantly activated in the hypothalamus, as evidenced by cytosol thickening, increases in the number of microglial branches, and microglia enriched in the PVN; (3) in SCM, the microglia in the PVN exhibited increased central and peripheral cardiac sympathetic activity and increased the expression of neuroinflammatory factors; and (4) it is possible that inhibiting microglial activation could suppress the sympathetic activity of the central nervous system and heart and increase cardiac electrical stability in SCM rats.

SCM was induced in SD rats by immobilization stress, acting through the activation of the hypothalamic microglia. The activated microglia were specifically enriched in the PVN, increasing the activity of the central and peripheral sympathetic nervous systems by regulating the expression of neuro-inflammatory factors, mediating dysfunction of the left ventricle, and increasing the susceptibility to ventricular arrhythmias.

There is uncertainty about the use of the CHA2DS2-VASc score to predict clinical events in patients with Takotsubo syndrome (TTS). This study aimed to assess the short-term prognostic role of CHA2DS2-VASc score in this population.

All admissions with a primary diagnosis of TTS were included using data from the National Inpatient Sample database during 2016-2019. The primary outcome was in-hospital mortality and secondary outcomes included ischemic stroke, intracardiac thrombus, cardiogenic shock, requirement for mechanical circulatory support, and renal replacement therapy. Patients were divided into 3 groups according to the CHA2DS2-VASc score. (0-3, 4-6, and >6). Logistic regression was used to estimate odds ratios (OR) with 95 % confidence intervals (CI).

A total 32,595 weighted hospitalizations were included (median age was 67 [58-76] years; 90 % female). The median CHA2DS2-VASc score value was 4 (2-5). In the adjusted models, in-hospital mortality was significantly higher in the CHA2DS2-VASc 4-6 (OR 1.86, 95 % CI 1.09-3.16, p = 0.022) and CHA2DS2-VASc >6 (OR 3.35, 95 % CI 1.60-7.04, p = 0.001) groups compared to the CHA2DS2-VASc 0-3 group. Likewise, the CHA2DS2-VASc >6 group had significantly higher odds of ischemic stroke (OR 2.92, 95 % CI 1.22-6.96, p = 0.016), intracardiac thrombus (OR 3.56, 95 % CI 1.36-9.30, p = 0.010), cardiogenic shock (OR 1.73, 95 % CI 1.05-2.86, =0.033), and renal replacement therapy (OR 2.87, 95 % CI 1.04-7.92, p = 0.042).

Our results suggest that the CHA2DS2-VASc score is relatively useful for predicting in-hospital mortality and a range of clinical events in hospitalized patients with TTS.

Takotsubo syndrome (TTS) is a condition of acute ventricular dysfunction mainly in aging women that is frequently precipitated by episodes of physical or emotional stress. The association with negative emotional triggers such as fear, grief, or interpersonal conflicts was observed soon after the first description of TTS three decades ago and led to the popular term "broken heart syndrome". However, more recent research shows that TTS can also be provoked by pleasant emotions in some patients, referred to as "happy heart syndrome". This review will discuss the role of stressful triggers in patients with TTS and their impact on the course of the disease with a particular focus on characteristic features of happy heart syndrome.

This article summarizes findings seen in various cardiomyopathies on myocardial perfusion imaging (MPI) with positron emission tomography (PET).

MPI is the cornerstone for evaluation of coronary ischemia, and technological advancements have yielded improved imaging quality and reduction in radiation exposure, particularly with PET. Multi-specialty guidelines and appropriate use criteria provide guidance on utilization of PET MPI in various scenarios related to evaluation of chest pain, new onset cardiomyopathy, and other scenarios where coronary ischemia should be assessed. Various non-ischemic cardiomyopathies such as septal and apical hypertrophic cardiomyopathy, amyloidosis, sarcoidosis, takotsubo, and dilated cardiomyopathy have typical imaging findings on PET MPI and can be identified if these patterns are understood. It is essential to recognize specific imaging patterns in non-ischemic cardiomyopathies which may aide in diagnosis. Ultimately, multimodality imaging, including echocardiography and cardiac magnetic resonance, complement PET MPI in diagnosing and guiding treatment options for these conditions.

Takotsubo cardiomyopathy is typically triggered by excessive catecholamine release. Here, we present a case of Takotsubo cardiomyopathy following gastrointestinal bleeding. The patient experienced cardiac arrest, necessitating extracorporeal cardiopulmonary resuscitation. Coronary angiography revealed severe coronary vasospasm, and echocardiography showed left ventricular dysfunction with ballooning. The patient was transferred out of the emergency intensive care unit on the ninth day with improved consciousness.

Apical ballooning syndrome, commonly known as Takotsubo syndrome, is a distinct cardiomyopathy often resembling acute myocardial infarction in presentation. Takotsubo syndrome patients exhibit varied patterns of left ventricular wall motion abnormalities, most frequently apical dyskinesis with basal hyperkinesis, that are characteristically transient. Although emotional or physical stressors precipitate Takotsubo syndrome in most cases, a significant proportion presents without identifiable triggers, with a pronounced female predominance. Despite recovery of left ventricular function, Takotsubo syndrome may lead to serious complications akin to acute coronary syndromes. The pathophysiology remains incompletely understood, with catecholamine surge implicated in the genesis of myocardial injury, although direct causation remains debated. Diagnosis involves integrating clinical history, imaging modalities like echocardiography, and cardiac MRI. Psychiatric disorders, particularly anxiety and depression, are frequently associated with Takotsubo syndrome, suggesting a role of chronic stress in disease susceptibility. Management includes supportive care, with anticoagulation considered in cases of apical thrombus, alongside close monitoring for complications and recovery of left ventricular function. This article reviews the current understanding, challenges in diagnosis, and management strategies for Takotsubo syndrome.

Takotsubo syndrome (TS) is a reversible cause of heart failure; however, a minority of patients can develop serious complications, including cardiac rupture (CR).

Analyze case reports of CR related to TS, detailing patient characteristics to uncover risk factors and prognosis for this severe complication.

We conducted a systematic search of MEDLINE and Embase databases to identify case reports of patients with TS complicated by CR, from inception to October 2023.

We included 44 subjects (40 females; 4 males) with a median age of 75 (IQR 71-82) years, of White/Caucasian (61%) or East Asian/Japanese (39%) ethnicity. An emotional trigger was present in 15 (34%) subjects and an apical ballooning pattern was observed in all cases (100%). ST-segment elevation was reported in 39 (93%) of 42 cases, with the anterior myocardial segments (37 [88%]) being the most compromised, followed by lateral (26 [62%]) and inferior (14 [33%]) segments. The median time to cardiac rupture was 48 (5-120) hours since admission, with the left ventricular free wall (25 [57%]) being the most frequent site of perforation. Surgery was attempted in 16 (36%) cases, and 28 (64%) patients did not survive.

CR related to TS is a rare complication associated with high mortality and affecting elderly females, specially from White/Caucasian or East Asian/Japanese descent, presenting with anterior or lateral ST-segment elevation, and an apical ballooning pattern. Although data is limited and additional prospective studies are needed, the awareness of this life-threatening complication is crucial to early identify high-risk patients.

Cardiac rupture is a rare complication of Takotsubo syndrome. We conducted a systematic review of cases complicated by cardiac rupture, and we identified 44 subjects (40 females and 4 males) with a median age of 75 (IQR 71-82) years, of White/Caucasian (61%) or East Asian/Japanese (39%) ethnicity, all with an apical ballooning pattern (100%). The median time to cardiac rupture was 48 (5-120) hours since admission, with the left ventricular free wall (25 [57%]) being the most frequent site of perforation. Surgery treatment was attempted in 16 (36%) cases, and 28 (64%) patients did not survive.

A postmenopausal woman presented with recurrent takotsubo syndrome on 3 different occasions. The first and second episodes presented as broken heart syndrome and the third as happy heart syndrome. After literature review, the authors believe this is the first recorded case of a patient having broken and happy heart syndrome on separate occasions.

Anesthesiologists develop anesthetic plans according to the surgical procedure, patient's medical history, and physical exams. Patients with ischemic heart disease are predisposed to intraoperative cardiac complications from surgical blood loss. Unanticipated events can lead to intraoperative complications despite careful anesthesia planning.

This anesthetic management simulation was developed for the anesthesiology residency curriculum during the first clinical anesthesia year (CA 1/PGY 2 residents). A total of 23 CA 1 residents participated. A 50-minute encounter focused on a 73-year-old male who presents for an elective total hip replacement and develops acute myocardial stunning in the setting of critical acute blood loss and a delay in the transportation of blood products.

One hundred percent of the residents felt the simulation was educationally valuable in the immediate postsimulation survey (Kirkpatrick level 1). The follow-up survey showed that 100% of residents felt the simulation increased their knowledge of managing acute cardiac ischemia (Kirkpatrick level 2), and 93% felt it increased awareness and confidence in similar real-life situations that positively affected patient outcomes (Kirkpatrick level 3).

Our simulation provides a psychologically safe environment for anesthesiology residents to develop management skills for acute critical anemia and cardiogenic shock and foster communication skills with a surgery team.

Stress cardiomyopathy refers to a syndrome of acute but reversible left ventricular dysfunction, often triggered by emotional or physical stress. Reverse Takotsubo cardiomyopathy is an uncommon variant that occurs in about 5% of cases. Classically, it has been known to be following a catecholamine surge due to physical or emotional stress. This case highlights the importance for physicians to be aware of the possibility of developing stress cardiomyopathy in patients with acute intra-abdominal processes.

Forty-one-year-old Caucasian female with was admitted with an acute small bowel obstruction. After failing conservative management, it was decided to proceed with surgery. After induction with anesthesia but prior to the surgeons first incision, the patient developed a tachyarrhythmia with hemodynamic compromise requiring the surgery to be aborted. That evening, she developed chest pain with concerns for an acute coronary syndrome. She was taken urgently to the for invasive angiography, which demonstrated reverse Takotsubo.

Intra-abdominal processes and intubation have previously been reported be catalyst for this disease process. This patient had multiple stressors including mechanical bowel obstruction and anesthesia after failing conservative management. The diagnosis was confirmed by coronary angiography and left ventriculogram, and followed up with repeat outpatient echocardiography.

A case of small bowel obstruction that developed reverse Takotsubo preceded by sustained ventricular tachycardia after intubation. The patient did well and had complete recovery cardiac function. Risk factors and underlining mechanism for the different variants of stress cardiomyopathy are not well understood, further investigation is warranted.

This study aimed to evaluate the impact of race on in-hospital outcomes of Takotsubo cardiomyopathy using the National Inpatient Sample.

We conducted a retrospective study using data from the National Inpatient Sample database 2006 to 2018. We focused on Takotsubo cardiomyopathy hospitalizations, excluding those with acute coronary syndrome as the primary diagnosis. Two study groups consisted of White patients or Black patients. Univariate and multivariable logistic models evaluated race's effect on death, cardiac arrest, cardiogenic shock, length of stay, while adjusting for potential confounders. The Bayesian model averaging technique was used to further elucidate the factors influencing death within each racial group. Significant differences were observed between the 2 racial groups. Black patients presented at a younger age, had a higher proportion of men, a higher burden of comorbidities, and a lower median household income compared with their White counterparts. In the univariate model, the Black cohort showed an increased risk of cardiac arrest (odds ratio, 1.45 [95% CI, 1.15-1.82]). However, the difference did not reach statistical significance in the multivariable model. Black patients also had a significantly longer hospital stay in both the univariate model (risk ratio, 1.26 [95% CI, 1.22-1.31]) and the multivariable model (risk ratio, 1.06 [95% CI, 1.04-1.07]). No significant difference in all-cause death was observed between the racial groups.

The outcome differences between 2 racial groups in our study are likely influenced by racial disparities in demographics, comorbidities, and socioeconomic factors. Individualized care based on racial group needs is crucial in clinical practice.

Takotsubo cardiomyopathy is a rare cardiac presentation. It can be associated with severe complications such as hemodynamically significant ventricular septal defect and cardiac free wall rupture. In cases of mechanical complications, surgical repair is often indicated. Despite best medical and surgical efforts, patients with Takotsubo cardiomyopathy and mechanical complications carry significant mortality risk. Herein, we present an unusual presentation of Takotsubo cardiomyopathy that was associated with a mechanical complication. Although the patient underwent a successful surgical repair, she passed away from multiorgan failure during the postoperative period.

Takotsubo syndrome (TTS) is a reversible form of acute myocardial injury due to a neurocardiogenic mechanism associated with a relevant risk for life-threatening ventricular arrhythmias, occurring in up to 25% of all patients and including both ventricular arrhythmias (especially) in the context of QT prolongation and atrial tachy- or bradyarrhythmias. The pathogenetic mechanisms of TTS-related arrhythmic complications are not completely understood, and there are no randomized clinical trials addressing the pharmacologic and nonpharmacologic management in this specific setting. In this narrative review, the authors provide an overview of the pathogenesis and the therapeutic management of arrhythmic complications in patients with TTS, along with the future perspectives and the remaining knowledge gaps in this field.

Takotsubo syndrome (TTS) is being diagnosed more often with its increased recognition over the past 2 decades and with the availability of imaging such as point-of-care echocardiography and tissue characterization by cardiovascular magnetic resonance (CMR).

A young man developed pericarditis and was treated with steroids. A few weeks later, he suffered classic TTS and then presented a week later with the rare complication of apical myocardial rupture and a left ventricular (LV) pseudoaneurysm. He subsequently sustained two recurrences, likely secondary to the poor tensile strength of the repair in the region of necrotic myocardium.

Various features of both syndromes are discussed herein (myopericarditis and TTS) as well as their classic imaging findings with an emphasis on the echocardiographic diagnosis of an LV pseudoaneurysm and differentiating it from an aneurysm. Furthermore, we elucidate the classic imaging findings of CMR in myocarditis, myocardial infarction with non-obstructive coronary arteries, and TTS. Lastly, we discuss treatment options for LV pseudoaneurysms and strategies to prevent recurrence.

Psychosocial stress can affect cardiovascular health through multiple pathways. Certain stressors, such as socioeconomic disadvantage, childhood adversity, intimate partner violence, and caregiving stress, are especially common among women. The consequences of stress begin at a young age and persist throughout the life course. This is especially true for women, among whom the burden of negative psychosocial experiences tends to be larger in young age and midlife. Menarche, pregnancy, and menopause can further exacerbate stress in vulnerable women. Not only is psychosocial adversity prevalent in women, but it could have more pronounced consequences for cardiovascular risk among women than among men. These differential effects could reside in sex differences in responses to stress, combined with women's propensity toward vasomotor reactivity, microvascular dysfunction, and inflammation. The bulk of evidence suggests that targeting stress could be an important strategy for cardiovascular risk reduction in women.

Polymorphic ventricular tachycardia (PVT) and ventricular fibrillation (VF) are life-threatening complications of takotsubo syndrome (TTS). Data regarding risk factors for PVT/VF based on the TTS variant are lacking. This study aimed to identify demographic and clinical factors associated with PVT and VF in patients with TTS. Patients meeting the InterTak criteria for TTS between 2010 and 2022 were retrospectively identified. The occurrence of PVT/VF with each risk factor was analyzed using logistic regression. Sensitivity analysis was performed to assess the interaction between risk factors. PVT/VF occurred in 27 of 296 patients with TTS (9.1%). Patients with PVT/VF were younger (52 vs 62 years, p = 0.019) and more frequently used stimulants in the 4 weeks before admission (22.2% vs 8.2%, odds ratio [OR] 3.20, p = 0.023). All PVT/VF occurred within 24 hours of hospitalization. An initial QTc threshold of 490 ms had the highest sensitivity and specificity for the occurrence of PVT/VF (area under the curve = 0.687). Patients with PVT/VF were more likely to have a QTc >490 ms on admission (55.6% vs 18.7%, OR 5.45, p <0.01), apical variant TTS (78% vs 56%, OR 2.69, p = 0.038), and an admission ejection fraction <30% (63% vs 41.5%, OR 2.39, p = 0.032); each factor was independently associated with PVT/VF irrespective of QTc duration on sensitivity analysis. In conclusion, nearly 1 in 10 patients with TTS had PVT/VF. A QTc >490 ms, recent stimulant use, apical variant TTS, and severe left ventricular systolic dysfunction on admission are associated with higher PVT/VF risk, with the first 24 hours being a high-risk period.

Cannabis is one of the most widely used psychoactive substances. Its components act through several pathways, producing a myriad of side effects, of which cardiovascular events are the most life-threatening. However, only a limited number of studies address cannabis's perioperative impact on patients during noncardiac surgery.

Studies were identified by searching the PubMed, Medline, EMBASE, and Google Scholar databases using relevant keyword combinations pertinent to the topic.

Current evidence shows that cannabis use may cause several cardiovascular events, including abnormalities in cardiac rhythm, myocardial infarction, heart failure, and cerebrovascular events. Additionally, cannabis interacts with anticoagulants and antiplatelet agents, decreasing their efficacy. Finally, the interplay of cannabis with inhalational and intravenous anesthetic agents may lead to adverse perioperative cardiovascular outcomes.

The use of cannabis can trigger cardiovascular events that may depend on factors such as the duration of consumption, the route of administration of the drug, and the dose consumed, which places these patients at risk of drug-drug interactions with anesthetic agents. However, large prospective randomized clinical trials are needed to further elucidate gaps in the body of knowledge regarding which patient population has a greater risk of perioperative complications after cannabis consumption.

Background: Takotsubo syndrome (TTS) in male patients is under-studied, particularly in the older population. Methods and Results: From 226 patients with TTS, 44 older male patients (prevalence rate: 19.5%, age: median 77 years) were compared with 182 older female patients (prevalence rate: 80.5%, age: median 80 years). Emotional triggers of TTS were less frequent (2% vs. 19%; P=0.007), whereas physical triggers were more frequent (75% vs. 58%; P=0.040) in older men than in women. Among physical triggers, serious respiratory infection was more common in older men than in women. As initial clues to the diagnosis, ECG T-wave inversion was more frequent (48% vs. 29%; P=0.018) and chest pain and/or dyspnea were less common (23% vs. 38%; P=0.050) in older men than in women. In total, 14 patients (6%) had cardiogenic shock and 41 (18%) had severe heart failure as complications, although there were no significant differences in the frequency of these complications between older men and women. Although cardiac death occurred in 3 female patients (1%) and noncardiac death in 3 male and 5 female patients (4%), there were no significant differences in death rate between older men and women. Conclusions: Emotional triggers of TTS were extremely infrequent whereas physical triggers were common in older men. Although severe heart failure was common, there were no significant differences in the frequency of complications and in-hospital deaths between older men and women.

Takotsubo syndrome (TTS) is an acute reversible form of myocardial dysfunction, often preceded by a physical or emotional stressful event, that acts as a trigger. Despite, recent advances in the comprehension of the mechanisms leading to TTS, its pathophysiology is far from being completely understood. However, several studies seem to suggest that an acute coronary microvascular dysfunction may represent a crucial pathogenic mechanism involved in TTS occurrence. In this article, we aim to review the complex pathophysiology of TTS and the possible different mechanisms underlying this clinical condition, focusing on the role of coronary microvascular dysfunction and the remaining knowledge's gaps in the field.