Differences between Takotsubo cardiomyopathy and reverse Takotsubo cardiomyopathy associated with subarachnoid hemorrhage

Abstract

Background: Both Takotsubo cardiomyopathy (TTC) and reverse TTC (r-TTC) are characterized by reversible regional wall motion abnormalities of the heart unrelated to coronary artery pathology. It remains unclear whether and/or how r-TTC differs from TTC. Subarachnoid hemorrhage (SAH) is occasionally causative of TTC/r-TTC, and this study was conducted to detect possible differences between TTC and r-TTC associated with SAH.

Methods: A single-center retrospective study was conducted on 328 consecutive SAH patients. They routinely underwent transthoracic echocardiography (TTE), ECG, and measurements of plasma catecholamines and other cardiac biomarkers within 24 h of admission. Demographic, echocardiographic, electrocardiographic and neurochemical profiles were compared between patients with TTC and r-TTC. The diagnosis of TTC/r-TTC was based on the revised Mayo Clinic Criteria.

Results: Data of 21 SAH-induced TTC and 10 SAH-induced r-TTC patients admitted between January 2009 and December 2014 were analyzed. The patients with r-TTC were significantly younger than those with TTC (51.8 ± 10.9 vs. 63.5 ± 14.4 years, p = 0.04). The former exhibited significantly higher plasma epinephrine levels than the latter (809 ± 710 vs. 380 ± 391 pg/mL, p = 0.04). Plasma norepinephrine levels did not differ significantly (2421 ± 1374 vs. 1724 ± 1591 pg/mL, p = 0.25). No significant differences were observed in other demographic/physiologic variables, echocardiographic parameters, frequency of ECG abnormalities, and 90-day mortality. Moreover, none of the patients who underwent a follow-up TTE exhibited morphologic change from one type to the other.

Conclusions: The pathomechanisms in TTC and r-TTC may not be identical: however, distinguishing the two conditions may not have great importance from the standpoint of clinical management and prognostication.

Keywords: Reverse Takotsubo cardiomyopathy; Subarachnoid hemorrhage; Takotsubo cardiomyopathy; Transthoracic echocardiography.

Fig. 1

Comparison of the 16 segment model between Takotsubo cardiomyopathy (TTC, A) and reverse Takotsubo cardiomyopathy (r-TTC, B) associated with subarachnoid hemorrhage revealing that there were marked differences in the frequency of regional wall motion abnormality in the apical and basal segments.

Fig. 2

Plasma epinephrine levels (pg/mL) were 380 ± 391 in Takotsubo cardiomyopathy (TTC) and 809 ± 710 in reverse Takotsubo cardiomyopathy (r-TTC) patients (A). The difference was statistically significant (p = 0.04). Plasma norepinephrine levels (pg/mL) were 1724 ± 1591 for TTC and 2421 ± 1374 for r-TTC patients (B). The difference was not statistically significant (p = 0.25).

Fig. 3

Linear regression analysis showing that the plasma epinephrine and norepinephrine levels were not correlated in the 21 TTC patients (0.18, p = 0.447) (A). The plasma epinephrine and norepinephrine levels were weakly correlated in the 10 r-TTC patients (R = 0.57, p = 0.09) (B).