Connecting the pieces of Takotsubo ‘broken heart’

Connecting the pieces of Takotsubo ‘broken heart’ A panel of cardiology experts from around the world have developed the first international expert consensus statement on the diagnosis, risk stratification and management of Takotsubo syndrome  ‘Broken Heart Syndrome’—also known as Takotsubo syndrome (TTS)—is a term used to describe severe chest pain typically triggered by stressful situations. The condition, which predominantly affects post-menopausal women, was first reported by a group of Japanese cardiologists in 1990.1 The cardiologists gave the syndrome the name ‘Takotsubo’ after the Japanese word for ‘octopus trap’, due to the resemblance of the shape of the left ventricle at the end of systole to a bulbous earthenware pot used historically to trap octopus. The signs and symptoms of TTS—including chest pain and breathing difficulties—are often indistinguishable from classic acute coronary syndrome (ACS), making diagnosis difficult.2 To this day, TTS is still an underappreciated and poorly understood disorder. Due to the low numbers of reported cases worldwide, a registry approach was needed to collect sufficient data on this enigmatic disease. Consequently, the global International TAK (InterTAK) Registry was established in 2011 (www.takotsubo-registry.com; ClinicalTrials.gov Identifier: NCT01947621).3 Over 40 international cardiovascular centres from 12 countries are currently participating. Data from the InterTAK Registry have been instrumental in increasing the understanding of TTS. For example, TTS was originally thought to be a temporary and benign disease, yet InterTAK Registry data show it has similar mortality to age- and gender-matched patients with ACS.4 Such scientific evidence that people can actually ‘die of a broken heart’ was picked up by the mainstream media when actress Debbie Reynolds died in 2016, just 1 day after the death of her daughter Carrie Fisher. Another surprising finding that attracted global media attention was that positive emotional stress, such as winning the lottery, can also trigger TTS.5 This discovery, termed ‘Happy Heart syndrome’, was cited in 232 news stories, making it one of the top 100 most-discussed journal articles of 2016 (www.altmetric.com/top100/2016/). Takotsubo syndrome is now considered to be a heterogeneous condition that can be preceded by various emotional and physical triggers and affects many people in addition to post-menopausal women. Due to the growing awareness of TTS around the world—and the lack of robust clinical guidelines—a unifying, international consensus on this condition was urgently needed. Accordingly, a panel of 46 TTS cardiology experts from America, Europe, Australia, and Asia came together to discuss different controversial issues regarding TTS. The expert panel was led by two prominent researchers in the field: Christian Templin, MD, PhD, FESC, Professor of Cardiology (Head of Acute Cardiac Care and Deputy-Head of Interventional Cardiology at the Andreas Grüntzig Heart Catheterization laboratory, University Hospital Zurich; Principal Investigator of the InterTAK Registry) and Jelena Ghadri, MD (Attending Physician and Senior Research Scientist at the Department of Cardiology, University Hospital Zurich; Co-Principle Investigator of the InterTAK Registry). After agreement on the available scientific evidence and expert opinion, the panel developed a two-part International Expert Consensus Document on TTS. The statement summarizes current knowledge of the nomenclature, epidemiology, pathophysiology, triggers, and risk factors for TTS (Part I). A major outcome from this discussion was the development of a consensus on the diagnostic criteria for TTS, termed InterTAK criteria (Part I), which will help improve the identification and stratification of TTS in daily clinical practice. Among the most important changes, pheochromocytoma no longer excludes the presence of TTS, and coronary artery disease is not considered an exclusion criterion. The experts concluded that four major types of TTS exist based on the distribution of regional wall motion abnormalities, including the typical apical ballooning type and three atypical TTS types (mid-ventricular, basal, and focal wall motion patterns), although other morphological variants are also evident.6 A diagnostic algorithm for TTS (Part II) incorporating the InterTAK Diagnostic Score was also proposed. This score comprises seven parameters, based on clinical features and electrocardiography, which can be used to predict the probability of the presence of TTS. The panel also summarized the latest evidence on the use of biomarkers (e.g. B-type natriuretic peptide, interleukin-6, and certain circulating microRNAs) and imaging techniques (e.g. computed tomography angiography and magnetic resonance imaging) that should help the clinician in their diagnostic workup (Part II). Finally, the panel proposed a therapeutic management approach for patients with TTS (Part II), based on clinical experience and expert consensus (evidence level C). For example, the panel recommends electrocardiogram monitoring in the acute phase, due to the occurrence of acute complications such as arrhythmias. In terms of medical management, the panel recommend beta-blockers should be used with caution as they may not be beneficial for acute or chronic treatment of TTS (even though catecholamine levels are elevated in TTS). For long-term management of TTS, the panel recommends angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers to prevent recurrence; however, they stress that this strategy requires validation. Indeed, as no prospective, randomized trials have been performed, it remains difficult to provide evidence-based guidelines for the medical management of TTS.7 The new consensus statement should facilitate timely and accurate diagnosis of TTS in daily clinical practice and improve patient outcomes. Nevertheless, there are many outstanding issues in the field. As such, further research is required to investigate the precise pathogenesis of TTS. Further research should continue to fill in the missing pieces on our understanding of TTS, thereby improving outcomes for patients with a ‘Broken Heart’ condition. Andros Tofield docandros@bluewin.ch Conflict of interest: none declared. References References are available as supplementary material at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal Oxford University Press

Connecting the pieces of Takotsubo ‘broken heart’

European Heart Journal , Volume Advance Article (22) – Jun 7, 2018

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Publisher
Oxford University Press
Copyright
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.
ISSN
0195-668X
eISSN
1522-9645
D.O.I.
10.1093/eurheartj/ehy254
Publisher site
See Article on Publisher Site

Abstract

A panel of cardiology experts from around the world have developed the first international expert consensus statement on the diagnosis, risk stratification and management of Takotsubo syndrome  ‘Broken Heart Syndrome’—also known as Takotsubo syndrome (TTS)—is a term used to describe severe chest pain typically triggered by stressful situations. The condition, which predominantly affects post-menopausal women, was first reported by a group of Japanese cardiologists in 1990.1 The cardiologists gave the syndrome the name ‘Takotsubo’ after the Japanese word for ‘octopus trap’, due to the resemblance of the shape of the left ventricle at the end of systole to a bulbous earthenware pot used historically to trap octopus. The signs and symptoms of TTS—including chest pain and breathing difficulties—are often indistinguishable from classic acute coronary syndrome (ACS), making diagnosis difficult.2 To this day, TTS is still an underappreciated and poorly understood disorder. Due to the low numbers of reported cases worldwide, a registry approach was needed to collect sufficient data on this enigmatic disease. Consequently, the global International TAK (InterTAK) Registry was established in 2011 (www.takotsubo-registry.com; ClinicalTrials.gov Identifier: NCT01947621).3 Over 40 international cardiovascular centres from 12 countries are currently participating. Data from the InterTAK Registry have been instrumental in increasing the understanding of TTS. For example, TTS was originally thought to be a temporary and benign disease, yet InterTAK Registry data show it has similar mortality to age- and gender-matched patients with ACS.4 Such scientific evidence that people can actually ‘die of a broken heart’ was picked up by the mainstream media when actress Debbie Reynolds died in 2016, just 1 day after the death of her daughter Carrie Fisher. Another surprising finding that attracted global media attention was that positive emotional stress, such as winning the lottery, can also trigger TTS.5 This discovery, termed ‘Happy Heart syndrome’, was cited in 232 news stories, making it one of the top 100 most-discussed journal articles of 2016 (www.altmetric.com/top100/2016/). Takotsubo syndrome is now considered to be a heterogeneous condition that can be preceded by various emotional and physical triggers and affects many people in addition to post-menopausal women. Due to the growing awareness of TTS around the world—and the lack of robust clinical guidelines—a unifying, international consensus on this condition was urgently needed. Accordingly, a panel of 46 TTS cardiology experts from America, Europe, Australia, and Asia came together to discuss different controversial issues regarding TTS. The expert panel was led by two prominent researchers in the field: Christian Templin, MD, PhD, FESC, Professor of Cardiology (Head of Acute Cardiac Care and Deputy-Head of Interventional Cardiology at the Andreas Grüntzig Heart Catheterization laboratory, University Hospital Zurich; Principal Investigator of the InterTAK Registry) and Jelena Ghadri, MD (Attending Physician and Senior Research Scientist at the Department of Cardiology, University Hospital Zurich; Co-Principle Investigator of the InterTAK Registry). After agreement on the available scientific evidence and expert opinion, the panel developed a two-part International Expert Consensus Document on TTS. The statement summarizes current knowledge of the nomenclature, epidemiology, pathophysiology, triggers, and risk factors for TTS (Part I). A major outcome from this discussion was the development of a consensus on the diagnostic criteria for TTS, termed InterTAK criteria (Part I), which will help improve the identification and stratification of TTS in daily clinical practice. Among the most important changes, pheochromocytoma no longer excludes the presence of TTS, and coronary artery disease is not considered an exclusion criterion. The experts concluded that four major types of TTS exist based on the distribution of regional wall motion abnormalities, including the typical apical ballooning type and three atypical TTS types (mid-ventricular, basal, and focal wall motion patterns), although other morphological variants are also evident.6 A diagnostic algorithm for TTS (Part II) incorporating the InterTAK Diagnostic Score was also proposed. This score comprises seven parameters, based on clinical features and electrocardiography, which can be used to predict the probability of the presence of TTS. The panel also summarized the latest evidence on the use of biomarkers (e.g. B-type natriuretic peptide, interleukin-6, and certain circulating microRNAs) and imaging techniques (e.g. computed tomography angiography and magnetic resonance imaging) that should help the clinician in their diagnostic workup (Part II). Finally, the panel proposed a therapeutic management approach for patients with TTS (Part II), based on clinical experience and expert consensus (evidence level C). For example, the panel recommends electrocardiogram monitoring in the acute phase, due to the occurrence of acute complications such as arrhythmias. In terms of medical management, the panel recommend beta-blockers should be used with caution as they may not be beneficial for acute or chronic treatment of TTS (even though catecholamine levels are elevated in TTS). For long-term management of TTS, the panel recommends angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers to prevent recurrence; however, they stress that this strategy requires validation. Indeed, as no prospective, randomized trials have been performed, it remains difficult to provide evidence-based guidelines for the medical management of TTS.7 The new consensus statement should facilitate timely and accurate diagnosis of TTS in daily clinical practice and improve patient outcomes. Nevertheless, there are many outstanding issues in the field. As such, further research is required to investigate the precise pathogenesis of TTS. Further research should continue to fill in the missing pieces on our understanding of TTS, thereby improving outcomes for patients with a ‘Broken Heart’ condition. Andros Tofield docandros@bluewin.ch Conflict of interest: none declared. References References are available as supplementary material at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

European Heart JournalOxford University Press

Published: Jun 7, 2018

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