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      Lifelong recurrent takotsubo cardiomyopathy: a case report

      case-report

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          Abstract

          Background

          Takotsubo cardiomyopathy is a transient left ventricular dysfunction with an established recurrence rate in populations, however, recurrences in the same individual have not been well described.

          Case summary

          We present a 76-year-old woman who had likely a total of six recurrent takotsubo cardiomyopathy episodes spanning over 33 years. Her diagnosis of takotsubo cardiomyopathy was first made in 2014 when she presented with chest pain, raised cardiac enzymes, and the presence of normal coronary arteries. Cardiac magnetic resonance was performed, ruling out any current or previous myocardial infarction. Subsequently, she had two further recurrences in 2015 and 2018. Stressors were identified on three occasions. She was diagnosed with ‘myocardial infarction’ in 1986, 1988, and 1998 when she presented with chest pain and electrocardiogram changes, despite demonstrating normal coronary arteries on each occasion.

          Discussion

          This case demonstrates three confirmed recurrent episodes of takotsubo in the same individual, showing three different left ventricular phenotypic morphologies on the background of three previous episodes of ‘myocardial infarction with normal coronary arteries’, which most likely might have been takotsubo episodes as well. Any myocardial infarction-type injury was definitely ruled out in the 2014 admission instigating a potential change in this patient’s past medical history and implicitly requirement for lifelong secondary prevention. It is notably difficult to make a confirmed diagnosis of takotsubo cardiomyopathy back in 1986, 1988, and 1998 due to the lack of awareness in this novel topic.

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          Most cited references4

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          Natural history and expansive clinical profile of stress (tako-tsubo) cardiomyopathy.

          This study was designed to define more completely the clinical spectrum and consequences of stress cardiomyopathy (SC) beyond the acute event. Stress cardiomyopathy is a recently recognized condition characterized by transient cardiac dysfunction with ventricular ballooning. Clinical profile and outcome were prospectively assessed in 136 consecutive SC patients. Patients were predominantly women (n = 130; 96%), but 6 were men (4%). Ages were 32 to 94 years (mean age 68 +/- 13 years); 13 (10%) were 2 months in 5%. Right and/or left ventricular thrombi were identified in 5 patients (predominantly by CMR imaging), including 2 with embolic events. Three patients (2%) died in-hospital and 116 (85%) have survived, including 5% with nonfatal recurrent SC events. All-cause mortality during follow-up exceeded a matched general population (p = 0.016) with most deaths occurring in the first year. In this large SC cohort, the clinical spectrum was heterogeneous with about one-third either male,
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            Four-year recurrence rate and prognosis of the apical ballooning syndrome.

            This study sought to assess the long-term prognosis of patients with apical ballooning syndrome (ABS). Apical ballooning syndrome is a recently described acute cardiac syndrome of uncertain etiology and prognosis. We retrospectively identified 100 unselected patients with a confirmed diagnosis of ABS by angiography. Recurrences of ABS and mortality were recorded. Over a mean follow-up of 4.4 +/- 4.6 years, 31 patients continued to have episodes of chest pain and 10 patients had recurrence of ABS, for a recurrence rate of 11.4% over the first 4 years. Seventeen patients died in 4.7 +/- 4.8 years of follow-up. There was no difference in survival or in cardiovascular survival to an age- and gender-matched population. The recurrence rate for ABS was 11.4% over 4 years after initial presentation. Recurrence of chest pain is common. Four-year survival was not different from that in an age-matched and gender-matched population.
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              Clinical and echocardiographic analysis of patients suffering from recurrent takotsubo cardiomyopathy

              Background Recurrence of takotsubo cardiomyopathy (TTC) is a well-known complication. However, current literature lists only a few isolated cases. We aimed to determine the incidence and clinical significance of recurrent TTC. Methods & Results Our institutional database constituted a collective of 114 patients diagnosed with TTC since 2003. Close follow-up of these patients revealed a recurrence of TTC in seven of these (6.1%). The time interval between the index event and its recurrence varied between six months and six years. Arterial hypertension was more revealed in the recurrence group of TTC compared to non-recurrence group, (P = 0.02). Chronic obstructive pulmonary disease and/or asthma was more diagnosed in the recurrence group, (P = 0.04). Clinical events like right ventricular involvement, TTC related complications such as life-threatening arrhythmias, pulmonary congestion and in hospital death were observed more frequently in the recurrent episode. Over a mean follow-up of one year the mortality rate was similar in both groups. Conclusions Recurrence of TTC within six years after index event is not an uncommon phenomenon. In the event of right ventricular involvement in the relapse phase, it might be associated with a higher complication rate. TTC recurrence should be the first differential diagnosis in patients with a past history of TTC.
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                Author and article information

                Contributors
                Role: Handling Editor
                Role: Editor
                Role: Editor
                Role: Editor
                Role: Editor
                Journal
                Eur Heart J Case Rep
                Eur Heart J Case Rep
                ehjcr
                European Heart Journal: Case Reports
                Oxford University Press
                2514-2119
                December 2019
                24 October 2019
                24 October 2019
                : 3
                : 4
                : 1-5
                Affiliations
                [1 ] Department of Cardiology, Aberdeen Royal Infirmary , Foresterhill Campus, Aberdeen AB25 2ZN, UK
                [2 ] School of Medicine and Dentistry, University of Aberdeen , Aberdeen AB25 2ZD, UK
                Author notes
                Corresponding author. Tel: +44 781 899 1658, Email: shekinah.kmchandy@ 123456nhs.net ; shekinahgrace2406@ 123456gmail.com
                Author information
                http://orcid.org/0000-0001-8016-0159
                http://orcid.org/0000-0003-2815-4469
                Article
                ytz191
                10.1093/ehjcr/ytz191
                7042134
                618a9708-7dc2-4395-957e-a495d934efe9
                © The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 19 June 2019
                : 27 June 2019
                : 01 October 2019
                Page count
                Pages: 5
                Funding
                Funded by: British Heart Foundation 10.13039/501100000274
                Award ID: PG/15/108/31928
                Categories
                Case Reports

                takotsubo cardiomyopathy,lifelong recurrence,variant morphologies,acute myocardial infarction,case report

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