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      International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology

      1 , 2 , 3 , 4 , 5 , 6 , 1 , 7 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 3 , 3 , 15 , 15 , 16 , 17 , 18 , 1 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 17 , 3 , 26 , 17 , 27 , 28 , 29 , 30 , 1
      European Heart Journal
      Oxford University Press
      Takotsubo syndrome, Broken heart syndrome, Takotsubo definition, Acute heart failure, Consensus statement, InterTAK Diagnostic Criteria

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          Takotsubo syndrome (TTS) is a poorly recognized heart disease that was initially regarded as a benign condition. Recently, it has been shown that TTS may be associated with severe clinical complications including death and that its prevalence is probably underestimated. Since current guidelines on TTS are lacking, it appears timely and important to provide an expert consensus statement on TTS. The clinical expert consensus document part I summarizes the current state of knowledge on clinical presentation and characteristics of TTS and agrees on controversies surrounding TTS such as nomenclature, different TTS types, role of coronary artery disease, and etiology. This consensus also proposes new diagnostic criteria based on current knowledge to improve diagnostic accuracy.

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          Most cited references177

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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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            Circadian variation in the frequency of onset of acute myocardial infarction.

            To determine whether the onset of myocardial infarction occurs randomly throughout the day, we analyzed the time of onset of pain in 2999 patients admitted with myocardial infarction. A marked circadian rhythm in the frequency of onset was detected, with a peak from 6 a.m. to noon (P less than 0.01). In 703 of the patients, the time of the first elevation in the plasma creatine kinase MB (CK-MB) level could be used to time the onset of myocardial infarction objectively. CK-MB-estimated timing confirmed the existence of a circadian rhythm, with a three-fold increase in the frequency of onset of myocardial infarction at peak (9 a.m.) as compared with trough (11 p.m.) periods. The circadian rhythm was not detected in patients receiving beta-adrenergic blocking agents before myocardial infarction but was present in those not receiving such therapy. If coronary arteries become vulnerable to occlusion when the intima covering an atherosclerotic plaque is disrupted, the circadian timing of myocardial infarction may result from a variation in the tendency to thrombosis. If the rhythmic processes that drive the circadian rhythm of myocardial-infarction onset can be identified, their modification may delay or prevent the occurrence of infarction.
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              Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigations in Japan.

              To determine the clinical features of a novel heart syndrome with transient left ventricular (LV) apical ballooning, but without coronary artery stenosis, that mimics acute myocardial infarction, we performed a multicenter retrospective enrollment study. Only several case presentations have been reported with regard to this syndrome. We analyzed 88 patients (12 men and 76 women), aged 67 +/- 13 years, who fulfilled the following criteria: 1) transient LV apical ballooning, 2) no significant angiographic stenosis, and 3) no known cardiomyopathies. Thirt-eight (43%) patients had preceding aggravation of underlying disorders (cerebrovascular accident [n = 3], epilepsy [n = 3], exacerbated bronchial asthma [n = 3], acute abdomen [n = 7]) and noncardiac surgery or medical procedure (n = 11) at the onset. Twenty-four (27%) patients had emotional and physical problems (sudden accident [n = 2], death/funeral of a family member [n = 7], inexperience with exercise [n = 6], quarreling or excessive alcohol consumption [n = 5] and vigorous excitation [n = 4]). Chest symptoms (67%), electrocardiographic changes (ST elevation [90%], Q-wave formation [27%] and T-wave inversion [97%]) and elevated creatine kinase (56%) were found. After treatment of pulmonary edema (22%), cardiogenic shock (15%) and ventricular tachycardia/fibrillation (9%), 85 patients had class I New York Heart Association function on discharge. The LV ejection fraction improved from 41 +/- 11% to 64 +/- 10%. Transient intraventricular pressure gradient and provocative vasospasm were documented in 13/72 (18%) and 10/48 (21%) of the patients, respectively. During follow-up for 13 +/- 14 months, two patients showed recurrence, and one died suddenly. A novel cardiomyopathy with transient apical ballooning was reported. Emotional or physical stress might play a key role in this cardiomyopathy, but the precise etiologic basis still remains unclear.

                Author and article information

                Eur Heart J
                Eur. Heart J
                European Heart Journal
                Oxford University Press
                07 June 2018
                29 May 2018
                29 May 2018
                : 39
                : 22 , Focus Issue on Takotsubo
                : 2032-2046
                [1 ]University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
                [2 ]Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
                [3 ]Division of Cardiovascular Diseases Mayo Clinic, Rochester, MN, USA
                [4 ]Cardiovascular Research Division, Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
                [5 ]Department of Cardiology, Hiroshima City Asa Hospital, Hiroshima, Japan
                [6 ]Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
                [7 ]Department of Cardiovascular Sciences, Catholic University of the Sacred Heart, Rome, Italy
                [8 ]Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
                [9 ]Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
                [10 ]Department of Cardiovascular Medicine, Onga Nakama Medical Association Onga Hospital, Fukuoka, Japan
                [11 ]Clinica Medica, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
                [12 ]University Heart Center Luebeck, Medical Clinic II, Department of Cardiology, Angiology and Intensive Care Medicine, University of Luebeck, Luebeck, Germany
                [13 ]Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
                [14 ]Department of Cardiology, University Hospital Giessen, Giessen, Germany
                [15 ]Heart Department, University Hospital “San Giovanni di Dio e Ruggi d'Aragona”, Salerno, Italy
                [16 ]Department of Anatomy and Cell Biology, Wakayama Medical University School of Medicine, Wakayama, Japan
                [17 ]Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua Medical School, Padova, Italy
                [18 ]Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
                [19 ]Division of Cardiovascular Disease, Department of Medicine, University of Florida, Gainesville, FL, USA
                [20 ]NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
                [21 ]National Heart and Lung Institute, Imperial College, London, UK
                [22 ]Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
                [23 ]Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
                [24 ]Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
                [25 ]Department of Cardiology and Intensive Care, Centre Hospitalier de Compiegne, Compiegne, France
                [26 ]Department of Cardiology, Karolinska University Hospital, Huddinge, Stockholm, Sweden
                [27 ]Department of Cardiology, Basil Hetzel Institute, Queen Elizabeth Hospital, University of Adelaide, Adelaide, Australia
                [28 ]Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
                [29 ]Center for Molecular Cardiology, Schlieren Campus, University of Zurich, Zurich, Switzerland
                [30 ]Department of Cardiology, Royal Brompton & Harefield Hospital and Imperial College, London, UK
                Author notes

                The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

                This paper was guest edited by Bernard J. Gersh (Mayo Clinic, gersh.bernard@ 123456mayo.edu ).

                Corresponding author. Tel: +41 44 255 9585, Fax: +41 44 255 4401, Email: christian.templin@ 123456usz.ch


                © The Author(s) 2018. 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 Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                Page count
                Pages: 15
                Consensus Paper
                Editor's Choice

                Cardiovascular Medicine
                takotsubo syndrome,broken heart syndrome,takotsubo definition,acute heart failure,consensus statement,intertak diagnostic criteria


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