Focal type of the Takotsubo (stress) Cardiomyopathy
Marcos Danillo Peixoto Oliveira*, Ednelson Cunha Navarro, Rafaella Pinto Ferraz, Glenda Alves de Sá, Helio Jose Castello Júnior and Marcelo José de Carvalho Cantarelli
Department of Interventional Cardiology, Hospital Regional do Vale do Paraíba, Brazil
Submission: November 30, 2018; Published: January 24, 2019
*Corresponding author: Marcos Danillo Peixoto Oliveira, Department of Interventional Cardiology, Hospital Regional do Vale do Paraíba, Avenida Tiradentes, 280, Jardim das Nações, Taubaté - SP, Brazil
How to cite this article:Marcos D P O, Ednelson C N, Rafaella P F, Glenda A d S, et al. Focal type of the Takotsubo (stress) Cardiomyopathy. J Cardiol &
Cardiovasc Ther. 2019; 12(5): 555850. DOI: 10.19080/JOCCT.2019.12.555850
Takotsubo (stress) cardiomyopathy is characterized by transient systolic and diastolic left ventricular dysfunction with a variety of wall-motion abnormalities. it predominantly affects elderly women and is often preceded by emotional and/or physical triggers but has also been reported without evident trigger(s). The clinical presentation, electrocardiographic findings and cardiac biomarker profiles are often similar to those of Acute Coronary Syndromes (ACS). We report herein an interesting case of the most rare (focal) type of the Takotsubo (stress) cardiomyopathy.
Keywords: Cardiomiopathy, left ventricular; Electrocardiographic; Acute coronary syndromes; Brain–heart axis, Cigarrete smoker and alcoholic, Sincopal episodes, Dynamic alterations, Antero-lateral,
First described in Japan in 1990 , Takotsubo (stress) cardiomyopathy (TSC) is characterized by transient systolic and diastolic Left Ventricular (LV) dysfunction with a variet of wall-motion abnormalities [2,3]. Its name derives from the Japanese word takotsubo (“octopus pot”), describing the marked ballooning of the LV apex .
Generally recognized as a benign disorder, it predominantly affects elderly women and is often preceded by emotional and/or
physical triggers,  but has also been reported without evident trigger(s). The clinical presentation, electrocardiographic findings and cardiac biomarker profiles are often similar to those of Acute Coronary Syndromes (ACS).
Although the causes of TSC remain unknown, the role of the brain–heart axis in the pathogenesis of the disease has been described [6,7]. We report an interesting case of the most rare (focal) type of the Takotsubo (stress) cardiomyopathy.
A 45-years-old man, active, current cigarrete smoker and
alcoholic, without any other relevant classic cardiovascular risk
factors or co-morbidities. Due to recurrent sin copal episodes,
without chest pain, he was conducted to the emergency
department by his family. The serial resting electrocardiograms
revealed interesting dynamic alterations: initially marked
antero-lateral subepicardial ischemia; then, additional inferior
subepicardial ischemia; and, ultimately, it turned to the initial
isolated antero-lateral subepicardial ischemia. There was a typical
positive raising of the cardiac troponin. The clinical examination
was unremarkable. He was then referred to the catheterization
laboratory to an urgent invasive coronary stratification. Beyond
a mild mid portion left anterior descending myocardial bridging,
there were no significant coronary stenosis at any point (Figure
1). Surprisingly, it was found a focal (mid anterior wall) left
ventricular systolic dysfunction (akinesia), compatible with the
most rare (focal) type of TSC (Figure 2). Due to the absence of
significant coronary artery disease, the patient was optimally
medical managed, with aspirin, statin, angiotensin-convertingenzyme
inhibitor and beta-blocker, without recurrence of sincopal
episodes or any other related symptoms.
Templin et al.  recently demonstrated that TSC represents
an acute heart failure syndrome associated with a substantial risk
for adverse events. There is an uneven sex distribution, with a
female-to-male ratio of 9:1 [4,8]. TSC is predominantly preceded
by emotional triggers, but it may also occur with physical triggers
or even without any evident preceding factors [4-7], like in this
Of note, the coronary microcirculation is innervated
by neurons that originate in the brain stem and mediate
vasoconstriction, which supports the concept that myocardial
stunning due to microvascular dysfunction among patients with
takotsubo cardiomyopathy may be of neurogenic origin . Since
patients with TSC commonly present with symptoms similar to
those of ACS, initial diagnosis and treatment in the emergency
room remains challenging .
Therefore, early coronary angiography remains necessary
to rule out an ACS. Notably, up to 15.3% of patients with TSC
may have evidence of coexisting coronary artery disease on
angiography . This finding shows that the presence of coronary
artery disease is not an exclusion criterion for the diagnosis of TSC
Among the 1750 patients of The International Takotsubo
Registry (www.takotsubo-registry.com), the most common was
the apical type (81.7%), followed by the midventricular type
(14.6%), the basal type (2.2%) and the focal type (in only 1.5% of
patients). The case reported here reproduces the most rare (focal)
type of this condition.
TSC should be considered to be an acute heart failure
syndrome, as reflected by the markedly increased levels of brain
natriuretic peptide and left ventricular end-diastolic pressure.
Consistently, systolic LV function was reduced to an even greater
extent among patients with takotsubo cardiomyopathy than
among those with an acute coronary syndrome .
The spectrum of TSC is wide and ranges from low to very high
risk in the acute phase. The relatively rapid recovery of LV function
and a selection bias of previous reports toward low-risk patients
generated the misapprehension that it is a universally benign
disease. This condition, however, represents an acute heart failure
syndrome with substantial morbidity and mortality .