IJCA-18205; No of Pages 2 International Journal of Cardiology xxx (2014) xxx–xxx

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Letter to the Editor

A proposal for a diagnostic index for the differentiation between Takotsubo syndrome and acute coronary syndromes John E. Madias ⁎ Icahn School of Medicine at Mount Sinai, New York, NY, United States Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, United States

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Article history: Received 23 April 2014 Accepted 12 May 2014 Available online xxxx Keywords: Takotsubo syndrome Diagnostic indices Acute coronary syndromes Myocardial infarction Cardiac biomarkers Troponins Brain natriuretic peptides

To the Editor: A number of diagnostic indices for the differentiation between Takotsubo syndrome (TTS) and acute coronary syndromes (ACS) and/ or acute ST-segment elevation myocardial infarction (STEMI) have been proposed [1–3]; however what is imperative is not to provide laboratory algorithms which in retrospect show an association of these diagnostic markers with either of these 2 pathologies, but to conceive indices which could be employed to obviate the need for resort to coronary arteriography (COAR) for such differentiation. Since time is of the essence, and clinicians do not have the luxury to wait for acquisition of the peak values or appearances of laboratory biomarkers, by repeating blood sampling and waiting for the results, or recording the echocardiogram (ECHO), and the electrocardiogram (ECG) 2 or 3 times, it is paramount that we examine whether the single first post admission value, in the case of blood biomarkers, or appearance in the case of the ECHO and the ECG, by themselves, or in combination, are robust enough to provide immediate diagnostic differentiation between TTS and ACS. Appearances of the ECG (ST-segment elevation, T-wave inversion, Q-waves, and QTc prolongation) cannot differentiate TTS from ACS, but there are some ECG features summarized in a recent publication ⁎ Division of Cardiology, Elmhurst Hospital Center, 79–01 Broadway, Elmhurst, NY 11373, United States. Tel.: +1 718 334 5005; fax: +1 718 334 5990. E-mail address: [email protected].

[1], which can be employed for such differentiation, with modest success. In addition attenuation of the amplitude of the QRS complexes, either present in the admission ECG as a low voltage QRS, or realized by comparison with subsequent recorded ECGs in patients with TTS may provide an enhancement [1]. The ECG has some advantages in comparison with diagnostic blood biomarker while preparations for COAR are under way, because it can be repeated many times with results becoming available instantly, or comparison of the admission ECG with previous ECGs of the patients, recorded anywhere in the world can be attempted aided by “personal smart health cards”, “smart phones”, and “cloud computing” [1]. Performance of an ECHO upon admission may be very helpful in the diagnosis of TTS, with the appearance of a systolic apical and mid-ventricular “ballooning” and basal hyperkinesis, with a depressed left ventricular ejection fraction (LVEF) often more marked than the one noted in patients with ACS [2], and has been employed in combination with the values of troponin I (Tp I) in a product form (TEFP) This diagnostic tool employs an acute ECHO, but a peak TpI [2], and as per requirements outlined above, it would be of interest to evaluate the EEFP, based on the acute ECHO LVEF and the initial TpI value. Blood cardiac biomarkers like TpI, troponin T (TpT), creatine kinase (CK), creatine kinase MB fraction (CK-MB), and B-type natriuretic peptide (BNP), and N-terminal of the prohormone BNP (NT-proBNP) are included in the biochemical diagnostic panels employed on admission of patients who are thought to have either an ACS or TTS [2,3]. Indeed a recent study [3] employed the first simultaneously drawn laboratory values of BNP, TpT, and CK-MB in the form of ratios of BNP/TpT and BNP/CK-MB in the differentiation of TTS, based on the observation that BNP values are higher and TpT and TpT and CK-MB are lower in patients with TTS as compared with patients with acute STEMI, resulting in both ratios being higher in patients with TTS, than in patients with STEMI. Synthesizing the above one could consider including BNP (or NT-proBNP), TpI (or TpT), CK, and CK-MB, and LVEF (derived by ECHO) in an index employing the form of a ratio, appearing as follows: “BNP/TpI × CK × CK-MB × LVEF”. Another version could be “BNP/TpI × CK-MB × LVEF”. Finally if data from the ECG are available based on a comparison of the admission ECG with a previous ECG, in reference to the degree of attenuation of the QRS complexes in sums of either limb or precordial leads, or lead aVR (ΔΣQRS or ΔQRS), in the form of “BNP × ΔΣQRS/TpI × CK-MB × LVEF”, or “BNP × ΔΣQRS/TpI × CK × CK-MB × LVEF”. Variables which are proportionally higher in patients with TTS than in those with ACS or STEMI would be placed

http://dx.doi.org/10.1016/j.ijcard.2014.05.033 0167-5273/© 2014 Elsevier Ireland. Ltd

Please cite this article as: Madias JE, A proposal for a diagnostic index for the differentiation between Takotsubo syndrome and acute coronary syndromes, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.05.033

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in the numerator of the ratios, while variables which are lower in patients with TTS than in those with ACS or STEMI would be placed in the denominator of the ratios. Since test values for all the essential components of the above described formulas are acquired on admission routinely for patients suspected of having an ACS or TTS, these formulas can be compared with what has been employed so far in the literature [2,3], as to their performance in differentiating these 2 conditions. Conflicts of interest None.

References [1] Madias JE. Transient attenuation of the amplitude of the QRS complexes in the diagnosis of Takotsubo theo syndrome. Eur Heart J Acute Cardiovasc Care 2014 Mar;3(1):28–36. [2] Nascimento FO, Yang S, Larrauri-Reyes M, et al. Usefulness of the troponin-ejection fraction product to differentiate stress cardiomyopathy from ST-segment elevation myocardial infarction. Am J Cardiol 2014 Feb 1;113(3):429–33. [3] Randhawa MS, Dhillon AS, Taylor HC, Sun Z, Desai MY. Diagnostic utility of cardiac biomarkers in discriminating Takotsubo cardiomyopathy from acute myocardial infarction. J Card Fail 2014 Jan;20(1):2–8.

Please cite this article as: Madias JE, A proposal for a diagnostic index for the differentiation between Takotsubo syndrome and acute coronary syndromes, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.05.033

A proposal for a diagnostic index for the differentiation between Takotsubo syndrome and acute coronary syndromes.

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