International Journal of Cardiology 197 (2015) 208

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Invited Letter to the Editor Coronary flow assessment in Takotsubo cardiomyopathy with TIMI frame count Keywords: Takotsubo cardiomyopathy Diabetes mellitus TIMI frame count in Takotsubo cardiomyopathy Microcirculation in Takotsubo cardiomyopathy Left anterior descending artery

entity future large prospective studies will hopefully answer these questions. Funding None. Conflict of interest None.

To the Editor: We acknowledge with great interest the recent observations by Professor J.E. Madias [1] regarding our recently published article in International Journal of Cardiology entitled “Thrombolysis in Myocardial Infarction Frame Count (TFC) in Takotsubo cardiomyopathy (TC)” [2,3]. Madias et al. appropriately pointed out a key finding in our study i.e., the low prevalence of diabetes mellitus (DM) in our case subgroup which is in keeping with the recently published findings on comorbidities frequency in patients with TC [4,5]. The reported prevalence of DM in TC patients in these studies is between 10–17% [4,5] which is much lower than the previously reported National Health and Nutrition Examination Survey (NHANES) incidence of approximately 27% [5]. Based on these studies it has been hypothesized that the blunted autonomic responses and decreased catecholamine secretion in diabetes mellitus may play a protective role against the emergence of Takotsubo cardiomyopathy in the background of stressful triggers [5,6]. TIMI frame count provides an indirect assessment of microvascular function or coronary flow in patients with Takotsubo cardiomyopathy [2,3,6–8]. Previous studies have demonstrated multivessel (or diffuse) abnormalities of TFC involving all three coronary branches i.e., the left anterior descending (LAD), the left circumflex artery and the right coronary artery whereas our findings reflected abnormalities restricted to the territory of LAD alone [2,3]. The exact reason for this selective distribution of the microvascular function is uncertain. The selection criteria for our control population were age matched individuals presenting in the similar time frame as our case subgroup [2,3]. Most of our patients were referrals from other services with inconsistent time intervals of cardiac biomarkers, echocardiograms and thus coronary angiograms making it difficult to correlate these variables with the calculation of TIMI frame count [2,3]. We appreciate the astute comments of Professor Madias, and with the ever increasing awareness of this interesting

http://dx.doi.org/10.1016/j.ijcard.2015.06.078 0167-5273/© 2015 Published by Elsevier Ireland Ltd.

References [1] J.E. Madias, The complex issue of TIMI frame count in patients with Takotsubo syndrome, Int. J. Cardiol. 194 (2015) 65, http://dx.doi.org/10.1016/j.ijcard.2015.05.090 (Epub ahead of print). [2] N. Khalid, I. Iqbal, R. Coram, T. Raza, I. Fahsah, S. Ikram, Thrombolysis in myocardial infarction frame count in Takotsubo cardiomyopathy, Int. J. Cardiol. 191 (2015) 107–108. [3] N. Khalid, I. Iqbal, S. Ikram, Thrombolysis in myocardial infarction frame count in Takotsubo cardiomyopathy, J. Am. Coll. Cardiol. 61 (10_S) (2013) http://dx.doi.org/ 10.1016/S0735-1097 (13)60051-0. [4] F. Pelliccia, G. Parodi, C. Greco, et al., Comorbidities frequency in Takotsubo syndrome: an international collaborative systematic review including 1109 patients, Am. J. Med. 128 (2015) 654, http://dx.doi.org/10.1016/j.amjmed.2015.01.016 (e11-9). [5] J.E. Madias, Low prevalence of diabetes mellitus in patients with Takotsubo syndrome: a plausible ‘protective’ effect with pathophysiologic connotations, Eur. Heart J. Acute Cardiovasc. Care (2015) http://dx.doi.org/10.1177/2048872615570761 (pii: 2048872615570761. [Epub ahead of print]). [6] N. Khalid, Microcirculatory disorder hypothesis in Takotsubo cardiomyopathy, Int. J. Cardiol. 195 (2015) 29, http://dx.doi.org/10.1016/j.ijcard.2015.05.095 (Epub ahead of print). [7] N. Khalid, S.A. Ahmad, A. Umer, L. Chhabra, Role of microcirculatory disturbances and diabetic autonomic neuropathy in Takotsubo cardiomyopathy, Crit. Care Med. (2015) http://dx.doi.org/10.1097/CCM.0000000000001183. [8] N. Khalid, L. Chhabra, Takotsubo cardiomyopathy and microcirculatory dysfunction, Nat. Rev. Cardiol. (2015)http://dx.doi.org/10.1038/nrcardio.2015.88 [Epub ahead of print].

Nauman Khalid Department of Cardiovascular Medicine, University of Connecticut Health Center, Hartford Hospital, Hartford, CT, USA Corresponding author at: 263 Farmington Avenue, Farmington, CT (06030), USA. Tel.: +1 860 977 2879; fax: +1 888 598 6647. E-mail address: [email protected] Sohail Ikram Department of Cardiovascular Medicine, University of Louisville School of Medicine, Louisville, KY, USA 4 June 2015

Coronary flow assessment in Takotsubo cardiomyopathy with TIMI frame count.

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