International Journal of Cardiology 189 (2015) 197

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Letter to the Editor

Myopericarditis and takotsubo cardiomyopathy association: Author's reply Tsutomu Yoshikawa Department of Cardiology, Sakakibara Heart Institute, 2-5-4 Yoyogi, Shibuya-ku, 153-3111, Japan

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Article history: Received 6 April 2015 Accepted 8 April 2015 Available online 9 April 2015 Keywords: Takotsubo cardiomyopathy Myocarditis Pericarditis Inflammation

stress. Tissues obtained from this disorder have shown the presence of contraction band necrosis as well as some deposition with macrophage [7]. But, there are few reports supporting massive infiltration with inflammatory cells in takotsubo cardiomyopathy that is a characteristic feature in acute fulminant myocarditis. In this regard, further studies are required to confirm the association of myopericarditis with takotsubo cardiomyopathy, although some inflammatory processes indeed play a role in mediating the pathophysiology of this disorder. Funding None. Conflict of interest

In a letter from Chhabra L., et al., he proposed that there was an association between takotsubo cardiomyopathy and myopericarditis [1–3]. They stressed the importance of the role played by inflammatory process in the pathophysiology of takotsubo cardiomyopathy. I agree with this notion in terms of the following findings that have been previously reported. There are some evidences suggesting that cardiac inflammation plays a role in the pathophysiology of takotsubo cardiomyopathy. A study using magnetic resonance imaging showed that T2 imaging reflecting acute myocardial inflammation was positive in 67% of patients. In addition, myocardial edema was visible in 81%, and focal or patchy late gadolinium enhancement (LGE) was positive in 9% of patients. Patients with such minor LGE was associated with higher troponin levels at presentation [4]. ST segment elevation at initial presentation also supports this hypothesis. Cardiac biomarkers for myocardial damage such as creatinine phosphokinase and troponin are elevated in almost all the cases [5]. These findings suggest that inflammatory process is one of the pivotal features characterizing takotsubo cardiomyopathy. There are reports on cardiac rupture in cases with takotsubo cardiomyopathy [6]. In such cases, preceding episode of pericarditis almost always occurs. There are also evidences suggesting the role of oxidative

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http://dx.doi.org/10.1016/j.ijcard.2015.04.053 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.

None. References [1] L. Chhabra, N. Khalid, J. Kluger, D.H. Spodick, Lupus myopericarditis as a preceding stressor for takotsubo cardiomyopathy, Proc. (Baylor Univ. Med. Cent.) 27 (2014) 327–330. [2] H.R. Omar, Takotsubo–pericarditis association, Am. J. Emerg. Med. 30 (2012) 382–383. [3] J.W. Li, S. Nanda, S. Kongo, Acute pericarditis induced stress cardiomyopathy, Acta Cardiol. 65 (2010) 361–364. [4] I. Eitel, F. von Knobelsdorff-Brenkenhoff, P. Bernhardt, I. Carbone, K. Muellerleile, A. Aldrovandi, M. Francone, S. Desch, M. Gutberlet, O. Strohm, G. Schuler, J. SchulzMenger, H. Thiele, M.G. Friedrich, Clinical characteristics and cardiovascular magnetic resonance findings in stress (takotsubo) cardiomyopathy, JAMA 306 (2011) 277–286. [5] M. Madhavan, B.A. Borlaug, A. Lerman, C.S. Rihal, A. Prasad, Stress hormone and circulating biomarker profile of apical ballooning syndrome (Takotsubo cardiomyopathy): insights into the clinical significance of B-type natriuretic peptide and troponin levels, Heart 95 (2009) 1436–1441. [6] M. Jaguszewski, M. Fijalkowski, R. Nowak, P. Czapiewski, J.R. Ghadri, C. Templin, A. Rynkiewicz, Ventricular rupture in Takotsubo cardiomyopathy, Eur. Heart J. 33 (2012) 1027. [7] H.M. Nef, H. Möllmann, Y.J. Akashi, C.W. Hamm, Mechanisms of stress (Takotsubo) cardiomyopathy, Nat. Rev. Cardiol. 7 (2010) 187–193.

Myopericarditis and takotsubo cardiomyopathy association: Author's reply.

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