Invited commentary Takotsubo cardiomyopathy following epidural steroid injection: yet another way to break the heart n the relatively short period of time since takotsubo cardiomyopathy was described in Japan (1) or introduced to the United States (2), there has been an explosion of publications regarding the ways the cardiomyopathy is triggered, the patterns of the cardiomyopathy itself (typical and atypical), and potential mechanisms for the underlying pathology (3–5). Dr. McAllister et al describe yet another way in which patients with normal (or nearly normal) coronary arteries can incur devastating yet transient damage to the heart during physiologic and emotional stress. The patient in this case had several stressful issues occurring simultaneously, including the death of a brother, the declining health of her husband, and the pain of both her postherpetic neuralgia as well as the procedure to treat that pain. The features of this case, including the physical and emotional stress and the age and gender of the patient, have become commonplace and well recognized. It is such a well-recognized pattern that cardiology fellows see a ventriculogram of a left anterior descending artery infarct and mistakenly assume that it is another example of takotsubo cardiomyopathy rather than the much more common ischemic cardiomyopathy. While the triggers of the events seem to be a variety of stresses, it is becoming clearer that the final common pathophysiology pathway may be coronary spasm, although the details remain to be worked out (6). There are still many questions to answer, including why takotsubo cardiomyopathy happens infrequently, why there is an incredibly strong preponderance in menopausal women, and why it is so uncommon for a patient who had an initial event to experience it a second time.

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A recent article by Tobis suggests that gathering and collating data from multiple centers may allow us to gain insights into the cause of this fascinating and uncommon disease (7). With additional cases and information, the mystery may yet be solved. —Jeffrey M. Schussler, MD Division of Cardiology, Baylor University Medical Center Texas A&M Health Science Center, College of Medicine Dallas, Texas (e-mail: Jeff[email protected]) 1.

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Dote K, Sato H, Tateishi H, Uchida T, Ishihara M. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases [article in Japanese]. J Cardiol 1991;21(2):203–214. Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, Wu KC, Rade JJ, Bivalacqua TJ, Champion HC. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352(6):539–548. Mikail N, Hess S, Jesel L, El Ghannudi S, El Husseini Z, Trinh A, Ohlmann P, Morel O, Imperiale A. Takotsubo and takotsubo-like syndrome: a common neurogenic myocardial stunning pathway? Int J Cardiol 2013;166(1):248–250. Patankar GR, Choi JW, Schussler JM. Reverse takotsubo cardiomyopathy: two case reports and review of the literature. J Med Case Rep 2013;7(1):84. Patankar GR, Donsky MS, Schussler JM. Delayed takotsubo cardiomyopathy caused by excessive exogenous epinephrine administration after the treatment of angioedema. Proc (Bayl Univ Med Cent) 2012;25(3):229–230. Patel SM, Lerman A, Lennon RJ, Prasad A. Impaired coronary microvascular reactivity in women with apical ballooning syndrome (takotsubo/stress cardiomyopathy). Eur Heart J Acute Cardiovasc Care 2013;2(2):147–152. Tobis J. Takotsubo syndrome: a call to action. Catheter Cardiovasc Interv 2013;82914.

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