International Journal of Cardiology 172 (2014) e182–e183
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
“Happiness” and stress cardiomyopathy (apical ballooning syndrome/takotsubo syndrome) Dingxin Qin, Sandeep M. Patel, Hunter C. Champion ⁎ The Heart and Vascular Institute, Vascular Medicine Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
a r t i c l e
i n f o
Article history: Received 22 October 2013 Accepted 23 December 2013 Available online 4 January 2014 Keywords: Stress cardiomyopathy Takotsubo cardiomyopathy Happiness Positive emotions
Stress cardiomyopathy (SCM)/apical balloon syndrome (ABS; takotsubo cardiomyopathy) is a transient cardiomyopathy that is often associated with acute emotional or physical stress. Happiness or positive emotional excitement has not been previously identified as an inciting factor for SCM/ABS. In this letter, we report three cases of SCM/ABS occurring in association with positive emotions and discuss the possible link between “happy emotions” and cardiovascular diseases. Case 1. A 66-year-old female with a history of hypertension, hyperlipidemia and generalized anxiety disorder presented with acute onset of dizziness and nausea that began prior to boarding a plane to meet with her husband in China. Patient reported feeling immensely joyful and excited about the trip before the discomfort started. She denied any previous history of heart disease or cerebrovascular events. On admission, acute cerebrovascular accident was suspected and a thorough neurological evaluation was negative. Initial electrocardiogram showed normal sinus rhythm with deep, symmetrically inverted T-waves appeared in inferior and lateral leads. Blood work revealed a troponin-I level of 6.58 ng/dL (b 0.02). The patient was treated for acute coronary syndrome with appropriate medical therapy. Echocardiogram on the day of admission showed akinesis of the apex, mid to apical anterior wall and inferior wall with an ejection fraction of 30–35%. The patient then underwent coronary angiography which revealed only mild luminal
⁎ Corresponding author at: University of Pittsburgh, Bioscience Medical Tower, Suite E1243, 200 Lothrop Street, Pittsburgh, PA 15213, United States. Tel.: +1 412 624 8140; fax: +1 412 648 5980. E-mail address: [email protected] (H.C. Champion). 0167-5273/$ – see front matter © 2013 Published by Elsevier Ireland Ltd. http://dx.doi.org/10.1016/j.ijcard.2013.12.140
irregularities in the major epicardial vessels. A left ventriculogram (rightanterior oblique projection) demonstrated apical akinesis consistent with SCM/ABS. The patient's symptoms were resolved with medical therapy and she was discharged home on the fourth day of hospitalization. Followup transthoracic echocardiogram 4 weeks later demonstrated a complete recovery of the cardiac function without any regional wall motion abnormalities. Case 2. A 71-year-old female with a history of diabetes mellitus type 2, hypertension and hyperlipidemia was admitted for complaints of severe chest pain which began while she was attending her grandson's wedding. Patient reported being delightful and excited the entire day. As the end of the wedding ceremony approached, she developed a suddenonset of substernal chest pain radiating to the right shoulder, associated with shortness of breath. Patient took several of her husband's
Fig. 1. Left ventriculogram (RAO projection). Representative left ventriculogram demonstrating a typical hypercontractile base with apical ballooning/dyskinesia during systole as well described in ABS patients.
D. Qin et al. / International Journal of Cardiology 172 (2014) e182–e183
Fig. 2. Transthoracic echocardiogram (4-chamber). Four-chamber transthoracic echocardiogram demonstrating ballooning of the apex with preserved contractility in the base.
sublingual nitroglycerin tablets which provided temporary relief. She reported no previous history of heart disease. She denied any history of depression, anxiety, or recent emotional or physical stress. On presentation to the emergency department, her electrocardiogram showed normal sinus rhythm with a heart rate of 80 beats per minute and a 2 mm ST-segment elevation in the high lateral leads. Troponin-I level peaked at 1.91 ng/dL. Emergent coronary angiogram showed grossly patent coronary arteries with less than 20% stenosis in the left anterior descending and left circumflex arteries. Left ventriculogram revealed a dyskinetic apex with apical ballooning, a hyperdynamic base and an ejection fraction of 35% (Fig. 1). Transthoracic echocardiogram on the same day also revealed wall motion abnormalities consistent with SCM/ABS with LVEF of 35–40% (Fig. 2). The patient was treated with aspirin, beta-blockade, ace-inhibition, and statin therapy. She had no recurrent cardiac issues during the admission and was discharged home. Follow-up transthoracic echocardiogram 2 months later showed a normal ejection fraction and a complete resolution of the regional wall motion abnormalities. Case 3. A 63-year-old female with a history of stress cardiomyopathy in 2002 (due to a runway horse experience) presented with acute chest pain and shortness of breath when attending her daughter's graduation ceremony (11 years after her prior episode). She noted that she was very ecstatic during her daughter's graduation, when a sudden rush of severe chest pain and shortness of breath occurred. She denied any history of hypertension, diabetes, hyperlipidemia, tobacco abuse, anxiety, depression or coronary artery disease. Upon presenting to the local hospital, the electrocardiogram, echocardiogram and left heart catheterization findings were consistent with typical stress cardiomyopathy, and she was treated with betablockade, ace-inhibition and other supportive treatments. A full resolution of ejection fraction was noted in the follow-up echocardiogram. Discussion. As demonstrated in previous studies, emotional excitement, like other psychological stresses, can be associated with increased
e183
incidence of acute cardiovascular events. Wilbert-Lampen et al. showed that on days of the World Cup matches involving Germany, the incidence of acute myocardial infarction and symptomatic arrhythmia more than doubled in the great Munich area [1]. The extent of such an increase was unchanged even when Germany was winning the game, while such connection was more prominent among males and those with a previous history of coronary artery disease. While among SCM/ ABS cases, the emotional stress has only been reported as negative emotions like anger, frustration, grief, pain, fear, anxiety or interpersonal conflict. To the best of our knowledge, our report is the first series of ABS cases that were triggered by positive emotional excitement, and all three of our patients were females with no previous history of coronary artery disease. The possible mechanisms of the connection between emotional excitement and acute cardiovascular events involve sympathetic activation (supply vs. response) and endothelial dysfunction [2]. Piira et al. demonstrated that among enthusiastic ice-hockey spectators with stable CAD, both plasma catecholamines and endothelin-1 levels were markedly elevated before an ice-hockey match [2]. On the other hand, there is increasing evidence that sympathetic stimulation may play an important pathogenic role in the development of SCM/ABS [3–5]. Plasma catecholamines levels have been found to be significantly elevated in SCM/ABS patients; intravenous catecholamines were shown to precipitate the syndrome; and a recent study in rats suggest that Gi activation at high epinephrine concentration may underpin the acute depression of apical activities in the model [6]. Therefore, sympathetic activation with catecholamine increase may have also played an important role in the three SCM/ABS cases associated with positive emotional excitement in our report. Further, the history of anxiety disorder, hypertension, hyperlipidemia and diabetes mellitus in our ABS cases may serve as predisposing factors as reported in previous studies [7]. Although a positive psychological well-being has generally been considered to be protective for cardiovascular disease [8], our report suggests that positive emotional excitement can possibly trigger transient left ventricular dysfunction in elderly female patients with no previous history of coronary artery disease. References [1] Wilbert-Lampen U, Leistner D, Greven S, et al. Cardiovascular events during World Cup soccer. N Engl J Med Jan 31 2008;358(5):475–83. [2] Piira O-P, Mustonen PE, Miettinen JA, Huikuri HV, Tulppo MP. Leisure time emotional excitement increases endothelin-1 and interleukin-6 in cardiac patients. Scand Cardiovasc J Feb 2012;46(1):7–15. [3] Wittstein IS, Thiemann DR, Lima JAC, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med Feb 10 2005;352(6):539–48. [4] Wittstein IS. Stress cardiomyopathy: a syndrome of catecholamine-mediated myocardial stunning? Cell Mol Neurobiol Feb 2 2012;32(5):847–57. [5] Abraham J, Mudd JO, Kapur N, Klein K, Champion HC, Wittstein IS. Stress cardiomyopathy after intravenous administration of catecholamines and beta-receptor agonists. J Am Coll Cardiol Apr 14 2009;53(15):1320–5. [6] Paur H, Wright PT, Sikkel MB, et al. High levels of circulating epinephrine trigger apical cardiodepression in a 2-adrenergic receptor/Gi-dependent manner: a new model of takotsubo cardiomyopathy. Circulation Aug 6 2012;126(6):697–706. [7] Summers MR, Lennon RJ, Prasad A. Pre-morbid psychiatric and cardiovascular diseases in apical ballooning syndrome (tako-tsubo/stress-induced cardiomyopathy): potential pre-disposing factors? J Am Coll Cardiol Feb 16 2010;55(7):700–1. [8] DuBois CM, Beach SR, Kashdan TB, et al. Positive psychological attributes and cardiac outcomes: associations, mechanisms and interventions. Psychosomatics Jul–Aug 2012;53(4):303–18.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
“Happiness” and stress cardiomyopathy (apical ballooning syndrome/takotsubo syndrome) Dingxin Qin, Sandeep M. Patel, Hunter C. Champion ⁎ The Heart and Vascular Institute, Vascular Medicine Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
a r t i c l e
i n f o
Article history: Received 22 October 2013 Accepted 23 December 2013 Available online 4 January 2014 Keywords: Stress cardiomyopathy Takotsubo cardiomyopathy Happiness Positive emotions
Stress cardiomyopathy (SCM)/apical balloon syndrome (ABS; takotsubo cardiomyopathy) is a transient cardiomyopathy that is often associated with acute emotional or physical stress. Happiness or positive emotional excitement has not been previously identified as an inciting factor for SCM/ABS. In this letter, we report three cases of SCM/ABS occurring in association with positive emotions and discuss the possible link between “happy emotions” and cardiovascular diseases. Case 1. A 66-year-old female with a history of hypertension, hyperlipidemia and generalized anxiety disorder presented with acute onset of dizziness and nausea that began prior to boarding a plane to meet with her husband in China. Patient reported feeling immensely joyful and excited about the trip before the discomfort started. She denied any previous history of heart disease or cerebrovascular events. On admission, acute cerebrovascular accident was suspected and a thorough neurological evaluation was negative. Initial electrocardiogram showed normal sinus rhythm with deep, symmetrically inverted T-waves appeared in inferior and lateral leads. Blood work revealed a troponin-I level of 6.58 ng/dL (b 0.02). The patient was treated for acute coronary syndrome with appropriate medical therapy. Echocardiogram on the day of admission showed akinesis of the apex, mid to apical anterior wall and inferior wall with an ejection fraction of 30–35%. The patient then underwent coronary angiography which revealed only mild luminal
⁎ Corresponding author at: University of Pittsburgh, Bioscience Medical Tower, Suite E1243, 200 Lothrop Street, Pittsburgh, PA 15213, United States. Tel.: +1 412 624 8140; fax: +1 412 648 5980. E-mail address: [email protected] (H.C. Champion). 0167-5273/$ – see front matter © 2013 Published by Elsevier Ireland Ltd. http://dx.doi.org/10.1016/j.ijcard.2013.12.140
irregularities in the major epicardial vessels. A left ventriculogram (rightanterior oblique projection) demonstrated apical akinesis consistent with SCM/ABS. The patient's symptoms were resolved with medical therapy and she was discharged home on the fourth day of hospitalization. Followup transthoracic echocardiogram 4 weeks later demonstrated a complete recovery of the cardiac function without any regional wall motion abnormalities. Case 2. A 71-year-old female with a history of diabetes mellitus type 2, hypertension and hyperlipidemia was admitted for complaints of severe chest pain which began while she was attending her grandson's wedding. Patient reported being delightful and excited the entire day. As the end of the wedding ceremony approached, she developed a suddenonset of substernal chest pain radiating to the right shoulder, associated with shortness of breath. Patient took several of her husband's
Fig. 1. Left ventriculogram (RAO projection). Representative left ventriculogram demonstrating a typical hypercontractile base with apical ballooning/dyskinesia during systole as well described in ABS patients.
D. Qin et al. / International Journal of Cardiology 172 (2014) e182–e183
Fig. 2. Transthoracic echocardiogram (4-chamber). Four-chamber transthoracic echocardiogram demonstrating ballooning of the apex with preserved contractility in the base.
sublingual nitroglycerin tablets which provided temporary relief. She reported no previous history of heart disease. She denied any history of depression, anxiety, or recent emotional or physical stress. On presentation to the emergency department, her electrocardiogram showed normal sinus rhythm with a heart rate of 80 beats per minute and a 2 mm ST-segment elevation in the high lateral leads. Troponin-I level peaked at 1.91 ng/dL. Emergent coronary angiogram showed grossly patent coronary arteries with less than 20% stenosis in the left anterior descending and left circumflex arteries. Left ventriculogram revealed a dyskinetic apex with apical ballooning, a hyperdynamic base and an ejection fraction of 35% (Fig. 1). Transthoracic echocardiogram on the same day also revealed wall motion abnormalities consistent with SCM/ABS with LVEF of 35–40% (Fig. 2). The patient was treated with aspirin, beta-blockade, ace-inhibition, and statin therapy. She had no recurrent cardiac issues during the admission and was discharged home. Follow-up transthoracic echocardiogram 2 months later showed a normal ejection fraction and a complete resolution of the regional wall motion abnormalities. Case 3. A 63-year-old female with a history of stress cardiomyopathy in 2002 (due to a runway horse experience) presented with acute chest pain and shortness of breath when attending her daughter's graduation ceremony (11 years after her prior episode). She noted that she was very ecstatic during her daughter's graduation, when a sudden rush of severe chest pain and shortness of breath occurred. She denied any history of hypertension, diabetes, hyperlipidemia, tobacco abuse, anxiety, depression or coronary artery disease. Upon presenting to the local hospital, the electrocardiogram, echocardiogram and left heart catheterization findings were consistent with typical stress cardiomyopathy, and she was treated with betablockade, ace-inhibition and other supportive treatments. A full resolution of ejection fraction was noted in the follow-up echocardiogram. Discussion. As demonstrated in previous studies, emotional excitement, like other psychological stresses, can be associated with increased
e183
incidence of acute cardiovascular events. Wilbert-Lampen et al. showed that on days of the World Cup matches involving Germany, the incidence of acute myocardial infarction and symptomatic arrhythmia more than doubled in the great Munich area [1]. The extent of such an increase was unchanged even when Germany was winning the game, while such connection was more prominent among males and those with a previous history of coronary artery disease. While among SCM/ ABS cases, the emotional stress has only been reported as negative emotions like anger, frustration, grief, pain, fear, anxiety or interpersonal conflict. To the best of our knowledge, our report is the first series of ABS cases that were triggered by positive emotional excitement, and all three of our patients were females with no previous history of coronary artery disease. The possible mechanisms of the connection between emotional excitement and acute cardiovascular events involve sympathetic activation (supply vs. response) and endothelial dysfunction [2]. Piira et al. demonstrated that among enthusiastic ice-hockey spectators with stable CAD, both plasma catecholamines and endothelin-1 levels were markedly elevated before an ice-hockey match [2]. On the other hand, there is increasing evidence that sympathetic stimulation may play an important pathogenic role in the development of SCM/ABS [3–5]. Plasma catecholamines levels have been found to be significantly elevated in SCM/ABS patients; intravenous catecholamines were shown to precipitate the syndrome; and a recent study in rats suggest that Gi activation at high epinephrine concentration may underpin the acute depression of apical activities in the model [6]. Therefore, sympathetic activation with catecholamine increase may have also played an important role in the three SCM/ABS cases associated with positive emotional excitement in our report. Further, the history of anxiety disorder, hypertension, hyperlipidemia and diabetes mellitus in our ABS cases may serve as predisposing factors as reported in previous studies [7]. Although a positive psychological well-being has generally been considered to be protective for cardiovascular disease [8], our report suggests that positive emotional excitement can possibly trigger transient left ventricular dysfunction in elderly female patients with no previous history of coronary artery disease. References [1] Wilbert-Lampen U, Leistner D, Greven S, et al. Cardiovascular events during World Cup soccer. N Engl J Med Jan 31 2008;358(5):475–83. [2] Piira O-P, Mustonen PE, Miettinen JA, Huikuri HV, Tulppo MP. Leisure time emotional excitement increases endothelin-1 and interleukin-6 in cardiac patients. Scand Cardiovasc J Feb 2012;46(1):7–15. [3] Wittstein IS, Thiemann DR, Lima JAC, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med Feb 10 2005;352(6):539–48. [4] Wittstein IS. Stress cardiomyopathy: a syndrome of catecholamine-mediated myocardial stunning? Cell Mol Neurobiol Feb 2 2012;32(5):847–57. [5] Abraham J, Mudd JO, Kapur N, Klein K, Champion HC, Wittstein IS. Stress cardiomyopathy after intravenous administration of catecholamines and beta-receptor agonists. J Am Coll Cardiol Apr 14 2009;53(15):1320–5. [6] Paur H, Wright PT, Sikkel MB, et al. High levels of circulating epinephrine trigger apical cardiodepression in a 2-adrenergic receptor/Gi-dependent manner: a new model of takotsubo cardiomyopathy. Circulation Aug 6 2012;126(6):697–706. [7] Summers MR, Lennon RJ, Prasad A. Pre-morbid psychiatric and cardiovascular diseases in apical ballooning syndrome (tako-tsubo/stress-induced cardiomyopathy): potential pre-disposing factors? J Am Coll Cardiol Feb 16 2010;55(7):700–1. [8] DuBois CM, Beach SR, Kashdan TB, et al. Positive psychological attributes and cardiac outcomes: associations, mechanisms and interventions. Psychosomatics Jul–Aug 2012;53(4):303–18.
