International Journal of Cardiology 179 (2015) 193–194

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Letter to the Editor

Vagotonia, cancer, and fluid depletion in Takotsubo cardiomyopathy: The “not” good, the bad and the ugly Luisa De Gennaro a,1, Natale Daniele Brunetti b,⁎,1, Massimo Ruggiero a,1, David Rutigliano a,1, Cosimo Campanella a,1, Francesco Santoro b,1, Andrea Igoren Guaricci c,1, Matteo Di Biase b,1, Pasquale Caldarola a,1 a b c

Cardiology Department, Ospedale San Paolo, Bari, Italy Department of Medical & Surgical Sciences, University of Foggia, Italy Cardiology Department, Ospedali Riuniti, Foggia, Italy

a r t i c l e

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Article history: Received 24 October 2014 Accepted 26 October 2014 Available online 11 November 2014 Keywords: Takotsubo cardiomyopathy Stress cardiomyopathy Vagotonia Cancer Fluid depletion

values and for counteracting left ventricular depletion, commonly found in subjects with Takotsubo syndrome and left ventricular outflow tract obstruction [10,11]. Likewise, vagotonia is not uncommon in patients with stress cardiomyopathy [12–14], sometimes apparently precipitating the progression to apical ballooning [15,16]. A mild transient attenuation of the QRS complexes in ECGs was also observed [17], mainly in precordial leads. Conflict of interest statement Authors have no potential conflict of interest to disclose. References

To the Editor, We read with great interest the letter by Dr. Madias [1] commenting on a case report of Takotsubo cardiomyopathy in an old woman in distress while taking a swim off coast [2]. The paper sharply focuses on three unpleasant buddies of Takotsubo cardiomyopathy: cancer, vagotonia and fluid depletion. We agree that an increasing amount of evidence is linking stress cardiomyopathy with malignancies [3,4], chemotherapy [5] and neoplastic pain [6]. However, the exact underlying mechanism, beyond presumable stressor such as pain and poor general conditions, is not well known. Our patient, with pulmonary edema and hypotension, was treated with both fluids and low dose slow flow infusion diuretics, a usual expedient when diuretics are required in the presence of low systolic pressure values [7–9]. Fluid infusion may be useful in subjects with stress cardiomyopathy both for sustaining lower arterial blood pressure ⁎ Corresponding author at: Cardiology Department, University of Foggia, Viale Pinto 1, 71100 Foggia, Italy. E-mail address: [email protected] (N.D. Brunetti). 1 Ospedale San Paolo, Cardiology Department, Bari, University of Foggia, Cardiology Department, Foggia, Italy. 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.

[1] J.E. Madias, Adrift while swimming and Takotsubo syndrome: the vagotonia connection, Int. J. Cardiol. (Oct 2 2014), (Epub ahead of print). [2] L. De Gennaro, N.D. Brunetti, M. Ruggiero, D. Rutigliano, C. Campanella, F. Santoro, A. Guaricci, M. Di Biase, P. Caldarola, Adrift: Takotsubo cardiomyopathy in an old woman in distress while taking a swim off coast, Int. J. Cardiol. (Aug 30 2014), (Epub ahead of print). [3] M.T. Schweizer, R. Mehta, R. Salgia, V.M. Villaflor, Takotsubo cardiomyopathy in a patient with squamous cell esophageal carcinoma, J. Clin. Oncol. 29 (2011) e598–e600. [4] C. Burgdorf, H.M. Nef, D. Haghi, V. Kurowski, P.W. Radke, Tako-tsubo (stress-induced) cardiomyopathy and cancer, Ann. Intern. Med. 152 (2010) 830–831. [5] T.H. Franco, A. Khan, V. Joshi, B. Thomas, Takotsubo cardiomyopathy in two men receiving bevacizumab for metastatic cancer, Ther. Clin. Risk Manag. 4 (2008) 1367–1370. [6] S.B. Singh, I.A. Harle, Takotsubo cardiomyopathy secondary in part to cancer-related pain crisis: a case report, J. Pain Symptom Manag. 48 (2014) 137–142. [7] D.R. Salvador, N.R. Rey, G.C. Ramos, F.E. Punzalan, Continuous infusion versus bolus injection of loop diuretics in congestive heart failure, Cochrane Database Syst. Rev. 3 (2005) CD003178. [8] D.W. Rudy, J.R. Voelker, P.K. Greene, F.A. Esparza, D.C. Brater, Loop diuretics for chronic renal insufficiency: a continuous infusion is more efficacious than bolus therapy, Ann. Intern. Med. 115 (1991) 360–366. [9] S.L. Yelton, M.A. Gaylor, K.M. Murray, The role of continuous infusion loop diuretics, Ann. Pharmacother. 29 (1995) 1010–1014. [10] R. Ieva, F. Santoro, A. Ferraretti, G. Spennati, L. De Gennaro, M. Di Biase, N.D. Brunetti, Hyper-acute precipitating mechanism of Tako-Tsubo cardiomyopathy: in the beginning was basal hyperkinesis? Int. J. Cardiol. 167 (2013) e55–e57. [11] N.D. Brunetti, R. Ieva, G. Rossi, N. Barone, L. De Gennaro, P.L. Pellegrino, G. Mavilio, A. Cuculo, M. Di Biase, Ventricular outflow tract obstruction, systolic anterior motion and acute mitral regurgitation in Tako-Tsubo syndrome, Int. J. Cardiol. 127 (2008) e152–e157.


L. De Gennaro et al. / International Journal of Cardiology 179 (2015) 193–194

[12] F. Santoro, R. Ieva, G. Spennati, A. Ferraretti, G. Franzese, G. Tiscia, M. Di Biase, N.D. Brunetti, Tako-Tsubo cardiomyopathy and spontaneous cardioversion of permanent atrial fibrillation associated with acute hyperkalemia, Int. J. Cardiol. 167 (2013) e67–e70. [13] F. Santoro, A. Ferraretti, R. Ieva, M. Scarcia, M. Correale, L. De Gennaro, M. Di Biase, N.D. Brunetti, Recurrent Tako-Tsubo cardiomyopathy apparently induced by opposite triggers, Int. J. Cardiol. 165 (2013) 198–199. [14] S. Kurisu, I. Inoue, T. Kawagoe, M. Ishihara, Y. Shimatani, Y. Nakama, K. Ohkawa, T. Maruhashi, E. Kagawa, K. Dai, T. Aokage, Torsade de pointes associated with bradycardia and takotsubo cardiomyopathy, Can. J. Cardiol. 24 (2008) 640–642.

[15] F. Santoro, R. Ieva, A. Ferraretti, G. Carpagnano, M. Lodispoto, L. De Gennaro, M. Di Biase, N.D. Brunetti, Acute renal failure, digoxin toxicity and brady-arrhythmia as possible triggers in Tako-Tsubo cardiomyopathy, Int. J. Cardiol. 165 (3) (2013) e51–e52. [16] G. Sandhu, Z. Servetnyk, S. Croitor, E. Herzog, Atropine aggravates signs and symptoms of Takotsubo cardiomyopathy, Am. J. Emerg. Med. 28 (2010) 258.e5–258.e7. [17] J.E. Madias, Transient attenuation of the amplitude of the QRS complexes in the diagnosis of Takotsubo syndrome, Eur. Heart J. Acute Cardiovasc. Care 3 (2014) 28–36.

Vagotonia, cancer, and fluid depletion in Takotsubo cardiomyopathy: the "not" good, the bad and the ugly.

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