Stress-Induced Cardiomyopathy



Stress-induced cardiomyopathy (SIC) is an increasingly recognized disease entity and is accepted as a unique form of reversible cardiomyopathy. Typical apical ballooning precipitated by emotional stress with clinical features mimicking acute coronary syndrome and rapid recovery was a hallmark of SIC. Along with cumulative experiences, new features are well appreciated. These include atypical ballooning patterns (mid-ventricular and basal ballooning), contribution of physical stressors (acute medical illnesses and routine diagnostic and therapeutic procedures including surgery) to the development of SIC, and development of serious complications such as right ventricular dysfunction, thrombus formation, and left ventricular outflow tract obstruction with significant mortality rate and occasional recurrence, representing diverse clinical spectrum of SIC. Although the exact mechanism and standard treatment of SIC has not been established, physicians’ vigilance is needed for prompt diagnosis and adequate treatment for this potentially fatal disorder. Echocardiography can play a role as an easy and noninvasive imaging modality.


Stress Cardiomyopathy Echocardiography Stress-induced cardiomyopathy 



No potential conflict of interest relevant to this article was reported.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of importance

  1. 1.
    Maron BJ, Towbin JA, Thiene G, et al. Contemporary definitions and classification of the cardiomyopathies: an American Heart Association Scientific Statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention. Circulation. 2006;113:1807–16.PubMedCrossRefGoogle Scholar
  2. 2.
    Gianni M, Dentali F, Grand AM, et al. Apical ballooning syndrome or takotsubo cardiomyopathy: a systemic review. Eur Heart J. 2006;27:1523–9.PubMedCrossRefGoogle Scholar
  3. 3.
    •• Bybee KA, Prasad A. Stress-related cardiomyopathy syndromes. Circulation. 2008;118:397–409. An excellent review article. PubMedCrossRefGoogle Scholar
  4. 4.
    •• Zeb M, Sambu N, Scott P, Curzen N. Takotsubo cardiomyopathy: a diagnostic challenge. Postgrad Med J. 2011;87:51–59. Another outstanding review article. PubMedCrossRefGoogle Scholar
  5. 5.
    Tsuchihashi K, Ueshima K, Uchida T, et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. J Am Coll Cardiol. 2001;38:11–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Kurisu S, Sato H, Kawagoe T, et al. Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction. Am Heart J. 2002;143:448–55.PubMedCrossRefGoogle Scholar
  7. 7.
    Bybee KA, Kara T, Prasad A, et al. Transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med. 2004;141:858–65.PubMedGoogle Scholar
  8. 8.
    Hurst RT, Askew JW, Reuss CS, et al. Transient midventricular ballooning syndrome: a new variant. J Am Coll Cardiol. 2006;48:579–83.PubMedCrossRefGoogle Scholar
  9. 9.
    Guerrero J, Majid A, Ernst A. Cardiogenic shock secondary to Tako-tsubo syndrome after debridement of malignant endobronchial obstruction. Chest. 2009;135:217–20.PubMedCrossRefGoogle Scholar
  10. 10.
    Kurisu S, Inoue I, Kawagoe T, et al. Persistent left ventricular dysfunction in takotsubo cardiomyopathy after pacemaker implantation. Circ J. 2006;70:641–4.PubMedCrossRefGoogle Scholar
  11. 11.
    Jensen JB, Malouf JF. Takotsubo cardiomyopathy following cholecystectomy: a poorly recognized cause of acute reversible left ventricular dysfunction. Int J Cardiol. 2006;106:390–1.PubMedCrossRefGoogle Scholar
  12. 12.
    Gavish D, Rozenman Y, Hafner R, et al. Takotsubo cardiomyopathy after general anesthesia for eye surgery. Anesthesiology. 2006;105:621–3.PubMedCrossRefGoogle Scholar
  13. 13.
    Lentschener C, Vignaux O, Spaulding C, et al. Early postoperative tako-tsubo-like left ventricular dysfunction: transient left ventricular apical ballooning syndrome. Anesth Analg. 2006;103:580–2.PubMedCrossRefGoogle Scholar
  14. 14.
    Jabaudon M, Bonnin M, Bolandard F, et al. Takotsubo syndrome during induction of general anaesthesia. Anaesthesia. 2007;62:519–23.PubMedCrossRefGoogle Scholar
  15. 15.
    Park JH, Kang SJ, Song JK, et al. Left ventricular apical ballooning due to severe physical illness in patients admitted to the medical ICU. Chest. 2005;128:296–302.PubMedCrossRefGoogle Scholar
  16. 16.
    • Lee PH, Song JK, Sun BJ, et al. Outcomes of patients with stress-induced cardiomyopathy diagnosed by echocardiography in a tertiary referral hospital. J Am Soc Echocardiogr. 2010;23:766–71. Clinical features of stress-induced cardiomyopathy triggered by physical stressors are well described. PubMedCrossRefGoogle Scholar
  17. 17.
    Denney SD, Lakkireddy DR, Khan IA. Long QT syndrome and torsade de pointes in transient left ventricular apical ballooning syndrome. Int J Cardiol. 2005;100:499–501.PubMedCrossRefGoogle Scholar
  18. 18.
    Okada T, Miyata S, Hashimoto K, et al. Takotsubo cardiomyopathy associated with torsade de pointes and long QT interval: a case report. J Cardiol. 2007;50:83–8.PubMedGoogle Scholar
  19. 19.
    Akashi YJ, Tejima T, Sakurada H, et al. Left ventricular rupture associated with Takotsubo cardiomyopathy. Mayo Clin Proc. 2004;79:821–4.PubMedCrossRefGoogle Scholar
  20. 20.
    Sakai K, Ochiai H, Katayama N, et al. Ventricular septal perforation in a patient with takotsubo cardiomyopathy. Circ J. 2005;69:365–7.PubMedCrossRefGoogle Scholar
  21. 21.
    Sacha J, Maselko J, Wester A, et al. Left ventricular apical rupture caused by takotsubo cardiomyopathy – comprehensive pathological heart investigation. Circ J. 2007;71:982–5.PubMedCrossRefGoogle Scholar
  22. 22.
    Shinozaki K, Tamura A, Abe Y, et al. Left ventricular free wall rupture in takotsubo cardiomyopathy. Int J Cardiol. 2007;115:e3–4.PubMedCrossRefGoogle Scholar
  23. 23.
    Haghi D, Athanasiadis A, Papavassiliu T, et al. Right ventricular involvement in Takotsubo cardiomyopathy. Eur Heart J. 2006;27:2433–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Prasad A. Apical ballooning syndrome. An important differential diagnosis of acute myocardial infarction. Circulation. 2007;115:e56–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Bybee KA, Prasad A, Barsness GW, et al. Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome. Am J Cardiol. 2004;94:343–6.PubMedCrossRefGoogle Scholar
  26. 26.
    Sharkey SW, Lesser JR, Zenovich AG, et al. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation. 2005;111:472–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Elian D, Osherov A, Matetzky S, et al. Left ventricular apical ballooning syndrome: not an uncommon variant of acute myocardial infarction in women. Clin Cardiol. 2006;29:9–12.PubMedCrossRefGoogle Scholar
  28. 28.
    Kurowski V, Kaiser A, von Hof K, et al. Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): frequency, mechanisms, and prognosis. Chest. 2007;132:809–16.PubMedCrossRefGoogle Scholar
  29. 29.
    Van de Walle SO, Gevaert SA, Gheeraert PJ, et al. Transient stress-induced cardiomyopathy with an “inverted Takotsubo” contractile pattern. Mayo Clin Proc. 2006;81:1499–502.PubMedCrossRefGoogle Scholar
  30. 30.
    Parodi G, Del Pace S, Salvadori C, et al. Left ventricular apical ballooning syndrome as a novel cause of acute mitral regurgitation. J Am Coll Cardiol. 2007;50:647–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Sasaki O, Nishioka T, Akima T, et al. Association of Takotsubo cardiomyopathy and long QT syndrome. Circ J. 2006;70:1220–2.PubMedCrossRefGoogle Scholar
  32. 32.
    Samuelov-Kinori L, Kinori M, Kogan Y, et al. Takotsubo cardiomyopathy and QT interval prolongation: who are the patients at risk for torsades de pointes? J Electrocardiol. 2009;42:353–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Cherian J, Angelis D, Filiberti A, Saperia G. Recurrence of stress-induced (Takotsubo) cardiomyopathy. Cardiology. 2007;108:144–6.PubMedCrossRefGoogle Scholar
  34. 34.
    Shimizu M, Kato Y, Masai H, et al. Recurrent episodes of takotsubo-like transient left ventricular apical ballooning occurring in different regions: a case report. J Cardiol. 2006;48:101–7.PubMedGoogle Scholar
  35. 35.
    Elesber AA, Prasad A, Lennon RJ, et al. Four-year recurrence rate and prognosis of the apical ballooning syndrome. J Am Coll Cardiol. 2007;50:448–52.PubMedCrossRefGoogle Scholar
  36. 36.
    Teraoka K, Kiuchi S, Takada N, et al. Images in cardiovascular medicine. No delayed enhancement on contrast magnetic resonance imaging with Takotsubo cardiomyopathy. Circulation. 2005;111:e261–2.PubMedCrossRefGoogle Scholar
  37. 37.
    Mitchell JH, Hadden TB, Wilson JM, et al. Clinical features and usefulness of cardiac magnetic resonance imaging in assessing myocardial viability and prognosis in Takotsubo cardiomyopathy (transient left ventricular apical ballooning syndrome). Am J Cardiol. 2007;100:296–301.PubMedCrossRefGoogle Scholar
  38. 38.
    Haghi D, Fluechter S, Suselbeck T, et al. Cardiovascular magnetic resonance findings in typical versus atypical forms of the acute apical ballooning syndrome (Takotsubo cardiomyopathy). Int J Cardiol. 2007;120:205–11.PubMedCrossRefGoogle Scholar
  39. 39.
    Kawai S, Kitabatake A, Tomoike H. Takotsubo Cardiomyopathy Group. Guidelines for diagnosis of takotsubo (ampulla) cardiomyopathy. Circ J. 2007;71:990–2.PubMedCrossRefGoogle Scholar
  40. 40.
    Crimi E, Baggish A, Leffert L, et al. Acute reversible stress-induced cardiomyopathy associated with cesarean delivery under spinal anesthesia. Circulation. 2008;117:3052–3.PubMedCrossRefGoogle Scholar
  41. 41.
    Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005;352:539–48.PubMedCrossRefGoogle Scholar
  42. 42.
    Ueyama T, Kasamatsu K, Hano T, et al. Catecholamines and estrogen are involved in the pathogenesis of emotional stress-induced acute heart attack. Ann N Y Acad Sci. 2008;1148:479–85.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Asan Heart Institute Cardiac Imaging Center, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulSouth Korea

Personalised recommendations