Dear Editor,

Takotsubo syndrome (TS) is a relatively uncommon condition, with a clinical presentation often mimicking acute myocardial infarction [1]. Its estimated prevalence is approximately 1.7–2.2% of patients with suspected acute coronary syndrome [1], and diagnosis is defined by Mayo Clinic criteria [2]. Many stressful medical conditions, as well as emotional stressors, such as death of a family member, bad news, assault, and many others, are established causes capable of triggering TS [3]. We aimed to test the hypothesis that suicide attempt could represent a cause of TS.

We systematically explored PubMed database, using the searching keywords ‘Takotsubo cardiomyopathy’ or ‘stress-induced cardiomyopathy’, in combination with ‘suicide’ and ‘attempted suicide’. A further search was performed on Google Scholar source. For each case, we reported gender, age, suicide method, possible triggers, presentation signs, outcome, author, journal, and year of publication. Deadline for electronic search was December 31, 2017. We found 12 items, reporting 13 cases (Table 1). The majority of patients were women (n = 9, 69%), and the mean age was 37.5 ± 21.8 years (range 65, 15–80). Suicide methods included self-poisoning (n = 6, 46%), hanging (n = 6, 46%), and jumping from a height (n = 1, 8%). Potential triggering conditions were present in six cases (46%), not present in one (8%), and not reported in six (46%). The outcome was always favorable.

Table 1 Systematic review of case reports with attempted suicide followed by onset of Takotsubo syndrome (TS)
Full size table

Suicidal ideation is a common condition evaluated in the Emergency Department (ED), with more than 400,000 annual ED visits in the United States [4]. For many patients with suicidal ideation, ED represents the first option for treatment, and it has been estimated that as many as one in ten individuals with completed suicide have been seen in the ED within the prior 2 months [5]. In agreement with the previous literature reports, in our mini-cohort of case reports with attempted suicide followed by TS, self-poisoning and hanging represents more than 90% of the cases. Data from the United Kingdom show that both deliberate self-harm and suicides are increasing in the youngest age groups, and particularly in males [6]. Among methods of suicidal self-poisoning, drug overdose is the preferred choice in most females, in the young, and in the medical profession [6]. According to data from the United States, the overall suicide rate has increased by 16% between 2000 and 2010 (10.4–12.1 per 100,000 population) [7]. The great part of this increase is attributable to suicide by hanging/suffocation (52%) and by poisoning (19%). In particular, hanging is a suicide method characterized by a high mortality: the case fatality rates for suicide by hanging/suffocation range from 69 to 84% [7]. Emotional or physical stress is a common trigger for the development of TS, and attempting suicide undoubtedly represents a highly stressful condition. The circadian variation of some biological functions, some of which stress-related [8], may explain, at least in part, the preference for a morning onset for either TS and suicidal behavior [9, 10]. Stress favors catecholamine excess, potentially harmful to the heart [8], and cardiac damage in TS seems to be due to catecholamine hypersecretion and actions on β-adrenoceptors [11]. Catecholamine hyperactivity is also the basis for the typical regional negative inotropism of different segments of the heart, characterized by different densities of β1- and β2 adrenoceptors [11]. Moreover, a further possible emerging trigger factor for TS may be acute respiratory failure. In fact, Ghadri et al. [12] describe the onset of transient severe reduction of ejection fraction and haemodynamic instability, secondary to acute respiratory distress, in a female patient undergoing bilateral lung transplantation seven years before. In the same year, Fujiwara and Kobata [13] report the case of a 29-year-old woman who attempted suicide by hanging. She was found pulseless and in a deep coma by her mother, who started chest compressions. After admission to the intensive care unit, generalized tonic–clonic convulsions and abrupt increase of body temperature > 39 °C appeared [13].

The common underlying mechanism of both cases could be Paroxysmal sympathetic hyperactivity (PSH), a syndrome characterized by a striking presentation, with paroxysmal tachycardia, arterial hypertension, tachypnea, hyperthermia, and decerebrate posturing occurring in response to afferent stimulation [14]. Patients surviving a brain injury can develop a sympathetic hyperactivity for weeks or months, with episodes of increased heart rate and blood pressure, maybe secondary to loss of inhibitory control over excitatory autonomic centres [14]. Thus, given the catecholamine storm based on these mechanisms, it is likely that severe anoxic brain injury by hanging/suffocation and severe hypotension following acute drug poisoning may trigger the onset of TS.

Contrary to common opinion, TS should no longer be simply considered as a benign disease. In fact, although the prognosis of TS patients is generally thought to be favorable with complete recovery of left ventricular function, prognosis depends on many factors, including comorbidities, clinical presentation, gender, and in-hospital or out-hospital setting [15].

Attempted suicide, as a high stressful condition, can be included among possible triggers of TS, and self-poisoning and hanging may also share with severe respiratory distress and PSH as underlying causes. Since patients presenting with attempted suicide are mostly evaluated by ED physicians, a high level of attention could be maintained even during the immediate hours following successful rescue intervention, keeping in mind the possible risk of a TS. In particular, protection toward severe hypoxemia should be promptly provided in the case of either self-poisoning or hanging, although the final outcome has been favorable in all reported cases.