Summary
Background
Several patterns of Tako-Tsubo cardiomyopathy (TTC) have been described recently.
Aims
To assess the prevalence and characteristics of an apical-sparing variant of TTC.
Methods
This study included consecutive patients admitted to our catheterization laboratory for suspected acute coronary syndrome (ACS). All patients underwent coronary and left ventricular angiography systematically if no significant coronary lesions were found.
Results
Among 2893 patients with a suspected ACS, 38 had confirmed TTC. Nine patients presented with the apical-sparing variant, resulting in a 24% prevalence in our TTC population. At admission, mean left ventricular ejection fraction (LVEF) was significantly higher in patients with apical-sparing TTC (45 ± 4% vs 35 ± 7%, p = 0.01). Patients with classic TTC were significantly older (74 ± 10 years vs 63 ± 14 years, p = 0.01) and had a significantly higher mean heart rate and New York Heart Association functional class ( p = 0.04 and p = 0.002, respectively). Surgical or disease-related stress was found more frequently among patients with the apical-sparing variant ( p = 0.02). At day 7, mean LVEF was significantly higher in patients with apical-sparing TTC (55 ± 6% vs 48 ± 6%, p = 0.04). At 1-month and 1-year follow-up, no significant difference in LVEF was observed between the two patterns of TTC ( p = 0.60 and p = 0.46, respectively).
Conclusions
The apical-sparing variant of TTC is not rare and differs in several ways from the classic pattern of TTC. Physicians should be aware of and recognize this partial pattern of TTC.
Résumé
Contexte
Plusieurs aspects de cardiomyopathie de Tako-Tsubo (CTT) ont été décrits.
Objectif
Évaluer la prévalence et les caractéristiques des formes épargnant l’apex dans la CTT.
Méthode
Cette étude a inclus de manière consécutive les patients admis en salle de cathétérisme pour une suspicion de syndrome coronaire aigu (SCA). Tous les patients ont bénéficié d’une coronarographie et d’une ventriculographie si aucune lésion coronaire n’était retrouvée.
Résultats
Parmi 2893 patients ayant une suspicion de SCA, 38 avaient un diagnostic confirmé de CTT. Neuf patients avaient une forme épargnant l’apex, permettant d’estimer la prévalence de cette forme partielle de CTT à 24 %. À l’admission, la fraction d’éjection ventriculaire gauche (FEVG) moyenne était significativement plus élevée en cas de forme épargnant l’apex (45 ± 4 % vs 35 ± 7 %, p = 0,01). Les patients ayant une forme typique de CTT étaient significativement plus âgés (74 ± 10 vs 63 ± 14 ans, p = 0,01) et la fréquence cardiaque moyenne et la classe NYHA étaient significativement plus élevées dans la forme typique apicale de la CTT ( p = 0,04 and p = 0,002, respectivement). Le stress induit par un geste chirurgical ou une pathologie aigüe était plus fréquemment retrouvé chez les patients ayant une forme épargnant l’apex ( p = 0,02). À J7, la FEVG moyenne était significativement plus élevée en cas de forme épargnant l’apex (55 ± 6 % vs 48 ± 6 %, p = 0,04). À un mois et à un an, aucune différence significative concernant la FEVG n’était retrouvée entre les deux aspects de CTT ( p = 0,60 and p = 0,46, respectivement).
Conclusions
La forme de CTT épargnant l’apex n’est pas rare, avec une prévalence estimée à 24 %, et présente des caractéristiques différentes comparées à la forme apicale typique de la CTT. Les médecins doivent être informés que cette forme partielle de CTT peut se produire et doit être reconnue.
Background
Tako-Tsubo cardiomyopathy (TTC) is a recent clinical entity, mimicking an acute coronary syndrome (ACS) . It is defined as a transient left ventricular (LV) systolic dysfunction, found mainly after a stressful event . Regional wall-motion abnormalities extend beyond a single epicardial vascular distribution and are different from the dysfunction found in patients with coronary artery disease . The classic apical pattern of TTC is characterized by akinesia of the mid and apical segments of all walls, with visual hyperkinesia of the base, resembling a traditional Japanese octopus trap, or “Tako-Tsubo”, with a round bottom and narrow neck.
Partial and circular patterns of TTC, sparing the apical LV segments, have been described recently . Because of this atypical LV pattern, the diagnosis of an apical-sparing variant of TTC may be difficult to make, leading to misdiagnosis. The aim of this study was to assess the prevalence and characteristics of apical-sparing TTC.
Methods
From January 2000 to April 2009, we reviewed in our database all patients referred to our catheterization laboratory for a suspected ACS ( n = 2893). The catchment area of the hospital covered part of the Hauts-de-Seine Department (Boulogne, Chaville, Garches, Marnes-la-Coquette, Meudon, Saint-Cloud, Sèvres, Vaucresson, Ville-d’Avray), corresponding to a population of around 300,000 subjects. Criteria for selection included age 18 years and over and presentation with a suspected ACS. All patients underwent coronary angiography and LV angiography systematically if no significant coronary lesions were found, within 48 hours of symptom onset. Ventricular angiograms were used to calculate LV ejection fraction (LVEF) and detect wall-motion abnormalities. Patients with known renal failure, defined as creatinine clearance less than 30 mL/min, did not have an LV angiogram; LV characteristics were assessed systematically by transthoracic echocardiography.
Tako-Tsubo cardiomyopathy was defined as: acute chest pain associated with ST-segment abnormalities and/or increased serum troponin level; transient LV systolic dysfunction; and no significant coronary lesions . From 2004, the diagnosis of TTC was performed prospectively. LV systolic dysfunction in TTC was defined as regional wall-motion abnormalities extending beyond a single epicardial coronary distribution. We identified two patterns of TTC: classic TTC, defined as akinesia of the mid and apical segments of all walls, with visual hyperkinesia of the base; and an apical-sparing variant, defined as akinesia of the basal and mid segments of all walls or limited akinesia of the mid segments of all LV walls ( Fig. 1 ) . Electrocardiogram and laboratory markers (plasma creatinine kinase and troponin I) were assessed systematically in all patients. Treatment was left to the discretion of the physician.
Statistical analysis
Statistical analysis was performed using StatView version 4.5 (Abacus Concepts Inc., Cary, NC, USA). Continuous variables are presented as means ± standard deviations and categorical data as absolute values and percentages. Continuous and categorical variables were compared using Fisher’s exact test or an unpaired t test. A p -value < 0.05 was considered significant.
Results
Population characteristics
Among 2893 patients presenting with a suspected ACS, 38 had confirmed TTC, with a prevalence of 1.3%. The mean age of patients with TTC was 70 ± 13 years. Twenty-nine patients had the classic apical pattern of TTC, whereas nine had the apical-sparing variant. Thus, the prevalence of apical-sparing TTC was 24% of all patients with TTC and 0.31% of patients with a suspected ACS.
The characteristics of patients with classic and apical-sparing TTC are presented in Table 1 . Surgical or disease-related stress was found more frequently among patients with apical-sparing TTC ( p = 0.02). The mean peaks of plasma creatinine kinase and troponin I were 324 ± 258 IU/L and 6.5 ± 6.5 μg/L, respectively. Mean LVEF was 38 ± 8% among all patients with TTC. At admission, mean LVEF was significantly higher in patients with apical-sparing TTC ( p = 0.01). Patients with classic TTC were significantly older ( p = 0.01). At admission, mean heart rate, mean New York Heart Association functional class and mean plasma B-natriuretic peptide concentration were significantly higher in patients with classic TTC ( p = 0.04, p = 0.002 and p = 0.04, respectively).
| Variable | Classic TTC ( n = 29) | Apical-sparing variant of TTC ( n = 9) | p |
|---|---|---|---|
| Age (years) | 74 ± 10 | 63 ± 14 | 0.01 |
| Women | 29 (100) | 8 (89) | 0.24 |
| Previous arterial hypertension | 18 (62) | 3 (33) | 0.25 |
| Diabetes | 1 (3) | 1 (11) | 0.42 |
| Previous medical treatment | |||
| ACE inhibitors or angiotensin receptor blocker | 11 (38) | 3 (33) | 0.99 |
| Beta-blockers | 2 (7) | 1 (11) | 0.99 |
| Calcium channel blockers | 4 (14) | 0 | 0.55 |
| Precipitating factor | |||
| Emotional or physical stress | 19 (66) | 3 (33) | 0.13 |
| Surgical or disease-related stress | 4 (14) | 5 (56) | 0.02 |
| No obvious factor | 6 (21) | 1 (11) | 0.66 |
| At admission | |||
| Systolic blood pressure (mmHg) | 130 ± 20 | 128 ± 27 | 0.73 |
| Diastolic blood pressure (mmHg) | 75 ± 16 | 77 ± 16 | 0.75 |
| Heart rate (beats per minute) | 84 ± 17 | 74 ± 5 | 0.04 |
| Heart failure | 9 (31) | 1 (11) | 0.4 |
| NYHA functional class | 1.8 ± 0.9 | 1.1 ± 0.1 | 0.002 |
| Peak of creatinine kinase (IU/L) | 318 ± 258 | 268 ± 119 | 0.59 |
| Peak of troponin I (μg/L) | 7.3 ± 7.1 | 4.2 ± 4.1 | 0.22 |
| Plasma B-natriuretic peptide concentration (ng/L) | 257 ± 344 | 1073 ± 1095 | 0.04 |
| Left ventricular ejection fraction (%) | 35 ± 7 | 45 ± 4 | 0.01 |
| Left ventricular outflow tract obstruction | 8 (28) | 1 (11) | 0.41 |
| Electrocardiographic data at admission | |||
| ST-segment elevation | 22 (76) | 3 (33) | 0.04 |
| Non-ST-segment elevation | 5 (22) | 5 (56) | 0.04 |
| Q waves | 5 (22) | 2 (22) | 0.99 |
| QT interval (ms) | 410 ± 44 | 395 ± 42 | 0.42 |
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