Takotsubo syndrome (TTS) was first described in 1991, and as of October 12, 2012, there are 1,450 entries in PubMed retrievable using the inquiry term “Takotsubo syndrome”. Reading this avalanche of relevant research, mostly case reports, provides a stereotypical take on TTS: women are mostly afflicted, by a ratio to men of >6:1; patients in the original descriptions were mostly Japanese; the illness emerges in the “heat” of some psychological, physical, or other disease-related upheaval of varying intensity; apical “ballooning” due to dyskinesia, associated with a hyperkinetic left ventricular (LV) base, and marked decrease of the LV ejection fraction are detected by transthoracic echocardiography or contrast left ventriculography; the coronary arteries are normal, or they reveal nonobstructive coronary artery disease (CAD); there is severe, localized impairment of the microcirculation; electrocardiography shows ST-segment elevation or ST-segment depression with associated T-wave inversions and QT interval prolongation, with the T-wave inversions sometimes lingering for several weeks; there are modest, for the degree of LV dysfunction, transient increases in myocardial biomarkers; there are only a few distinguishing features between TTC and acute coronary syndromes, but they are not false proof, and they become apparent later in the course; there is full recovery of LV function within days to weeks at follow-up; there is no recurrence of TTS during short-term follow-up; mortality is rare, but morbidity is substantial and similar to that encountered in patients with acute coronary syndromes; and most patients respond to supportive, nonspecific care.

The ever expanding body of research on TTS has started to lose its stereotypical features, by including patients from all over the world, both women and men, and even children, with “variant” forms of TTS, consisting of regional LV contraction abnormalities of great topographic variety or with hypokinesia of the LV base and hyperkinesia of the apex (“inverse TTS”), recurrence of the illness, association with co-morbidities, varying degrees of CAD, and absence of seemingly stressful precipitants. In witnessing this “transformation” of TTS and contemplating the “commonness” of the disease-inciting substrate, particularly in the elderly (postmenopausal status in women and exposure to a large range of psychological and physical stressors, some pertaining to medical or surgical and testing procedures), one might conclude that TTS must be common and that TTS must have a range of severity in its presentation. Some observations that provide support for this conjecture are as follows: (1) Some patients present with a picture of acute coronary syndromes with or without electrocardiographic changes and with or without mild increases in myocardial biomarkers, are found to have normal coronary arteries or nonobstructive CAD on coronary arteriography, and are asymptomatic at follow-up with no medical therapy. (2) Some of such patients show persisting T-wave inversions for many months at follow-up. (3) Some of such patients show amelioration or normalization of acutely detected LV regional contraction abnormalities and depressed LV ejection fractions at follow-up. (4) Some of such patients show mismatch of LV regional contraction abnormalities and myocardial distribution of occasionally detected obstructive CAD. (5) Some of such patients have results of myocardial perfusion imaging during stress testing incriminating for CAD, with normal coronary arteries on subsequent coronary arteriography. (6) In reviewing the electrocardiograms of some patients who have not been admitted to hospitals but who have been followed in clinics, one frequently encounters electrocardiograms with unexplained reversible T-wave inversions recorded serially over the course of several months. (7) In reviewing serial echocardiograms of some patients who have not been admitted to hospitals but who have been followed in clinics, one occasionally encounters echocardiograms showing unexplained reversible LV regional contraction abnormalities and decreases in the LV ejection fraction.

With so many modalities (including cardiac magnetic resonance imaging) at our disposal for the evaluation of the reversible regional myocardial stunning, and myocardial edema, both encountered in TTS, attuned clinicians will soon unravel the causative underpinning of TTS and establish its real prevalence.