Chronobiological variation in the occurrence of Tako-tsubo cardiomyopathy: Experiences of two tertiary cardiovascular centers

doi:10.1016/j.hrtlng.2012.09.004

Heart & Lung

Volume 42, Issue 1, January–February 2013, Pages 40-47

https://doi.org/10.1016/j.hrtlng.2012.09.004 Get rights and content

Abstract

Background

There have been few data to review and analyze the temporal preference of the onset of Tako-tsubo cardiomyopathy (TTC). Aim of this study was to investigate chronobiological variations in the occurrence of TTC and changes of these variations according to age and gender.

Methods

One hundred and thirty-seven patients were enrolled from our TTC registry database from January 2004 to December 2010 in Korea.

Results

The median age of the entire study population was 59 years (inter-quartile range 53–72 years). The majority of patients were women (n = 101, 74%). The onset of TTC differed as a function of season (P = .001), with the peak in July and the nadir in March. Events were most frequent in summer (n = 53%, 38.7%) and least so in winter (n = 26, 19%, chi-square = 13.92, P = .003). TTC was most frequent in the morning (n = 56, 40.9%) and least so at night (n = 22, 16.1%, chi-square = 21.98, P = .001). Also, TTC was most frequent on Monday (n = 34, 24.8%) and least so on Saturday (n = 7, 5.1%, chi-square = 30.44, P = .001). Stressor pattern, age and gender do not influence these increases of occurrence in summer, on Monday, and in the morning of TTC.

Conclusions

TTC seems to exhibit a temporal variation of occurrence with preferred peaks during morning, Monday, and summer. Stressor pattern, age and gender do not influence these temporal patterns of the occurrence of TTC. Further studies are needed to investigate the potential link between chronobiological variations of TTC onset and underlying pathophysiologic mechanisms.

Introduction

Tako-tsubo cardiomyopathy (TTC), also known as transient left ventricular (LV) ballooning syndrome, or stress-induced cardiomyopathy is characterized by transient LV dysfunction in the absence of significant angiographic coronary stenoses, typically triggered by preceding emotional or physical stress.1, 2, 3, 4, 5 A growing body of evidence indicates that the onset of several cardiovascular events, such as acute myocardial infarction (AMI), stroke, and aortic dissection, is not randomly distributed over time, but exhibits temporal patterns along the day (circadian), month or season (circannual), and day of the week (weekly or circaseptan).6, 7, 8, 9, 10, 11 Among these cardiovascular events, AMI has known to show well-defined temporal patterns in their occurrence throughout the year and the day, which is characterized by peaks in winter and troughs in summer.⁶ TTC is prevalent in elderly women presenting with a history of emotional or physical stress that mimics the clinical scenario of AMI.1, 2, 3, 4, 5 However, there have been few data to review and analyze the temporal preference of the onset of TTC in detail.12, 13, 14, 15, 16 In this study, we investigated chronobiological variations in the occurrence of TTC and changes of these variations according to stressor pattern, age and gender.

Section snippets

Study subjects

We approached 137 consecutive patients enrolled from the TTC registry database at the Konkuk University Medical Center and Samsung Changwon Hospital from January 2004 to December 2010. From 6078 consecutive patients with diagnosis of an acute coronary syndrome, including ST- and non-ST-elevation myocardial infarction who had an urgent coronary angiography (CAG), 137 (2%) patients were diagnosed with TTC. The criteria for inclusion were as follows: (1) transient akinesia/dyskinesia beyond a

Clinical characteristics, laboratory parameters, electrocardiographic and echocardiographic findings in patients with TTC

The clinical characteristics and initial presentations of patients with TTC are presented in Table 1. The median age of the entire study population was 59 years (IQR: 53–72 years). The majority of patients were women (n = 101, 74%). The apical form of TTC was markedly prevalent (n = 106, 77%). Presenting symptoms were chest pain (n = 71, 52%), dyspnea (n = 77, 56%), palpitation (n = 11, 8%), and nausea/vomiting (n = 14, 10%). Forty-eight (35%) patients presented with cardiogenic shock and 57

Discussion

The main findings of this study were as follows: First, TTC seems to exhibit a temporal variation of occurrence with preferred peaks during morning, Monday, and summer. Second, stressor pattern, age and gender do not influence these chronobiological patterns of the occurrence of TTC.

To the best of our knowledge, this is one of the largest studies investigating the chronobiological variations of TTC onset and analyzing changes of these variations according to stressor pattern, age and gender.

Conclusions

TTC seems to exhibit a temporal variation of occurrence with preferred peaks during morning, Monday, and summer. Also, stressor patterns, age and gender do not influence these temporal patterns of occurrence of TTC. Further studies are needed to investigate the potential link between chronobiological variations of TTC onset and underlying pathophysiologic mechanisms.

References (33)

N.K. Singh et al.
Stress cardiomyopathy: clinical and ventriculographic characteristics in 107 North American subjects
Int J Cardiol
(2010)
S.W. Sharkey et al.
Natural history and expansive clinical profile of stress (tako-tsubo) cardiomyopathy
J Am Coll Cardiol
(2010)
B.G. Song et al.
Clinical characteristics, ballooning pattern, and long-term prognosis of transient left ventricular ballooning syndrome
Heart Lung
(2010)
G. Cocco et al.
Stress induced cardiomyopathy: a review
Eur J Intern Med
(2007)
R. Manfredini et al.
Monday preference in onset of ischemic stroke
Am J Med
(2001)
R. Regnante et al.
Clinical characteristics and four-year outcomes of patients in the Rhode Island Takotsubo cardiomyopathy registry
Am J Cardiol
(2009)
R. Citro et al.
Chronobiological patterns of onset of tako-tsubo cardiomyopathy
J Am Coll Cardiol
(2009)
V. Menon et al.
The clinical profile of patients with suspected cardiogenic shock due to predominant left ventricular failure: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cadiogenic shocK
J Am Coll Cardiol
(2000)
R.M. Lang et al.
Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology
J Am Soc Echocardiogr
(2005)
A.M. Hansen et al.
Seasonal and biological variation of urinary epinephrine, norepinephrine, and cortisol in healthy women
Clin Chim Acta
(2001)

M. Gianni et al.

Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review

Eur Heart J

(2006)

J.E. Muller et al.

Circadian variation in the frequency of onset of acute myocardial infarction

N Engl J Med

(1985)

R. Manfredini et al.

Seasonal variation in onset of myocardial infarction: a 7-year single-center study in Italy

Chronobiol Int

(2005)

M. Gallerani et al.

Seasonal variation in heart failure hospitalization

Clin Cardiol

(2011)

R.H. Mehta et al.

Chronobiological patterns of acute aortic dissection

Circulation

(2002)

S.N. Willich et al.

Weekly variation of acute myocardial infarction: increased Monday risk in the working population

Circulation

(1994)

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Clinical characteristics and outcome correlates of Chinese patients with takotsubo syndrome: Results from the first Chinese takotsubo syndrome registry
2023, International Journal of Cardiology
To investigate clinical features and outcomes of Chinese patients with Takotsubo syndrome (TTS).
We established the first Chinese Registry of Takotsubo Syndrome (ChiTTS Registry) and analyzed demographic, clinical, therapeutical, and outcome data to characterize clinical and outcome features of Chinese TTS patients.
In 112 enrolled patients in the ChiTTS registry from 02/01/2016 to 12/28/2021, the mean age was 59.4 ± 18.7 years old, and 27.7% were men. A total of 41.1% patients experienced respiratory and circulatory complications during hospitalization, and 17.3% patients developed cardiogenic shock. Physical triggers, dyspnea, tachycardia, and younger age (< 70 years old) predicted in-hospital complications. The MACCE rate during follow up was 13.9% per patient per year and the rate of all-cause death was 12.8% per patient per year. TTS patients with in-hospital complications developed more long-term MACCE (24.6% vs. 6.6% per patient-year, P < 0.001) and higher all-cause mortality (21.9% vs. 6.6% per patient-year, P = 0.001) than those without. The Kaplan-Meier survival analysis showed that more MACCE occurred in TTS patients with tachycardia during 3-year follow-up (HR 4.18; 95% CI 1.80–9.74; log-rank test P < 0.001). Among all medications at discharge, only beta-blocker was associated with reduced long-term MACCE (HR: 0.35; 95% CI: 0.12–0.996; P = 0.049).
We investigated clinical and outcome features of patients in the first Chinese TTS Registry. Tachycardiac TTS patients developed more inpatient and long-term adverse cardiovascular events.
Takotsubo Cardiomyopathy Triggered by Venous Air Embolism During Craniotomy in the Sitting Position
2017, World Neurosurgery
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An increasing age in men was a predictor for SCM. SCM seems to occur most frequently on Mondays and least frequently on Saturdays and more often in the morning than in the evening.5 The Mayo Clinic diagnostic criteria (transient LV dysfunction, absence of obstructive coronary disease, new ST-segment elevation/T-wave inversion or troponin elevation, absence of pheochromocytoma or myocarditis)6 can be used for diagnosis.
We present a case of stress-induced cardiomyopathy (Takotsubo cardiomyopathy) caused by a venous air embolism during a craniotomy performed in the sitting position.
A 69-year-old woman was admitted to the neurosurgical department and scheduled for elective resection of a cerebellar metastasis in the sitting position. After craniotomy and opening of the posterior fossa, a venous air embolism was detected via transesophageal echocardiography. The patient immediately presented with cardiac decompensation with signs of takotsubo or stress-induced cardiomyopathy.
Intensivists and anesthesiologists in the operating room and in intensive care units need to be aware of stress-induced cardiomyopathy as a probably underdiagnosed disease entity, especially as management differs significantly from other forms of cardiogenic shock. Diagnosis can be accomplished quickly by bedside echocardiography, emphasizing the need for availability of this tool and the integration of stress-induced cardiomyopathy in diagnostic algorithms in the intensive care unit.
Circaseptan Periodicity of Cardiovascular Diseases
2017, Heart Failure Clinics
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A limited number of studies is available on the circaseptan variability of takotsubo cardiomyopathy. Two studies confirmed a Monday peak,35,36 one found a non–statistically significant peak on Tuesday,37 and another did not demonstrate any weekly periodicity.38 Last, a Monday peak was found in subjects with acute aortic diseases,39 aortic rupture or dissection were reported to have a higher incidence on Monday.40,41
Chronobiology of Takotsubo Syndrome and Myocardial Infarction: Analogies and Differences
2016, Heart Failure Clinics
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Moreover, in healthy women with a routine lifestyle, the excretion of norepinephrine was higher during working hours (9 am–3 pm).86 Moreover, catecholamines are stimulated by acute stressful events, and most physical stressors capable of triggering TTS, for example, surgeries, bronchoscopies, endoscopies, and chemotherapy for cancer, are scheduled to take place in the mornings (and least at nights).44 Monday represents a critical day for cardiovascular events.
Contemporary burden of excess cardiovascular mortality on Monday. A retrospective study in the Veneto region of Italy
2016, International Journal of Cardiology
An increased risk for adverse cardiovascular events on Monday has been consistently reported in the literature. It remains to be assessed if a Monday peak in cardiovascular deaths can still be detected within the contemporary context of decreasing mortality rates from circulatory diseases in developed countries.
Mortality records were extracted from January 2000 to December 2013 in the Veneto region (Italy). The Monday excess in mortality from cerebrovascular diseases, ischemic heart diseases, and other circulatory diseases was investigated in subjects aged 35–74 years by means of Poisson regression models adjusted by age, gender, time trend and seasonality.
Among 41,024 deaths from circulatory diseases registered in the study population, mortality rates on Monday were increased by 13% (CI 9–17%) with respect to Sunday and by 6% (CI 4–9%) with respect to the overall daily mean. The Monday peak could be detected in both genders and in all the analyzed disease categories, and was more pronounced in younger age classes and in more recent years.
The persistency of the Monday effect on cardiovascular mortality is confirmed by recent large population-based data. Further research is warranted to investigate causal mechanisms.
Differences and similarities of repolarization patterns during hospitalization for takotsubo cardiomyopathy and acute coronary syndrome
2013, American Journal of Cardiology
Citation Excerpt :
Nonetheless, a persistent prolonged QT interval is a very attractive hypothesis to explain the genesis of malignant ventricular arrhythmias as a TC complication and, as previously reported, suggests a possible role of TC as an acquired cause of long QT syndrome.19 Ventricular tachycardia and ventricular fibrillation are all known life-threatening complications,6,20 and torsades de pointes has also been described after TC,21 especially when bradycardia is also present. It seems feasible to hypothesize that bradycardia-induced QT prolongation could be further augmented by TC, resulting in a favorable substrate for this arrhythmia.
Takotsubo cardiomyopathy (TC) is characterized by an acute transient left ventricular systolic dysfunction mimicking acute coronary syndrome (ACS) without significant coronary stenosis. The aim of this study was to examine the electrocardiographic repolarization patterns of TC and ACS and to compare them from hospital admission to hospital discharge. Forty-five patients with TC were matched with 45 patients with ACS according to age, gender, and presence or absence of ST elevation at hospital admission. A complete 12-lead electrocardiography was performed within 12 hours after symptoms onset and then repeated after 3, 5, and 7 days. All patients underwent coronary angiography, and patients with ACS also underwent percutaneous revascularization. Within 12 hours from the symptoms' onset, patients with TC had a significantly fewer number of leads with ST elevation and a significantly more number of leads with T-wave inversion. These differences, however, were not present after 72 hours and a similar trend was seen over time during the 7-day follow-up. Patients with TC had a significant longer corrected QT interval at admission and during the whole follow-up. In conclusion, in the electrocardiograms collected 12 hours within symptoms onset, patients with TC and those with ACS showed significant differences in cardiac repolarization. However, the number of leads with either ST-segment deviation or T-wave alterations in patients with TC soon matched the ACS group undergoing percutaneous revascularization. In contrast, corrected QT interval was persistently longer in patients with TC and, despite a similar reduction in length over time in both groups, it was still significantly longer after 7 days.

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Care of People who have Heart FailureChronobiological variation in the occurrence of Tako-tsubo cardiomyopathy: Experiences of two tertiary cardiovascular centers

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Study subjects

Clinical characteristics, laboratory parameters, electrocardiographic and echocardiographic findings in patients with TTC

Discussion

Conclusions

Int J Cardiol

J Am Coll Cardiol

Heart Lung

Eur J Intern Med

Am J Med

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

Clin Chim Acta

Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review

Eur Heart J

Circadian variation in the frequency of onset of acute myocardial infarction

N Engl J Med

Seasonal variation in onset of myocardial infarction: a 7-year single-center study in Italy

Chronobiol Int

Seasonal variation in heart failure hospitalization

Clin Cardiol

Chronobiological patterns of acute aortic dissection

Circulation

Weekly variation of acute myocardial infarction: increased Monday risk in the working population

Circulation

Care of People who have Heart Failure
Chronobiological variation in the occurrence of Tako-tsubo cardiomyopathy: Experiences of two tertiary cardiovascular centers