Takotsubo Syndrome: An International Expert Consensus Report on Practical Challenges and Specific Conditions (Part-2: Specific Entities, Risk Stratification and Challenges After Recovery)

Figures

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  Figure 1. A proposed algorithm for the differentiation between mechanically-triggered and neurogenic TTS episodes in patients with HCM (or hypertensive heart disease) presenting with an apical ballooning pattern. TTS, Takotsubo syndrome; HCM, hypertrophic cardiomyopathy; LVOTO, left ventricular outflow tract obstruction; MVO, midventricular obstruction. *: Morphological features of HCM may not be evident on initial echocardiogram in certain cases. Accordingly, some patients with a history of apparently neurogenic TTS were diagnosed as having HCM on follow-up raising the possibility of a previous mechanically-triggered TTS episode.1 Cardiac magnetic resonance imaging (and rarely endomyocardial biopsy) may be necessary to establish the HCM diagnosis in patients with borderline features on echocardiogram.1 Exclusion of HCM or hypertensive heart disease may, to a large extent, rule out a mechanically-triggered TTS episode. Nevertheless, challenge tests may be necessary in certain cases with ambiguous features. **: Mostly dobutamine or exercise echocardiogram.

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  Figure 2. (A) Invasive left ventriculogram in a female patient with mid-apical pattern of TTS. (B) left coronary angiogram (CAG) in the caudal projection demonstrating marked coronary slow flow (CSF) (yellow asterix) in the left anterior descending artery (LAD) compared with near- normal coronary flow pattern (white asterix) in the left circumflex artery. (C) Left CAG in the right cranial projection demonstrating LAD with its septal branches. The septal branches from the proximal LAD segment are clearly visible (thick white arrows), while the septal branches from the distal half of the LAD (thin dotted black arrows) within the affected left ventricular (LV) segment are not visible (or barely visible) due to the compression imposed by the stunned LV mid-apical segment (cardiac cramp). Compression of the septal arteries also contributes to the CSF pattern in the LAD.

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  Figure 3. A summary of established and promising risk markers in patients with TTS. TTS, Takotsubo syndrome; CSF, coronary slow flow; CAG, coronary angiogram; LVEF, left ventricular ejection fraction; RV, right ventricle; BP, blood pressure; LVOTO, left ventricle outflow tract obstruction; MR, mitral regurgitation; DM, diabetes mellitus; LA, left atrium; MRI, magnetic resonance imaging; E-PIV, echocardiographic particle imaging velocimetry; pFAi, pericoronary fat attenuation index; CT, computed tomography; MIBG, metaiodobenzylguanidine; IL, interleukin; CEA, carcinoembryonic antigen; CA, carbohydrate antigen. &: The listed risk markers are based on references33,34,36,45,46,48,49,50-52,56-69,71,85,86 *: Definition of advanced age varies in reports. It is mostly regarded as an age of > 70 years46,50 or > 75 years.47 **: Physical stressors are more likely to be associated with atypical TTS variants includind midventricular and basal TTS.46 ***: Definition of high-risk LVEF also varies in various reports (LVEF 30%46 or ≤ 35%47 or ≤ 45%50). LVEF is also incorporated into certain risk scores (including the GEIST score) as a variable with decimal values (ranging between 0.15 and 0.70).49 ****:…