Prevalence and Clinical Characteristics of Right Ventricular Dysfunction in Transient Stress Cardiomyopathy

doi:10.1016/j.amjcard.2009.02.049

The American Journal of Cardiology

Volume 104, Issue 1, 1 July 2009, Pages 133-136

https://doi.org/10.1016/j.amjcard.2009.02.049 Get rights and content

Transient stress cardiomyopathy (TSC) is a cause of reversible left ventricular (LV) dysfunction that is increasingly recognized. Reports to date have focused primarily on LV involvement, with little attention paid to associated right ventricular (RV) dysfunction. With other forms of LV dysfunction, RV involvement has been shown to confer an adverse prognosis. Prevalence, clinical characteristics, and short-term prognosis of RV dysfunction in TSC remain ill-defined. Presenting echocardiograms of 40 patients with TSC were reviewed. RV function was assessed by evaluating regional wall motion and calculating a wall motion score index (WMSI). RV dysfunction was defined as a WMSI >1.0. Clinical and demographic characteristics of patients with and without RV dysfunction were compared. RV dysfunction was identified in 27% of patients (11 of 40). RV WMSI was 1.20 ± 0.30 for the entire cohort compared with 1.72 ± 0.30 for those with RV dysfunction (p <0.05). In each case with RV dysfunction, regional wall motion abnormalities involved the apex and spared the base. Patients with RV dysfunction had higher B-type natriuretic peptide levels, higher pulmonary artery systolic pressures, and longer hospital stays. RV dimensions, clinical characteristics, electrocardiographic findings, other biomarkers, and in-hospital complications were similar. In conclusion, RV wall motion abnormalities, predominantly involving the apex and sparing the base, occur in slightly >1/4 of cases of TSC. Although associated with higher B-type natriuretic peptide levels, higher pulmonary artery systolic pressures, and longer hospital stays, RV dysfunction was not associated with significant differences in short-term cardiac morbidity or increased early mortality.

Section snippets

Methods

An ongoing collaborative effort at the University of Massachusetts (Worcester, Massachusetts) and Tufts Medical Centers (Boston, Massachusetts) has identified >40 consecutive patients with TSC, as defined by proposed Mayo Clinic criteria,² who presented acutely to the emergency department. All patients underwent coronary angiography. A single reviewer blinded to clinical data assessed 2-dimensional echocardiograms of these patients performed within 24 hours of presentation to the hospital. RV

Results

As required for study inclusion, all patients met the proposed Mayo Clinic criteria² for TSC. By definition, no patient had occlusive coronary heart disease (no angiographic stenosis >60% luminal diameter) and no acute plaque rupture was found. Patients tended to be older women who had experienced a physiologic stress (Table 1). RV dysfunction was identified in 27% of patients (11 of 40). There were no significant differences in demographic characteristics or presenting clinical features in

Discussion

In this retrospective cohort study of patients presenting acutely with proved TSC, RV involvement was identified in 27% of cases. This incidence is similar to that reported for RV dysfunction in acute TSC by other groups.4, 5, 6

In a prospective evaluation of 30 patients presenting with TSC, Elesber et al⁴ found that 8 (26%) had RV involvement. The RV apex was affected in every patient, the mid-RV free wall was affected in 75% (6 of 8), and basal segments of the right ventricle were always

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Cited by (25)

Incidence and Clinical Impact of Right Ventricular Involvement (Biventricular Ballooning) in Takotsubo Syndrome: Results From the GEIST Registry
2021, Chest
Citation Excerpt :
Several studies have reported a higher rate of in-hospital complications in patients with TTS with RV involvement compared with LV patients with TTS; however, the actual mortality rate remains a subject of much debate. Kagiyama et al12 reported a higher in-hospital mortality rate of 14% vs 1% in patients with RV involvement (18.5% of all population), whereas Fitzgibbons et al23 reported similar mortality rates in both groups in a cohort of 40 patients (11 [27%] with RV involvement). In line with our data, Citro et al11 reported a similar in-hospital mortality rate in patients with RV involvement compared with patients with TTS with no evidence of RV involvement, albeit with a higher incidence of acute heart failure in the RV involvement group.
The short- and long-term prognosis of Takotsubo syndrome (TTS) presenting with right ventricular (RV) involvement remains poorly understood.
What is the incidence and clinical outcome of RV involvement in TTS?
This study analyzed 839 consecutive patients with TTS (758 female subjects and 81 male subjects) in a multicenter registry. RV involvement was defined as wall motion abnormality of the RV free wall, with or without apical involvement. The median long-term follow-up was 2.1 years (interquartile range, 0.3-4.5 years). The primary outcome was in-hospital and out-of-hospital all-cause mortality. The secondary end point was a composite of in-hospital death, thromboembolic events, cardiogenic shock, pulmonary edema, and malignant arrhythmias.
The incidence of RV involvement in TTS was 11% (n = 93). More often patients with RV involvement were male compared with patients without RV involvement (P = .02). There was a slight difference in the left ventricular ejection fraction measured in patients with RV involvement vs those patients with isolated left ventricular TTS (38 ± 10% vs 40 ± 10%; P = .03). No major differences in terms of comorbidities were observed between groups except regarding a history of cancer, which was significantly more prevalent in patients with TTS presenting with RV involvement (P = .03). Physical stressors were more prevalent in the RV group (P < .01), whereas emotional stressors were less prevalent (P < .01). Patients with RV involvement had a higher incidence of in-hospital cardiogenic shock (P = .02). The primary outcome (in- and out-of-hospital all-cause mortality) was observed in 12.8% of patients without RV involvement compared with 29% of patients with RV involvement. Although the in-hospital mortality rate was similar in both groups, a higher out-of-hospital all-cause mortality rate (log-rank test, P = .008) was observed in the RV involvement group. The Cox multivariable regression analysis showed that physical triggers were independent predictors of RV involvement.
RV involvement defines a high-risk cohort of patients with TTS.
ClinicalTrials.gov; No.: NCT04361994; URL: www.clinicaltrials.gov.
Myocardial strain may be useful in differentiating Takotsubo cardiomyopathy from left anterior descending coronary artery ischemia
2017, International Journal of Cardiology
Citation Excerpt :
RV dysfunction from coronary artery disease is usually due to involvement of the right coronary artery and therefore may be helpful to differentiate SCM from LAD. Multiple studies have demonstrated RV involvement in SCM [6,7,13–21]. The frequency of RV involvement in these studies varied between 14.5% and 87%.
Stress-induced cardiomyopathy (SCM) is characterized by transient apical wall motion abnormalities of the left ventricle (LV) in the absence of obstructive coronary artery disease. Although the echocardiographic findings of SCM mimic those of left anterior descending coronary artery ischemia or infarction (LAD), the regional LV wall motion pattern and degree of RV involvement may differ.
We sought to systematically assess regional LV and RV function with myocardial strain imaging to assess if ventricular involvement may differ between SCM and LAD.
This was a retrospective cohort study, with 3 groups: patients with SCM (n = 55), patients with LAD (n = 36), and 37 normal subjects. All the patients had a comprehensive transthoracic echocardiographic examination, including assessment of longitudinal strain (LS). Global LV longitudinal strain was markedly decreased in both the SCM and LAD groups. However, SCM patients differed by more severe involvement the mid-inferolateral, mid-inferior, apical-lateral, and apical-inferior segments. When compared to the LAD patients, SCM patients had significantly more RV involvement both visually and quantitatively (27–42% versus 0–25%). Predictors of SCM included visually reduced RV systolic function, abnormal TAPSE, RVS′ and RV LS in the apical segment. Of the LV variables, regional LS in the mid-inferior and apical-inferior segments could differentiate the groups.
Our results suggest that RV involvement and the pattern of LV regional LS abnormalities may help differentiate SCM from LAD disease during echocardiographic imaging.
Takotsubo Cardiomyopathy: A Clinical Update for the Cardiovascular Anesthesiologist
2017, Journal of Cardiothoracic and Vascular Anesthesia
Psychiatric history, post-discharge distress, and personality characteristics among incident female cases of takotsubo cardiomyopathy: A case–control study
2016, Heart and Lung
The role of psychological factors in the onset of takotsubo cardiomyopathy (TC) is still controversial. Associations with previous psychiatric conditions are registry-based; associations with personality characteristics and psychological sequelae of TC have been largely unexplored. This case–control study sought to study pre-admission psychiatric morbidity, personality traits, and post-discharge distress in incident cases of TC.
TC cases (Mayo clinic criteria) and acute myocardial infarction (MI) controls were recruited among women admitted to two Emergency Departments in New England. Healthy controls (HC) were recruited from a volunteers' registry. Preadmission psychiatric history (DSM-IV-TR) was abstracted from the medical record. PTSD symptoms (Impact of Events Scale); distress (Hospital Anxiety and Depression Scale); perceived stress (PS scale) and personality traits (optimism; hostility, type D personality) were collected via phone interview one month after discharge.
From March 2013 through October 2015, 107 participants (45 TC, 32 MI and 30 HC) were enrolled. The prevalence of preadmission anxiety disorders was 24.4% in TC, 9.4% in MI, and 0 in HC (p = 0.007) while that of mood disorders was similar across groups. TC had higher psychological distress, perceived stress, and PTSD symptoms post-discharge vs. MI and HC. In adjusted models, PTSD symptoms remained higher in TC vs. MI (b = 0.55, p < 0.05) and vs. HC (b = 0.92, p < 0.01). Optimism and hostility scores were similar across groups, while type D (social inhibition) scores were higher in TC and MI vs. HC.
Preadmission anxiety, but not depression, was associated with the occurrence of TC. High distress and PTSD symptoms post-discharge indicate that TC women may be at risk for poor psychological adjustment.
Characteristics and long-term outcome of right ventricular involvement in Takotsubo cardiomyopathy
2016, International Journal of Cardiology
Citation Excerpt :
Although multiple studies have reported a higher in-hospital event rate for patients with biventricular SCM, data on in-hospital mortality in patients with biventricular compared with classical SCM remains controversial. While Kagiyama et al. reported a higher in-hospital mortality in patients with RV involvement, Fitzgibbons et al. reported similar outcomes in both groups in a cohort of 40 patients in which 11 patients showed RV involvement [7,11]. A major contributor to in-hospital mortality in patients with SCM is cardiogenic shock.
Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy (SCM) resembles a reversible cardiomyopathy that is characterized by localized wall motion abnormalities in the absence of stenotic coronary vascular disease. Patients typically present with apical ballooning of the left ventricle (LV), however the right ventricle (RV) is also affected in up to 50.0% of patients. Long-term prognosis of classical SCM resembles that of patients after ST elevation myocardial infarction. Data on long-term prognosis of biventricular compared to classical SCM is controversial. The aim of this study was therefore to analyze patients with biventricular SCM regarding in-hospital outcome and long-term prognosis.
114 consecutive patients with SCM were retrospectively analyzed. 88 patients presented with classical SCM, 26 patients (22.8%) were diagnosed with biventricular SCM. Follow-up was conducted for a total of 4.4 years. Mean age was 67.1 years with 83.3% of patients being female. The primary endpoint was a composite of all-cause mortality, recurrence of SCM and re-hospitalization due to heart failure.
Although patients with biventricular SCM presented with a tendency towards an increased rate of cardiogenic shock (30.8% vs. 15.9%; p = 0.09) and significantly more usage of inotropic support upon hospital admission (34.6% vs. 13.6%; p = 0.01), there was no difference concerning the primary endpoint in both groups (50.0% vs. 44.3%; p = 0.31). Furthermore, there was no difference in mortality both in-hospital (7.7% vs. 7.9%; p = 0.66) and during long-term follow-up (27.3% vs. 23.1%; p = 0.46).
Patients with biventricular SCM have the same in-hospital and long-term outcome compared to classical SCM.
Right ventricular involvement and recovery after acute stress-induced (Tako-tsubo) cardiomyopathy
2016, American Journal of Cardiology
Citation Excerpt :
This is not surprising because CMR is the accepted gold standard for RV assessment, and thus, it is possible that previous studies may have underestimated the extent of RV involvement in this condition. A reduced RV EF and increased PaP characterize the RV + group, in keeping with previous observations.3–5 Interestingly, in our study, the group designated RV - by visual assessment of wall motion also showed a modest but significantly reduced TAPSE acutely, which improved at follow-up, suggesting discrete abnormalities in the long-axis function of the RV even in this group.
Acute stress-induced (Tako-tsubo) cardiomyopathy is an increasingly recognized but insufficiently characterized syndrome. Here, we investigate the pathophysiology of right ventricular (RV) involvement in Tako-tsubo and its recovery time course. We prospectively recruited 31 patients with Tako-tsubo with predominantly ST-elevation electrocardiogram and 18 controls of similar gender, age, and co-morbidity distribution. Patients underwent echocardiography and cardiac magnetic resonance (CMR) imaging on a 3T Philips scanner in the acute phase (day 0 to 3 after presentation) and at 4-months follow-up. Visually, echocardiography was able to identify only 52% of patients who showed RV wall motion abnormalities on CMR. Only CMR-derived RV ejection fraction (p = 0.01) and echocardiography-estimated pulmonary artery pressure (p = 0.01) identify RV functional involvement in the acute phase. Although RV ejection fraction normalizes in most patients by 4 months, acutely there is RV myocardial edema in both functioning and malfunctioning segments, as measured by prolonged native T1 mapping (p = 0.02 for both vs controls), and this persists at 4 months in the acutely malfunctioning segments (p = 0.002 vs controls). The extracellular volume fraction was significantly increased acutely in all RV segments and remained increased at follow-up compared with controls (p = 0.004 for all). In conclusion, in a Tako-tsubo population presenting predominantly with ST-elevation electrocardiogram, we demonstrate that although RV functional involvement is seen in only half of the patients, RV myocardial edema is present acutely throughout the RV myocardium in all patients and results in microscopic fibrosis at 4-month follow-up.

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CardiomyopathyPrevalence and Clinical Characteristics of Right Ventricular Dysfunction in Transient Stress Cardiomyopathy

Section snippets

Methods

Results

Discussion

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Chest

Cardiomyopathy
Prevalence and Clinical Characteristics of Right Ventricular Dysfunction in Transient Stress Cardiomyopathy