FREE NEJM E-TOC    HOME   |   SUBSCRIBE   |   CURRENT ISSUE   |   PAST ISSUES   |   COLLECTIONS   |   Search Term  Advanced Search

Sign in | Get NEJM's E-Mail Table of Contents — Free | Subscribe

Previous Volume 352:539-548 February 10, 2005 Number 6 Next

	Full Text PDF PDA Full Text PowerPoint Slide Set Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear PubMed Citation

ABSTRACT

Background Reversible left ventricular dysfunction precipitated by emotional stress has been reported, but the mechanism remains unknown.

Methods We evaluated 19 patients who presented with left ventricular dysfunction after sudden emotional stress. All patients underwent coronary angiography and serial echocardiography; five underwent endomyocardial biopsy. Plasma catecholamine levels in 13 patients with stress-related myocardial dysfunction were compared with those in 7 patients with Killip class III myocardial infarction.

Results The median age of patients with stress-induced cardiomyopathy was 63 years, and 95 percent were women. Clinical presentations included chest pain, pulmonary edema, and cardiogenic shock. Diffuse T-wave inversion and a prolonged QT interval occurred in most patients. Seventeen patients had mildly elevated serum troponin I levels, but only 1 of 19 had angiographic evidence of clinically significant coronary disease. Severe left ventricular dysfunction was present on admission (median ejection fraction, 0.20; interquartile range, 0.15 to 0.30) and rapidly resolved in all patients (ejection fraction at two to four weeks, 0.60; interquartile range, 0.55 to 0.65; P<0.001). Endomyocardial biopsy showed mononuclear infiltrates and contraction-band necrosis. Plasma catecholamine levels at presentation were markedly higher among patients with stress-induced cardiomyopathy than among those with Killip class III myocardial infarction (median epinephrine level, 1264 pg per milliliter [interquartile range, 916 to 1374] vs. 376 pg per milliliter [interquartile range, 275 to 476]; norepinephrine level, 2284 pg per milliliter [interquartile range, 1709 to 2910] vs. 1100 pg per milliliter [interquartile range, 914 to 1320]; and dopamine level, 111 pg per milliliter [interquartile range, 106 to 146] vs. 61 pg per milliliter [interquartile range, 46 to 77]; P<0.005 for all comparisons).

Conclusions Emotional stress can precipitate severe, reversible left ventricular dysfunction in patients without coronary disease. Exaggerated sympathetic stimulation is probably central to the cause of this syndrome.

Source Information

From the Division of Cardiology, Department of Medicine (I.S.W., D.R.T., J.A.C.L., S.P.S., G.G., K.C.W., J.J.R., H.C.C.), and the Brady Urological Institute (T.J.B.), Johns Hopkins University School of Medicine, Baltimore; the Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore (D.R.T.); and the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston (K.L.B.).

Address reprint requests to Dr. Wittstein at the Division of Cardiology, Johns Hopkins Hospital, Carnegie 568, 600 N. Wolfe St., Baltimore, MD 21287, or at iwittste{at}jhmi.edu.

Full Text of this Article

Related Letters:

Myocardial Stunning Due to Sudden Emotional Stress
Maseri A., Kurisu S., Inoue I., Kawagoe T., Kadhiravan T., Wittstein I. S., Champion H. C.
Extract | Full Text | PDF  
N Engl J Med 2005; 352:1923-1925, May 5, 2005. Correspondence

This article has been cited by other articles:

• Davidson, K. W., Burg, M., Shimbo, D. (2010). Endothelin-1 Release and Stimulation of the Inflammatory Cascade: Is Acute Coronary Syndrome Triggered by Watching Spectator Sports?. J Am Coll Cardiol 55: 643-644 [Full Text]  
• Summers, M. R., Lennon, R. J., Prasad, A. (2010). Pre-Morbid Psychiatric and Cardiovascular Diseases in Apical Ballooning Syndrome (Tako-Tsubo/Stress-Induced Cardiomyopathy): Potential Pre-Disposing Factors?. J Am Coll Cardiol 55: 700-701 [Full Text]  
• Mansencal, N., El Mahmoud, R., Dubourg, O. (2010). Occurrence of Tako-Tsubo Cardiomyopathy and Chronobiological Variation. J Am Coll Cardiol 55: 500-501 [Full Text]  
• Fang, F., Keating, N. L., Mucci, L. A., Adami, H.-O., Stampfer, M. J., Valdimarsdottir, U., Fall, K. (2010). Immediate Risk of Suicide and Cardiovascular Death After a Prostate Cancer Diagnosis: Cohort Study in the United States. JNCI J Natl Cancer Inst : djp537v1-8 [Abstract] [Full Text]  
• Sclarovsky, S., Nikus, K. C. (2010). The role of oestrogen in the pathophysiologic process of the Tako-Tsubo cardiomyopathy. Eur Heart J 31: 377-377 [Full Text]  
• Esler, M. (2010). The 2009 Carl Ludwig Lecture: pathophysiology of the human sympathetic nervous system in cardiovascular diseases: the transition from mechanisms to medical management. J. Appl. Physiol. 108: 227-237 [Abstract] [Full Text]  
• Pernicova, I., Garg, S., Bourantas, C. V., Alamgir, F., Hoye, A. (2010). Takotsubo Cardiomyopathy: A Review of the Literature. ANGIOLOGY 61: 166-173 [Abstract]  
• Sharkey, S. W., Windenburg, D. C., Lesser, J. R., Maron, M. S., Hauser, R. G., Lesser, J. N., Haas, T. S., Hodges, J. S., Maron, B. J. (2010). Natural History and Expansive Clinical Profile of Stress (Tako-Tsubo) Cardiomyopathy. J Am Coll Cardiol 55: 333-341 [Abstract] [Full Text]  
• Dupuis, M. J.M., Evrard, F., van Rijckevorsel, K., Dworetzky, B. A., Espinosa, P. S., Lee, J. W., Tedrow, U. B. (2010). SUDDEN UNEXPECTED NEAR DEATH IN EPILEPSY: MALIGNANT ARRHYTHMIA FROM A PARTIAL SEIZURE. Neurology 74: 181-182 [Full Text]  
• Spinelli, L., Trimarco, V., Di Marino, S., Marino, M., Iaccarino, G., Trimarco, B. (2010). L41Q polymorphism of the G protein coupled receptor kinase 5 is associated with left ventricular apical ballooning syndrome. Eur J Heart Fail 12: 13-16 [Full Text]  
• Heidecker, B., Lamirault, G., Kasper, E. K., Wittstein, I. S., Champion, H. C., Breton, E., Russell, S. D., Hall, J., Kittleson, M. M., Baughman, K. L., Hare, J. M. (2009). The gene expression profile of patients with new-onset heart failure reveals important gender-specific differences. Eur Heart J 0: ehp549v1-ehp549 [Abstract] [Full Text]  
• Barletta, G., Del Pace, S., Boddi, M., Del Bene, R., Salvadori, C., Bellandi, B., Coppo, M., Saletti, E., Gensini, G. F. (2009). Abnormal coronary reserve and left ventricular wall motion during cold pressor test in patients with previous left ventricular ballooning syndrome. Eur Heart J 30: 3007-3014 [Abstract] [Full Text]  
• Metcalf, C. S., Poelzing, S., Little, J. G., Bealer, S. L. (2009). Status epilepticus induces cardiac myofilament damage and increased susceptibility to arrhythmias in rats. Am. J. Physiol. Heart Circ. Physiol. 297: H2120-H2127 [Abstract] [Full Text]  
• Triposkiadis, F., Karayannis, G., Giamouzis, G., Skoularigis, J., Louridas, G., Butler, J. (2009). The sympathetic nervous system in heart failure physiology, pathophysiology, and clinical implications.. J Am Coll Cardiol 54: 1747-1762 [Abstract] [Full Text]  
• Agarwal, S., Lyon, A., Nachev, P., Everitt, A. (2009). The nervous heart: a case report and discussion of an under-recognized clinical problem. QJM 102: 807-809 [Full Text]  
• Griffin, S., Logue, B. (2009). Takotsubo Cardiomyopathy: A Nurse's Guide. Crit Care Nurse 29: 32-42 [Full Text]  
• Tsai, T. T., Nallamothu, B. K., Prasad, A., Saint, S., Bates, E. R. (2009). A Change of Heart. NEJM 361: 1010-1016 [Full Text]  
• Nef, H. M., Mollmann, H., Troidl, C., Kostin, S., Voss, S., Hilpert, P., Behrens, C. B., Rolf, A., Rixe, J., Weber, M., Hamm, C. W., Elsasser, A. (2009). Abnormalities in intracellular Ca2+ regulation contribute to the pathomechanism of Tako-Tsubo cardiomyopathy. Eur Heart J 30: 2155-2164 [Abstract] [Full Text]  
• Dunser, M. W., Hasibeder, W. R. (2009). Sympathetic Overstimulation During Critical Illness: Adverse Effects of Adrenergic Stress. J Intensive Care Med 24: 293-316 [Abstract]  
• Madhavan, M, Borlaug, B A, Lerman, A, Rihal, C S, Prasad, A (2009). Stress hormone and circulating biomarker profile of apical ballooning syndrome (Takotsubo cardiomyopathy): insights into the clinical significance of B-type natriuretic peptide and troponin levels. Heart 95: 1436-1441 [Abstract] [Full Text]  
• Kent, L. K., Weston, C. A., Heyer, E. J., Sherman, W., Prudic, J. (2009). Successful Retrial of ECT Two Months After ECT-Induced Takotsubo Cardiomyopathy. Am. J. Psychiatry 166: 857-862 [Full Text]  
• Ripa, C., Olivieri, F., Antonicelli, R. (2009). Tako-Tsubo-Like Syndrome With Atypical Clinical Presentation: Case Report and Literature Review. ANGIOLOGY 60: 513-517 [Abstract]  
• Eitel, I., Schuler, G., Thiele, H. (2009). Myocarditis mimicking Takotsubo cardiomyopathy or Takotsubo cardiomyopathy with secondary inflammation?. Eur J Heart Fail 11: 809-809 [Full Text]  
• Omerovic, E. (2009). Did Jesus die of a 'broken heart'?. Eur J Heart Fail 11: 729-731 [Full Text]  
• Heggemann, F., Weiss, C., Hamm, K., Kaden, J., Suselbeck, T., Papavassiliu, T., Borggrefe, M., Haghi, D. (2009). Global and regional myocardial function quantification by two-dimensional strain in Takotsubo cardiomyopathy. Eur J Echocardiogr 10: 760-764 [Abstract] [Full Text]  
• Rolf, A., Nef, H. M., Mollmann, H., Troidl, C., Voss, S., Conradi, G., Rixe, J., Steiger, H., Beiring, K., Hamm, C. W., Dill, T. (2009). Immunohistological basis of the late gadolinium enhancement phenomenon in tako-tsubo cardiomyopathy. Eur Heart J 30: 1635-1642 [Abstract] [Full Text]  
• Latib, A., Ielasi, A., Montorfano, M., Colombo, A. (2009). Broken heart syndrome: tako-tsubo cardiomyopathy. CMAJ 180: 1033-1034 [Full Text]  
• Ghosh, A. K, Hatfield, E., Connolly, S. (2009). Catecholamine-induced transient myocardial dysfunction. BMJ Case Reports 2009: bcr1220081349-bcr1220081349 [Abstract] [Full Text]  
• Lee, S. J., Kang, J. G., Ryu, O. H., Kim, C. S., Ihm, S.-H., Choi, M. G., Yoo, H. J., Hong, K. S. (2009). The relationship of thyroid hormone status with myocardial function in stress cardiomyopathy. Eur J Endocrinol 160: 799-806 [Abstract] [Full Text]  
• Margey, R., Diamond, P., McCann, H., Sugrue, D. (2009). Dobutamine stress echo-induced apical ballooning (Takotsubo) syndrome. Eur J Echocardiogr 10: 395-399 [Abstract] [Full Text]  
• Abraham, J., Mudd, J. O., Kapur, N., Klein, K., Champion, H. C., Wittstein, I. S. (2009). Stress Cardiomyopathy After Intravenous Administration of Catecholamines and Beta-Receptor Agonists. J Am Coll Cardiol 53: 1320-1325 [Abstract] [Full Text]  
• Yousuf, M. A., Adjei, S., Kinder, B. (2009). A 58-Year-Old Woman With ST-Segment Elevation, Seizures, and Altered Mental Status in the Setting of Opiate Withdrawal. Chest 135: 1098-1101 [Full Text]  
• Chen, F., Kan, H., Hobbs, G., Finkel, M. S. (2009). p38 MAP kinase inhibitor reverses stress-induced myocardial dysfunction in vivo. J. Appl. Physiol. 106: 1132-1141 [Abstract] [Full Text]  
• KUBZANSKY, L. D., KOENEN, K. C. (2009). Is posttraumatic stress disorder related to development of heart disease? An update*. Cleveland Clinic Journal of Medicine 76: S60-S65 [Abstract] [Full Text]  
• Coons, J. C., Barnes, M., Kusick, K. (2009). Takotsubo cardiomyopathy. Am J Health Syst Pharm 66: 562-566 [Abstract] [Full Text]  
• Meimoun, P., Malaquin, D., Benali, T., Boulanger, J., Zemir, H., Tribouilloy, C. (2009). Transient impairment of coronary flow reserve in tako-tsubo cardiomyopathy is related to left ventricular systolic parameters. Eur J Echocardiogr 10: 265-270 [Abstract] [Full Text]  
• Bijulal, S., Harikrishnan, S., Namboodiri, N., Ajitkumar, V. K, Gupta, D., Mathuranath, P S (2009). Tako-tsubo cardiomyopathy in a patient with myasthenia gravis crisis: a rare clinical association. BMJ Case Reports 2009: bcr0620080182-bcr0620080182 [Abstract] [Full Text]  
• Derrick, D. (2009). The"Broken Heart Syndrome": Understanding Takotsubo Cardiomyopathy. Crit Care Nurse 29: 49-57 [Full Text]  
• POZUELO, L., TESAR, G., ZHANG, J., PENN, M., FRANCO, K., JIANG, W. (2009). Depression and heart disease: What do we know, and where are we headed?. Cleveland Clinic Journal of Medicine 76: 59-70 [Abstract] [Full Text]  
• Guerrero, J., Majid, A., Ernst, A. (2009). Cardiogenic Shock Secondary to Tako-tsubo Syndrome After Debridement of Malignant Endobronchial Obstruction. Chest 135: 217-220 [Abstract] [Full Text]  
• Burg, M. M., Graeber, B., Vashist, A., Collins, D., Earley, C., Liu, J., Lampert, R., Soufer, R. (2009). Noninvasive Detection of Risk for Emotion Provoked Myocardial Ischemia. Psychosom. Med. 71: 14-20 [Abstract] [Full Text]  
• Angelini, P. (2009). Midventricular Variant of Transient Apical Ballooning: A Likely Demonstration of Its Pathophysiologic Mechanism. Mayo Clin Proc. 84: 92-93 [Full Text]  
• Akashi, Y. J., Goldstein, D. S., Barbaro, G., Ueyama, T. (2008). Takotsubo Cardiomyopathy: A New Form of Acute, Reversible Heart Failure. Circulation 118: 2754-2762 [Full Text]  
• Eitel, I., Behrendt, F., Schindler, K., Kivelitz, D., Gutberlet, M., Schuler, G., Thiele, H. (2008). Differential diagnosis of suspected apical ballooning syndrome using contrast-enhanced magnetic resonance imaging. Eur Heart J 29: 2651-2659 [Abstract] [Full Text]  
• Afonso, L., Bachour, K., Awad, K., Sandidge, G. (2008). Takotsubo cardiomyopathy: pathogenetic insights and myocardial perfusion kinetics using myocardial contrast echocardiography. Eur J Echocardiogr 9: 849-854 [Abstract] [Full Text]  
• Bandettini, W P, Arai, A E (2008). Advances in clinical applications of cardiovascular magnetic resonance imaging. Heart 94: 1485-1495 [Abstract] [Full Text]  
• Whitten, S. E. (2008). Systolic Heart Failure in a Patient With Hypertrophic Obstructive Cardiomyopathy: A Potentially Life-Threatening Complication. Crit Care Nurse 28: 44-52 [Full Text]  
• Roy-Byrne, P. P., Davidson, K. W., Kessler, R. C., Asmundson, G. J.G., Goodwin, R. D., Kubzansky, L., Lydiard, R. B., Massie, M. J., Katon, W., Laden, S. K., Stein, M. B. (2008). Anxiety Disorders and Comorbid Medical Illness. Focus 6: 467-485 [Abstract] [Full Text]  
• Parulekar, P, Khawaja, M Z O, McWilliams, E T (2008). Chest pain after emotional and physical upset. BMJ 337: a107-a107 [Full Text]  
• De Santis, V., Vitale, D., Tritapepe, L., Greco, C., Pietropaoli, P. (2008). Use of Levosimendan for Cardiogenic Shock in a Patient with the Apical Ballooning Syndrome. ANN INTERN MED 149: 365-367 [Full Text]  
• Zywica, K., Jenni, R., Pellikka, P.A., Faeh-Gunz, A., Seifert, B., Attenhofer Jost, C.H. (2008). Dynamic left ventricular outflow tract obstruction evoked by exercise echocardiography: prevalence and predictive factors in a prospective study. Eur J Echocardiogr 9: 665-671 [Abstract] [Full Text]  
• Baumert, M., Lambert, G. W., Dawood, T., Lambert, E. A., Esler, M. D., McGrane, M., Barton, D., Nalivaiko, E. (2008). QT interval variability and cardiac norepinephrine spillover in patients with depression and panic disorder. Am. J. Physiol. Heart Circ. Physiol. 295: H962-H968 [Abstract] [Full Text]  
• Bergman, B. R., Reynolds, H. R., Skolnick, A. H., Castillo, D. (2008). A Case of Apical Ballooning Cardiomyopathy Associated with Duloxetine. ANN INTERN MED 149: 218-219 [Full Text]  
• Schummer, C., Wirsing, M., Schummer, W. (2008). The Pivotal Role of Vasopressin in Refractory Anaphylactic Shock. Anesth. Analg. 107: 620-624 [Abstract] [Full Text]  
• Bybee, K. A., Prasad, A. (2008). Stress-Related Cardiomyopathy Syndromes. Circulation 118: 397-409 [Full Text]  
• Crimi, E., Baggish, A., Leffert, L., Pian-Smith, M. C.M., Januzzi, J. L., Jiang, Y. (2008). Acute Reversible Stress-Induced Cardiomyopathy Associated with Cesarean Delivery under Spinal Anesthesia. Circulation 117: 3052-3053 [Full Text]  
• Schwenk, T. L., Spitters, C. E., Lippi, G., Targher, G., Farzaneh-Far, R., Farzaneh-Far, A., Wilbert-Lampen, U., Steinbeck, G. (2008). Cardiovascular events during World Cup soccer.. NEJM 358: 2408-2408 [Full Text]  
• Ketterer, M. W., Knysz, W., Keteyian, S.J., Schairer, J., Jafri, S., Alam, M., Farha, A.J., Deveshwar, S. (2008). Cardiovascular Symptoms in Coronary-Artery Disease Patients Are Strongly Correlated With Emotional Distress. Psychosomatics 49: 230-234 [Abstract] [Full Text]  
• Ionescu, A. (2008). Subaortic dynamic obstruction: a contributing factor to haemodynamic instability in tako-tsubo syndrome?. Eur J Echocardiogr 9: 384-385 [Abstract] [Full Text]  
• Kogan, A., Ghosh, P., Schwammenthal, E., Raanani, E. (2008). Takotsubo Syndrome After Cardiac Surgery. Ann. Thorac. Surg. 85: 1439-1441 [Abstract] [Full Text]  
• Dimsdale, J. E. (2008). Psychological Stress and Cardiovascular Disease. J Am Coll Cardiol 51: 1237-1246 [Abstract] [Full Text]  
• Ramaraj, R. (2008). A pathophysiological study of tako-tsubo cardiomyopathy with F-18 fluorodeoxyglucose positron emission tomography. Eur Heart J 29: 681-681 [Full Text]  
• Yoshida, T., Hibino, T., Kako, N., Murai, S., Oguri, M., Kato, K., Yajima, K., Ohte, N., Yokoi, K., Kimura, G. (2008). A pathophysiological study of tako-tsubo cardiomyopathy with F-18 fluorodeoxyglucose positron emission tomography: reply. Eur Heart J 29: 681-682 [Full Text]  
• Nanda, S., Bhatt, S. P., Dale, T. H., Kurowski, V., Burgdorf, C., Radke, P. W. (2008). Tako-tsubo Cardiomyopathy: An Insight Into Pathogenesis. Chest 133: 583-584 [Full Text]  
• Holman, E. A., Silver, R. C., Poulin, M., Andersen, J., Gil-Rivas, V., McIntosh, D. N. (2008). Terrorism, Acute Stress, and Cardiovascular Health: A 3-Year National Study Following the September 11th Attacks. Arch Gen Psychiatry 65: 73-80 [Abstract] [Full Text]  
• Fazal, I. A, Alfakih, K., Walsh, J. T (2007). Takotsubo Cardiomyopathy. JRSM 100: 573-575 [Full Text]  
• Meimoun, P., Malaquin, D., Benali, T. (2007). Reply to the letter to the editor by F. Tona et al.. Eur J Echocardiogr 8: 413-415 [Full Text]  
• Hakeem, A., Marks, A. D., Bhatti, S., Chang, S. M. (2007). When the Worst Headache Becomes the Worst Heartache!. Stroke 38: 3292-3295 [Abstract] [Full Text]  
• Yoshida, T., Hibino, T., Kako, N., Murai, S., Oguri, M., Kato, K., Yajima, K., Ohte, N., Yokoi, K., Kimura, G. (2007). A pathophysiologic study of tako-tsubo cardiomyopathy with F-18 fluorodeoxyglucose positron emission tomography. Eur Heart J 28: 2598-2604 [Abstract] [Full Text]  
• Nef, H. M., Mollmann, H., Kostin, S., Troidl, C., Voss, S., Weber, M., Dill, T., Rolf, A., Brandt, R., Hamm, C. W., Elsasser, A. (2007). Tako-Tsubo cardiomyopathy: intraindividual structural analysis in the acute phase and after functional recovery. Eur Heart J 28: 2456-2464 [Abstract] [Full Text]  
• Guerrero, J., Majid, A., Feller-Kopman, D., Morgan, R., Anantham, D., Ernst, A. (2007). CARDIOGENIC SHOCK SECONDARY TO TAKOTSUBO SYNDROME AFTER DEBRIDEMENT OF MALIGNANT ENDOBRONCHIAL OBSTRUCTION. Chest Meeting 132: 674a-674 [Abstract]  
• Nef, H. M, Mollmann, H., Elsasser, A. (2007). Tako-tsubo cardiomyopathy (apical ballooning). Heart 93: 1309-1315 [Full Text]  
• Frey, N., Katus, H. A., Giannitsis, E. (2007). The Tako-Tsubo Syndrome: An Underappreciated, Novel Disease Entity. Chest 132: 743-744 [Full Text]  
• Kurowski, V., Kaiser, A., von Hof, K., Killermann, D. P., Mayer, B., Hartmann, F., Schunkert, H., Radke, P. W. (2007). Apical and Midventricular Transient Left Ventricular Dysfunction Syndrome (Tako-Tsubo Cardiomyopathy)* Frequency, Mechanisms, and Prognosis. Chest 132: 809-816 [Abstract] [Full Text]  
• Ramaraj, R. (2007). Stress cardiomyopathy: aetiology and management. Postgrad. Med. J. 83: 543-546 [Abstract] [Full Text]  
• Elesber, A. A., Prasad, A., Lennon, R. J., Wright, R. S., Lerman, A., Rihal, C. S. (2007). Four-Year Recurrence Rate and Prognosis of the Apical Ballooning Syndrome. J Am Coll Cardiol 50: 448-452 [Abstract] [Full Text]  
• Ziegelstein, R. C. (2007). Acute Emotional Stress and Cardiac Arrhythmias. JAMA 298: 324-329 [Abstract] [Full Text]  
• Samuels, M. A. (2007). The Brain-Heart Connection. Circulation 116: 77-84 [Full Text]  
• Vanacker, A., Meersseman, W., Knockaert, D. C., Wilmer, A., Blockmans, D. (2007). A 42-Year-Old Woman With Sudden Onset of Back Pain and Severe Dyspnea. Chest 131: 1595-1598 [Full Text]  
• Buchholz, S., Rudan, G. (2007). Tako-tsubo syndrome on the rise: a review of the current literature. Postgrad. Med. J. 83: 261-264 [Abstract] [Full Text]