Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 56, Num. 3, 2010, pp. 211-212

Journal of Postgraduate Medicine, Vol. 56, No. 3, July-September, 2010, pp. 211-212

Commentary

Takotsubo cardiomyopathy and arrhythmias: It's time we paid greater attention

Fazio G, Ferro G, Novo G, Novo S

Department of Cardiology, University of Palermo, Italy

Correspondence Address: Giovanni Fazio, Department of Cardiology, University of Palermo, Italy, giovanni.fazio-aaaa@poste.it

Code Number: jp10058

Takotsubo cardiomyopathy (TC) is a clinical syndrome characterized by transitory reversible hypokinesis, akinesis or dyskinesis of apical and mid-left ventricular segments with regional wall motion abnormalities in the absence of obstructive coronary artery disease. ^[1],[2],[3] Many patients with TC have excellent prognosis and demonstrate a rapid and complete recovery after a phase of transitory cardiac failure. Many ECG changes have been described with this disorder and these can be divided into two groups: Acute ischemic changes such as ST segment elevation, T-wave inversion, Q waves and new left bundle branch block; ^{[2],[3],[4],[5],[6]} and Rhythm disturbances likesino-atrial arrest, sinus bradycardia, atrioventricular (AV) block (Wenckebach, 2:1 and third degree), paroxysmal atrial fibrillation, QT interval prolongation, ventricular tachycardia and ventricular fibrillation.

Life-threatening arrhythmias like third-degree AV block, ventricular tachycardia, ventricular fibrillation and cardiac arrest are uncommon and they are seen in approximately 15% of patients diagnosed with TC. ^{[1],[2],[3],[4],[5],[6]} Atrial arrhythmias like sinus bradycardia and atrial fibrillation are seen in 17% of TC patients. ^[5] Rhythm disturbances seen in TC usually resolve within hours to days of acute presentation.Rarely, these changes canpersist even after complete functional recovery of left ventricular function and require intervention. ^{[1],[2],[3],[4],[5],[6]}

The authors have reported a case of a patient affected by atrial fibrillation as a consequence of Takotsubo cardiomyopathy. However, the atrial fibrillation, as determined by the atrial strain, persisted after the resolution of the cardiomyopathy. ^[1] Long-term follow-up revealed the persistence of arrhythmias. This case represents the first case report that shows long-term persistence of atrial fibrillation which developed during an episode of TC and it is interesting because it reveals the problem of atrial disarray post TC. This observation could be of great importance in patients who develop atrial fibrillation during the acute phase, as treating physicians will now have to consider monitoring them for a longer time to ensure return to sinus rhythm. Atrial fibirllation is a complication that is present in 8% of TC, and is important to treat these patients with oral anticoagulation if the atrial fibrillation is paroxysmal.

References

1.	Shah NR, Wallis W. Takotsubo cardiomyopathy presenting as postoperative atrial fibrillation. J Postgrad Med 2010;56:209-11.  Back to cited text no. 1  [PUBMED]
2.	Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E.Apical ballooning syndrome or Takotsubo cardiomyopathy: A systematic review. Eur Heart J 2006;27:1523-9.   Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.	Akashi YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo cardiomyopathy: A new form of acute, reversible heart failure. Circulation 2008;118:2754-62.   Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.	Park JH, Kang SJ, Song JK, Kim HK, Lim CM, Kang DH, et al. Left ventricular apical ballooning due to severe physical stress in patients admitted to medical ICU. Chest 2005;128:296-302.   Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.	Fazio G, Barbaro G, Sutera L, Guttilla D, Pizzuto C, Azzarelli S, et al. Clinical findings of Takotsubo cardiomyopathy: Results from a multicenter international study. J Cardiovasc Med (Hagerstown) 2008;9:239-44.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.	Dib C, Asirvatham S, Elesber A, Rihal C, Friedman P, Prasad A. Clinical correlates and prognostic significance of electrocardiographic abnormalities in apical ballooning syndrome (Takotsubo/stress-induced cardiomyopathy). Am Heart J 2009;157:933-8.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]

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