Practical update of Takotsubo syndrome | Medicina Clínica (English Edition)

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Las flechas muestran la parte afecta. B) Imagen equivalente a la anterior de un paciente con forma atípica, de predominio medioventricular. En este caso el ápex se contraía normalmente. Las flechas señalan la parte discinética." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Iván J. Núñez-Gil, Hernán D. Mejía-Rentería, Pedro Martínez-Losas" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Iván J." "apellidos" => "Núñez-Gil" ] 1 => array:2 [ "nombre" => "Hernán D." 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Núñez-Gil, Hernán D. Mejía-Rentería, Pedro Martínez-Losas" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Iván J." "apellidos" => "Núñez-Gil" "email" => array:1 [ 0 => "ibnsky@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Hernán D." "apellidos" => "Mejía-Rentería" ] 2 => array:2 [ "nombre" => "Pedro" "apellidos" => "Martínez-Losas" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cardiología, Hospital Clínico San Carlos, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Actualización práctica en síndrome de Takotsubo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 702 "Ancho" => 1951 "Tamanyo" => 255197 ] ] "descripcion" => array:1 [ "en" => "(A) Typical giant negative T wave with QTc prolongation in acute phase. (B) Continuous Doppler curve showing a substantial obstruction gradient of the left ventricle outflow tract (157mmHg) obtained by transthoracic echocardiography. (C) 3D-optical coherence tomography intracoronary image demonstrating the absence of narrowing or luminal lesions in a section of the left anterior descending artery." ] ] ] "textoCompleto" => "Takotsubo syndrome is a disorder described by Sato and Dote in the late 80s in Japan, which usually manifests, both clinically and biochemically, as an acute coronary syndrome.<a class="elsevierStyleCrossRefs" href="#bib0225">1–3</a> Interestingly, it is worth noting the fact that the imaging tests usually show a left ventricle motility impairment which includes various coronary regions without causal obstructive lesions being observed in the coronary angiography (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0235">3–7</a> In addition, segmental abnormalities are fully recovered (stunning) in a few days and in a good number of cases patients report a recent stressful situation, so it was described as stress cardiomyopathy or broken heart syndrome.<a class="elsevierStyleCrossRefs" href="#bib0240">4,6–12</a> Other names, such as transient apical dyskinesia, “ampulla” syndrome or even the name Takotsubo syndrome itself is derived from the curious systole-like shape which the left ventricle adopts in the acute phase (“takotsubo” meaning octopus trap pot in Japanese).<a class="elsevierStyleCrossRefs" href="#bib0240">4,7,8</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Originally described in Japanese, cases were then reported in all continents, races and ages.<a class="elsevierStyleCrossRefs" href="#bib0225">1,2,4,12–14</a>In the next few lines we will try to detail, as concisely as possible, the current situation regarding knowledge of this curious disease, which is based almost exclusively on, more or less, extensive series of patients with that disease and a limited number of basic studies.ClassificationInitially, depending on the ventriculography image (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) or other imaging tests, as per degree of acute myocardial involvement, we will differentiate the following types of Takotsubo syndrome<a class="elsevierStyleCrossRefs" href="#bib0240">4,7,15,16</a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1)Typical forms (apical ballooning). The most common, over 2 thirds of the cases, affects the apical region and midventricular segments, which either, do not move – systolic thickening – or are dyskinetic, with compensatory basal hyperkinesis.</li><li class="elsevierStyleListItem" id="lsti0010">2)Atypical forms or variants, without apex involvement. A variety of types have been reported, such as involvement of midventricular segments,<a class="elsevierStyleCrossRef" href="#bib0300">16</a> isolated lateral or lower side, only the basal portions (inverted forms),<a class="elsevierStyleCrossRef" href="#bib0295">15</a> associated or isolated right ventricle involvement, etc.</li></ul><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Lately, some authors have proposed, including ourselves, a work classification with prognostic implications,<a class="elsevierStyleCrossRefs" href="#bib0235">3,14,17</a> as follows:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015">-Primary forms. Those that happen without an obvious cause -idiopathic- and, perhaps, those occurring after the patient suffers extreme psychological stress (e.g. death of a relative, robbery, mugging).</li><li class="elsevierStyleListItem" id="lsti0020">-Secondary forms. Those occurring in a severe concomitant illness setting, which possibly determines a worse long-term prognosis (e.g., after an asthma attack, major surgery, a lung embolism, thyrotoxic crisis, etc.). They account for around 20% of cases.<a class="elsevierStyleCrossRefs" href="#bib0290">14,17,18</a></li></ul>EpidemiologyAs its incidence is difficult to estimate accurately because it is a rare and possibly underdiagnosed condition, it gives the impression that it has increased in recent years. This may be due, among other factors, to an increased knowledge of doctors about the disease linked to a generally more invasive management of acute coronary syndromes, often with early coronary angiography, even in elderly patients.<a class="elsevierStyleCrossRefs" href="#bib0240">4,10,12,19–21</a> Japanese series have reported an acute coronary syndrome incidence of 1.2–2.2%; 2.2% in the USA; 0.3–2.3% in Germany; and in Spain, the national registry on the disease (RETAKO), shows a 1.2% of catheterizations indicated with acute coronary syndrome diagnosis, having analyzed 202 consecutive patients between 2012 and 2013.<a class="elsevierStyleCrossRef" href="#bib0330">22</a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the diagnostic criteria used in the previously mentioned record. Some studies, which were only evaluating postmenopausal women reported up to 5.9%, with a prevalence of atypical forms.The profile of the patient, usually consistent in most published series,<a class="elsevierStyleCrossRefs" href="#bib0320">20–22</a> includes a female prevalence (about 90%), common cardiovascular risk factors, generally hypertension in more than half of the cases, and diabetes or smoking in a slightly lower number. In the RETAKO registry, 50% of patients referred a significant psychological stress situation, 20% physical stress (surgery or trauma), 3% reported both and about 27% could not find any trigger.<a class="elsevierStyleCrossRef" href="#bib0330">22</a> Although a clear seasonal or daily distribution was not found in the Spanish multicenter study, some authors have described a summer prevalence, while others a winter one.<a class="elsevierStyleCrossRef" href="#bib0330">22</a> What seems clear is that, as other cardiovascular disorders, significantly stressful global situations, such as earthquakes or football world championships, may be associated with Takotsubo “outbreaks”.<a class="elsevierStyleCrossRefs" href="#bib0330">22,23</a>Clinical signs and symptomsBy far, the most common symptom is chest pain (33–100%, 80% in RETAKO), which may manifest atypical characteristics or angina-like symptoms, making it indistinguishable from this condition. Vegetative symptoms are often associated. However, cases have been reported whose symptom index was dyspnoea, syncope or even cardiac arrest. The latter, without chest pain, are usually associated with the secondary forms.<a class="elsevierStyleCrossRefs" href="#bib0325">21,22</a>When its clinical presentation is that of an acute coronary syndrome, it is often accompanied by different grades of heart failure, sometimes even worse than in acute coronary syndromes without ST-segment elevation (<a class="elsevierStyleCrossRef" href="#fig0010">fig. 2</a>), making the careful management of these patients advisable.<a class="elsevierStyleCrossRefs" href="#bib0255">7,20,24</a><elsevierMultimedia ident="fig0010"></elsevierMultimedia>DiagnosisAlthough many diagnostic criteria have been proposed, initially by Japanese groups, and later by many other groups, in a disease that is diagnosed by exclusion of other diseases, we usually recommend the criteria modified by the Mayo Clinic (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). For diagnosis, it is essential to verify the normalization of ventricular segmental abnormalities (except in cases of exitus).<a class="elsevierStyleCrossRefs" href="#bib0235">3,4,6–8</a>Diagnostic testsNext, the most important findings in each diagnostic level will be briefly detailed.<a class="elsevierStyleCrossRefs" href="#bib0330">22,24</a><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025">-Lab test results: an elevation of myocardial necrosis biomarkers is observed, usually troponin, due to being more sensitive, which is within the range of acute coronary syndrome but in contrast with a significantly higher degree of ventricular dysfunction, as reflected by imaging tests. Other markers such as BNP or derivatives have been shown usually high, with uncertain prognosis meaning. d-dimers, occasionally elevated, or thyroid profile, usually normal, do not generally establish the diagnosis but can be very useful in uncertain cases. The PLATAKO study, which compared a small number of cases of Takotsubo syndrome with acute coronary syndromes (matched by elevation or non-elevation of ST), did not find a causal role for platelets, as in atherothrombotic infarctions (type I).<a class="elsevierStyleCrossRef" href="#bib0345">25</a> In contrast, it is worth noting that it agrees with the paradigmatic study by Wittstein et al., which showed higher blood concentrations of circulating catecholamines in patients with Takotsubo than in patients who had a heart attack, despite involving a degree of heart failure.<a class="elsevierStyleCrossRef" href="#bib0350">26</a> In the PLATAKO study, after the acute phase, a trend (p=0.06) showing higher levels of circulating catecholamines was observed in patients who had suffered from Takotsubo when compared to those who had a heart attack.<a class="elsevierStyleCrossRefs" href="#bib0345">25,26</a></li><li class="elsevierStyleListItem" id="lsti0030">-Electrocardiogram<a class="elsevierStyleCrossRefs" href="#bib0355">27,28</a>: without the criteria that would allow a clear differentiation from a heart attack and that could prevent a coronary angiography, repolarization changes are common. Precordial involvement in the acute phase is usually observed, with ST elevation first and then legitimization of T waves, which become very deep and condition a significant QT prolongation (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). As first electrocardiographic anomaly, white patients show a percentage of ST elevation, somewhat lower than Asian. In the RETAKO registry,<a class="elsevierStyleCrossRef" href="#bib0330">22</a> 89% of patients had an abnormal electrocardiogram at symptom onset, although only 61% had an elevated ST. Giant negative T waves, typical of the disease, are usually completely resolved within a few months, perhaps reflecting the degree of myocardial oedema. Segmental abnormalities improve much earlier, as assessed by echocardiography. The development and persistence of Q waves is exceptional. Electrical repolarization abnormalities can be observed even in patients with continuous stimulation by pacemaker.<a class="elsevierStyleCrossRef" href="#bib0365">29</a></li><li class="elsevierStyleListItem" id="lsti0035">-Echocardiogram<a class="elsevierStyleCrossRefs" href="#bib0255">7,22</a>: is the test “par excellence”, widely available, quick, inexpensive and non-invasive that can guide to diagnosis together with a compatible patient profile, in addition to ruling out complications. It clearly shows segmental abnormalities, assessing the degree of ventricular dysfunction, which has prognostic relevance and can guide management should any complications develop, such as dynamic left ventricular outflow tract obstruction (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B) with more or less mitral regurgitation,<a class="elsevierStyleCrossRef" href="#bib0370">30</a> the presence of pericardial effusion or intracardiac thrombi. Abnormalities have been published in recent years with more sophisticated techniques, such as 3D or strain and strainrate patterns measured by speckle tracking. Logically, it will also be an essential test to confirm ventricular recovery and meet the diagnostic criteria necessary to establish the final diagnosis.</li><li class="elsevierStyleListItem" id="lsti0040">-Catheterization: is one of the gold standard tests because it rules out obstructive coronary lesions that would explain the clinical signs and symptoms (considering<50% of coronary stenosis), it can detect the presence of mid-ventricular gradient and some valvular diseases, ventriculography being a classic means of classification. Although more complex techniques, such as the pressure guide-wire, intravascular ultrasound or optical coherence tomography (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C), provide interesting information, there aren’t enough studies supporting their efficacy.<a class="elsevierStyleCrossRefs" href="#bib0305">17,31</a> Coronary angiography was undertaken emergently in 38% of cases of the RETAKO registry, as if a primary angioplasty was to be performed.<a class="elsevierStyleCrossRef" href="#bib0330">22</a></li><li class="elsevierStyleListItem" id="lsti0045">-Cardiac magnetic resonance imaging: the myocardium gold standard study, besides visualizing segmental abnormalities, biventricular ejection fraction and certain valve disease in an excellent way, it is also an efficient method to rule out myocarditis in the differential diagnosis. Focal perfusion defects are not usually observed and late enhancement is rarely detected. However, signal hyperintensity on T2-STIR sequences are common, especially in acute phases, consistent with the presence of myocardial oedema, usually in a dyskinetic region, which has been linked to negative T-waves. The ventricular recovery takes place first in the systolic phase (quick, in days) and then the diastolic.<a class="elsevierStyleCrossRefs" href="#bib0380">32,33</a></li><li class="elsevierStyleListItem" id="lsti0050">-Nuclear imaging tests<a class="elsevierStyleCrossRefs" href="#bib0245">5,7,34,35</a>: with several techniques (SPECT, PET, etc.) and radiotracers, these have pointed to transient metabolic disorders, perfusion (201Th, 99mTc), fatty acid metabolism or 123I-meta-iodobenzylguanidine (MIBG) or beta-methyl-iodophenylpentadecanoic acid (BMIPP) uptake abnormalities, with abnormal distribution of cellular receptors or modulators (mainly adrenergic).<a class="elsevierStyleCrossRefs" href="#bib0390">34,35</a></li><li class="elsevierStyleListItem" id="lsti0055">-Endomyocardial biopsy<a class="elsevierStyleCrossRef" href="#bib0245">5</a>: data from small studies which have used electron microscopy optics and immunohistochemistry show that there has been a slight increase of reversible connective tissue lesions and the like as observed by catecholamine concentrations in pheochromocytoma or in subarachnoid haemorrhage, namely: contractile and cytoskeletal protein separation, contractile cell material reduces and moves to the periphery, a rounded nucleus is observed, there is cellular oedema with contraction and the typical “contraction bands” appear.</li></ul>AetiologyAssociated with multiple causes or triggers (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), the final cause remains partially unclear; we could be facing a “catchall” with multiple diseases that share phenotypic expression. The researchers who initially described the disease suggest that it could be due to a multivessel spasm.<a class="elsevierStyleCrossRefs" href="#bib0225">1,2,7</a> This theory, along with others, such as coronary variations (large and recurrent anterior descending CAD), ventricular outflow tract obstruction, myocarditis, evanescent intracoronary thrombi, have become obsolete.<a class="elsevierStyleCrossRef" href="#bib0340">24</a> Microcirculation abnormalities and metabolic disorders detected in certain tests are yet to be explained.<a class="elsevierStyleCrossRef" href="#bib0395">35</a> However, the influence of catecholamines remains as the most accepted hypothesis, especially adrenaline and noradrenaline in the genesis of the syndrome. Similar to what happens in subarachnoid haemorrhage or pheochromocytoma,<a class="elsevierStyleCrossRefs" href="#bib0245">5,18</a> it seems that patients suffer myocardial stunning caused by sympathetic hypertonia, even due to direct catecholaminergic lesion.<a class="elsevierStyleCrossRef" href="#bib0350">26</a> Lyon et al. reported that the etiopathogenic mechanism would be a kind of ‘defensive’ action by the beta-adrenergic receptors which, in order to protect the underlying muscle from an adrenergic hyperstimulation that could kill the cell, change their function to inhibitory, so that the muscle would temporarily stop moving.<a class="elsevierStyleCrossRef" href="#bib0400">36</a> At this point there is still no conclusive and clear theory to explain all phenomena present in this disease. Large numbers of receptors and modulator molecules associated with the same could be involved, the real meaning of which we are only beginning to understand.<a class="elsevierStyleCrossRef" href="#bib0405">37</a> The hormonal influence is also clear, since most patients are postmenopausal women. Also, the questionable possibility of a familial form (2 sisters’ syndrome) has been considered in some isolated cases.<a class="elsevierStyleCrossRef" href="#bib0410">38</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>PrognosisThe disease is generally benign and usually involves a good long-term prognosis, clearly much better than when compared with coronary syndromes without ST elevation.<a class="elsevierStyleCrossRefs" href="#bib0240">4,7,22</a> This is consistent with the conclusions of many studies already published. As a summary, it appears to be a transient myocardial stunning condition, which then reaches a complete or ad integrum recovery.<a class="elsevierStyleCrossRefs" href="#bib0415">39–42</a> However, it should be noted that it is usually accompanied by acute complications, such as heart failure, and that secondary forms involve a worse prognosis.<a class="elsevierStyleCrossRefs" href="#bib0330">22,24,43</a> A hospital mortality of 0–8% has been reported.<a class="elsevierStyleCrossRef" href="#bib0255">7</a> Patients with advanced stages of heart failure (Killip) (III–IV) during their hospital stay experience a worse long term progression, likely similar to those over 65 years of age, because of their greater frailty and comorbidities.<a class="elsevierStyleCrossRef" href="#bib0340">24</a> The recurrence rate is low; although it varies with the series, it is close to 3%, with chest pain recurrence being the most common (but without clear new segmental abnormalities).<a class="elsevierStyleCrossRef" href="#bib0330">22</a>TreatmentAs there are no solid data available from clinical studies, it is recommended that the initial management is similar to that applied in acute coronary syndrome.<a class="elsevierStyleCrossRefs" href="#bib0255">7,8</a> As for chronic cardiac pump failure, it usually requires diuretic therapy and, in some cases, the need of some mechanical support has been reported. Levosimendan calcium sensitizer might be the preferable inotropic agent, although the experience available is limited.<a class="elsevierStyleCrossRef" href="#bib0440">44</a> This is probably better than the use of catecholamines due to the very genesis of the disease, but certainly should be contraindicated in cases where left ventricle outflow tract obstruction is observed, which is not uncommon to manifest with hypotension and variable degrees of mitral regurgitation, even causing cardiogenic shock. These cases of obstruction usually experience significant improvements with volume and the use of intravenous beta blockers, which paradoxically raises their blood pressure.<a class="elsevierStyleCrossRef" href="#bib0340">24</a>Antithrombotic treatment is controversial and totally empirical, possibly benefiting from acute phase infarction treatment, with anticoagulation agents if an intraventricular thrombus is detected (until resolution, seen in 100% of cases). Taking into account the PLATAKO study results, the long-term treatment should probably be individualized, given patient comorbidities, evaluating the need for aspirin at low doses, depending on the patient profile, and prescribing beta-blockers in those cases where it may be advisable.<a class="elsevierStyleCrossRef" href="#bib0345">25</a>ConclusionsWe are faced with an interesting disease, whose diagnosis is increasingly common today and, although it generally carries a good prognosis with a low rate of recurrence, it is necessary to treat with extra care and stratify the patient's risk profile as it is not free of complications in the acute phase, sometimes even death, especially in the secondary forms, male and elderly or frail people. Still, we continue with many unanswered questions, both in terms of aetiology as well as in terms of what would be the optimal management of these patients. With this in mind, the RETAKO registry was started in 2012 on the Takotsubo syndrome. It has already recruited more than 400 patients thanks to the collaboration of more than 20 hospitals across the country. The study, currently underway, aims to bring together researchers interested in the disorder and answer some of the questions related to this enigmatic disease.Conflict of interestsThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres676848" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec682889" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres676849" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec682888" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Classification" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Epidemiology" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Clinical signs and symptoms" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Diagnosis" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnostic tests" ] ] ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Aetiology" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Prognosis" ] 10 => array:2 [ "identificador" => "sec0040" "titulo" => "Treatment" ] 11 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusions" ] 12 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interests" ] 13 => array:2 [ "identificador" => "xack228338" "titulo" => "Acknowledgements" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-04-21" "fechaAceptado" => "2015-04-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec682889" "palabras" => array:5 [ 0 => "Review" 1 => "Takotsubo" 2 => "Stress" 3 => "RETAKO" 4 => "Infarction" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec682888" "palabras" => array:5 [ 0 => "Revisión" 1 => "Takotsubo" 2 => "Estrés" 3 => "RETAKO" 4 => "Infarto" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Takotsubo syndrome, apical ballooning or “broken heart” syndrome, is a growing diagnostic entity which clinically mimics an acute coronary syndrome. Included into the stress cardiomyopathy group of cardiopathies, this condition is characterized by the absence of potentially responsible coronary lesions, while displaying a transient abnormal ventricular motion, usually affecting various coronary territories. It is generally observed in postmenopausal women and frequently seen in the presence of a stressful situation, both physical and emotional. With a prevalence of 1.2% among patients undergoing a cardiac catheterization with a suspected diagnosis of acute coronary syndromes, Takotsubo syndrome usually has a good prognosis. However, complications can occur in the acute phase, generally heart failure, which can even lead to death. In this review we discuss the latest available information on this disease and present it in a practical and useful way for the attending physician." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El síndrome de Takotsubo, apical balloning o síndrome del «corazón roto», es una entidad de diagnóstico creciente que mimetiza clínicamente un síndrome coronario agudo. Englobado en el grupo de las miocardiopatías de estrés, se caracteriza por la ausencia de lesiones coronarias potencialmente responsables del cuadro y una paradójica alteración en la motilidad ventricular de carácter transitorio, que suele interesar varios territorios coronarios. Se observa generalmente en mujeres posmenopáusicas y se describe con frecuencia la presencia de una situación estresante, tanto física como emocional. Con una incidencia aproximada del 1,2% de aquellos síndromes coronarios agudos sometidos a cateterismo, a pesar de conllevar generalmente un buen pronóstico, ocasionalmente presenta en la fase aguda complicaciones, generalmente insuficiencia cardiaca, que pueden conducir incluso al fallecimiento de los enfermos. En la presente revisión nos planteamos repasar la última información disponible y presentarla de un modo práctico y útil al clínico." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Núñez-Gil IJ, Mejía-Rentería HD, Martínez-Losas P. Actualización práctica en síndrome de Takotsubo. Med Clin (Barc). 2016;146:212–217." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 674 "Ancho" => 1798 "Tamanyo" => 98965 ] ] "descripcion" => array:1 [ "en" => "(A) Typical systolic shape ventriculography image (“octopus trap pot” shape or Takotsubo). The arrows show the affected area. (B) Image equivalent to the above but of a patient with atypical shape, predominantly midventricular. In this case the apex is normally contracted. The arrows indicate the dyskinetic area." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 702 "Ancho" => 1951 "Tamanyo" => 255197 ] ] "descripcion" => array:1 [ "en" => "(A) Typical giant negative T wave with QTc prolongation in acute phase. (B) Continuous Doppler curve showing a substantial obstruction gradient of the left ventricle outflow tract (157mmHg) obtained by transthoracic echocardiography. (C) 3D-optical coherence tomography intracoronary image demonstrating the absence of narrowing or luminal lesions in a section of the left anterior descending artery." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Transient abnormalities in left ventricular contractility (dyskinesia/akinesia or hypokinesia), with or without apical involvement; extending beyond a particular coronary artery; occasionally triggered by a stressful situation, but not always \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">New electrocardiographic changes (ST elevation and/or T-wave inversion) and slight troponin elevation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Absence of myocarditis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1110604.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Takotsubo syndrome diagnostic criteria used in the RETAKO National Registry (based on those modified by Mayo Clinic, 2008)." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mental stress \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Death or illness in the family \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bad news of any kind \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Storm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Strong arguments with family members, neighbours, work colleagues, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Public presentations (doctors, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Legal issues \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Traffic accident \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surprise party \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Economic loss, gambling, business, redundancy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Change of residence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Casual fall with inability to stand up (common in the elderly) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Physical stress \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Heart surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Non-cardiac surgery of any kind. Post-anaesthetic recovery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pacemaker implantation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Important adjuvant disease, e.g. asthma attack or sepsis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe pain: e.g. reno-ureteral fractures or crisis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Withdrawal of opioids and other addictive drugs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nortriptyline overdose \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pulmonary embolism \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Addiction to cocaine, amphetamines or other betamimetics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stress tests, such as exercise test, pharmacological tests (dobutamine) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hyperthyroidism and thyrotoxicosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Epileptic seizures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiac arrest recovery (treatment with epinephrine) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1110605.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Some triggers associated with stress cardiomyopathy. 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Practical update of Takotsubo syndrome

Actualización práctica en síndrome de Takotsubo

Iván J. Núñez-Gil

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ibnsky@yahoo.es

Corresponding author.

, Hernán D. Mejía-Rentería, Pedro Martínez-Losas

Servicio de Cardiología, Hospital Clínico San Carlos, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Takotsubo syndrome is a disorder described by Sato and Dote in the late 80s in Japan&#44; which usually manifests&#44; both clinically and biochemically&#44; as an acute coronary syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">1&#8211;3</span></a> Interestingly&#44; it is worth noting the fact that the imaging tests usually show a left ventricle motility impairment which includes various coronary regions without causal obstructive lesions being observed in the coronary angiography &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">3&#8211;7</span></a> In addition&#44; segmental abnormalities are fully recovered &#40;stunning&#41; in a few days and in a good number of cases patients report a recent stressful situation&#44; so it was described as stress cardiomyopathy or broken heart syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">4&#44;6&#8211;12</span></a> Other names&#44; such as transient apical dyskinesia&#44; &#8220;ampulla&#8221; syndrome or even the name Takotsubo syndrome itself is derived from the curious systole-like shape which the left ventricle adopts in the acute phase &#40;&#8220;takotsubo&#8221; meaning octopus trap pot in Japanese&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">4&#44;7&#44;8</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Originally described in Japanese&#44; cases were then reported in all continents&#44; races and ages&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;12&#8211;14</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In the next few lines we will try to detail&#44; as concisely as possible&#44; the current situation regarding knowledge of this curious disease&#44; which is based almost exclusively on&#44; more or less&#44; extensive series of patients with that disease and a limited number of basic studies&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Classification</span><p id="par0020" class="elsevierStylePara elsevierViewall">Initially&#44; depending on the ventriculography image &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; or other imaging tests&#44; as per degree of acute myocardial involvement&#44; we will differentiate the following types of Takotsubo syndrome<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">4&#44;7&#44;15&#44;16</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Typical forms <span class="elsevierStyleItalic">&#40;apical ballooning</span>&#41;&#46; The most common&#44; over 2 thirds of the cases&#44; affects the apical region and midventricular segments&#44; which either&#44; do not move &#8211; systolic thickening &#8211; or are dyskinetic&#44; with compensatory basal hyperkinesis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Atypical forms or variants&#44; without apex involvement&#46; A variety of types have been reported&#44; such as involvement of midventricular segments&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">16</span></a> isolated lateral or lower side&#44; only the basal portions &#40;inverted forms&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">15</span></a> associated or isolated right ventricle involvement&#44; etc&#46;</p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Lately&#44; some authors have proposed&#44; including ourselves&#44; a work classification with prognostic implications&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">3&#44;14&#44;17</span></a> as follows&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">Primary forms&#46; Those that happen without an obvious cause -idiopathic- and&#44; perhaps&#44; those occurring after the patient suffers extreme psychological stress &#40;e&#46;g&#46; death of a relative&#44; robbery&#44; mugging&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">Secondary forms&#46; Those occurring in a severe concomitant illness setting&#44; which possibly determines a worse long-term prognosis &#40;e&#46;g&#46;&#44; after an asthma attack&#44; major surgery&#44; a lung embolism&#44; thyrotoxic crisis&#44; etc&#46;&#41;&#46; They account for around 20&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">14&#44;17&#44;18</span></a></p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Epidemiology</span><p id="par0050" class="elsevierStylePara elsevierViewall">As its incidence is difficult to estimate accurately because it is a rare and possibly underdiagnosed condition&#44; it gives the impression that it has increased in recent years&#46; This may be due&#44; among other factors&#44; to an increased knowledge of doctors about the disease linked to a generally more invasive management of acute coronary syndromes&#44; often with early coronary angiography&#44; even in elderly patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">4&#44;10&#44;12&#44;19&#8211;21</span></a> Japanese series have reported an acute coronary syndrome incidence of 1&#46;2&#8211;2&#46;2&#37;&#59; 2&#46;2&#37; in the USA&#59; 0&#46;3&#8211;2&#46;3&#37; in Germany&#59; and in Spain&#44; the national registry on the disease &#40;RETAKO&#41;&#44; shows a 1&#46;2&#37; of catheterizations indicated with acute coronary syndrome diagnosis&#44; having analyzed 202 consecutive patients between 2012 and 2013&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">22</span></a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the diagnostic criteria used in the previously mentioned record&#46; Some studies&#44; which were only evaluating postmenopausal women reported up to 5&#46;9&#37;&#44; with a prevalence of atypical forms&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The profile of the patient&#44; usually consistent in most published series&#44;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">20&#8211;22</span></a> includes a female prevalence &#40;about 90&#37;&#41;&#44; common cardiovascular risk factors&#44; generally hypertension in more than half of the cases&#44; and diabetes or smoking in a slightly lower number&#46; In the RETAKO registry&#44; 50&#37; of patients referred a significant psychological stress situation&#44; 20&#37; physical stress &#40;surgery or trauma&#41;&#44; 3&#37; reported both and about 27&#37; could not find any trigger&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">22</span></a> Although a clear seasonal or daily distribution was not found in the Spanish multicenter study&#44; some authors have described a summer prevalence&#44; while others a winter one&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">22</span></a> What seems clear is that&#44; as other cardiovascular disorders&#44; significantly stressful global situations&#44; such as earthquakes or football world championships&#44; may be associated with Takotsubo &#8220;outbreaks&#8221;&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">22&#44;23</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical signs and symptoms</span><p id="par0060" class="elsevierStylePara elsevierViewall">By far&#44; the most common symptom is chest pain &#40;33&#8211;100&#37;&#44; 80&#37; in RETAKO&#41;&#44; which may manifest atypical characteristics or angina-like symptoms&#44; making it indistinguishable from this condition&#46; Vegetative symptoms are often associated&#46; However&#44; cases have been reported whose symptom index was dyspnoea&#44; syncope or even cardiac arrest&#46; The latter&#44; without chest pain&#44; are usually associated with the secondary forms&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">21&#44;22</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">When its clinical presentation is that of an acute coronary syndrome&#44; it is often accompanied by different grades of heart failure&#44; sometimes even worse than in acute coronary syndromes without ST-segment elevation &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#44; making the careful management of these patients advisable&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">7&#44;20&#44;24</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Diagnosis</span><p id="par0070" class="elsevierStylePara elsevierViewall">Although many diagnostic criteria have been proposed&#44; initially by Japanese groups&#44; and later by many other groups&#44; in a disease that is diagnosed by exclusion of other diseases&#44; we usually recommend the criteria modified by the Mayo Clinic &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; For diagnosis&#44; it is essential to verify the normalization of ventricular segmental abnormalities &#40;except in cases of exitus&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">3&#44;4&#44;6&#8211;8</span></a></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Diagnostic tests</span><p id="par0075" class="elsevierStylePara elsevierViewall">Next&#44; the most important findings in each diagnostic level will be briefly detailed&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">22&#44;24</span></a><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Lab test results&#58;</span> an elevation of myocardial necrosis biomarkers is observed&#44; usually troponin&#44; due to being more sensitive&#44; which is within the range of acute coronary syndrome but in contrast with a significantly higher degree of ventricular dysfunction&#44; as reflected by imaging tests&#46; Other markers such as BNP or derivatives have been shown usually high&#44; with uncertain prognosis meaning&#46; <span class="elsevierStyleSmallCaps">d</span>-dimers&#44; occasionally elevated&#44; or thyroid profile&#44; usually normal&#44; do not generally establish the diagnosis but can be very useful in uncertain cases&#46; The PLATAKO study&#44; which compared a small number of cases of Takotsubo syndrome with acute coronary syndromes &#40;matched by elevation or non-elevation of ST&#41;&#44; did not find a causal role for platelets&#44; as in atherothrombotic infarctions &#40;type <span class="elsevierStyleSmallCaps">I</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">25</span></a> In contrast&#44; it is worth noting that it agrees with the paradigmatic study by Wittstein et al&#46;&#44; which showed higher blood concentrations of circulating catecholamines in patients with Takotsubo than in patients who had a heart attack&#44; despite involving a degree of heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">26</span></a> In the PLATAKO study&#44; after the acute phase&#44; a trend &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;06&#41; showing higher levels of circulating catecholamines was observed in patients who had suffered from Takotsubo when compared to those who had a heart attack&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">25&#44;26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Electrocardiogram</span><a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">27&#44;28</span></a>&#58; without the criteria that would allow a clear differentiation from a heart attack and that could prevent a coronary angiography&#44; repolarization changes are common&#46; Precordial involvement in the acute phase is usually observed&#44; with ST elevation first and then legitimization of T waves&#44; which become very deep and condition a significant QT prolongation &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; As first electrocardiographic anomaly&#44; white patients show a percentage of ST elevation&#44; somewhat lower than Asian&#46; In the RETAKO registry&#44;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">22</span></a> 89&#37; of patients had an abnormal electrocardiogram at symptom onset&#44; although only 61&#37; had an elevated ST&#46; Giant negative T waves&#44; typical of the disease&#44; are usually completely resolved within a few months&#44; perhaps reflecting the degree of myocardial oedema&#46; Segmental abnormalities improve much earlier&#44; as assessed by echocardiography&#46; The development and persistence of Q waves is exceptional&#46; Electrical repolarization abnormalities can be observed even in patients with continuous stimulation by pacemaker&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">29</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Echocardiogram</span><a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">7&#44;22</span></a>&#58; is the test &#8220;par excellence&#8221;&#44; widely available&#44; quick&#44; inexpensive and non-invasive that can guide to diagnosis together with a compatible patient profile&#44; in addition to ruling out complications&#46; It clearly shows segmental abnormalities&#44; assessing the degree of ventricular dysfunction&#44; which has prognostic relevance and can guide management should any complications develop&#44; such as dynamic left ventricular outflow tract obstruction &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41; with more or less mitral regurgitation&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">30</span></a> the presence of pericardial effusion or intracardiac thrombi&#46; Abnormalities have been published in recent years with more sophisticated techniques&#44; such as 3D or <span class="elsevierStyleItalic">strain</span> and <span class="elsevierStyleItalic">strainrate</span> patterns measured by <span class="elsevierStyleItalic">speckle tracking</span>&#46; Logically&#44; it will also be an essential test to confirm ventricular recovery and meet the diagnostic criteria necessary to establish the final diagnosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Catheterization&#58;</span> is one of the gold standard tests because it rules out obstructive coronary lesions that would explain the clinical signs and symptoms &#40;considering<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37; of coronary stenosis&#41;&#44; it can detect the presence of mid-ventricular gradient and some valvular diseases&#44; ventriculography being a classic means of classification&#46; Although more complex techniques&#44; such as the pressure guide-wire&#44; intravascular ultrasound or optical coherence tomography &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#44; provide interesting information&#44; there aren&#8217;t enough studies supporting their efficacy&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">17&#44;31</span></a> Coronary angiography was undertaken emergently in 38&#37; of cases of the RETAKO registry&#44; as if a primary angioplasty was to be performed&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">22</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cardiac magnetic resonance imaging&#58;</span> the myocardium gold standard study&#44; besides visualizing segmental abnormalities&#44; biventricular ejection fraction and certain valve disease in an excellent way&#44; it is also an efficient method to rule out myocarditis in the differential diagnosis&#46; Focal perfusion defects are not usually observed and late enhancement is rarely detected&#46; However&#44; signal hyperintensity on T2-STIR sequences are common&#44; especially in acute phases&#44; consistent with the presence of myocardial oedema&#44; usually in a dyskinetic region&#44; which has been linked to negative T-waves&#46; The ventricular recovery takes place first in the systolic phase &#40;quick&#44; in days&#41; and then the diastolic&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">32&#44;33</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Nuclear imaging tests</span><a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">5&#44;7&#44;34&#44;35</span></a>&#58; with several techniques &#40;SPECT&#44; PET&#44; etc&#46;&#41; and radiotracers&#44; these have pointed to transient metabolic disorders&#44; perfusion &#40;<span class="elsevierStyleSup">201</span>Th&#44; <span class="elsevierStyleSup">99m</span>Tc&#41;&#44; fatty acid metabolism or <span class="elsevierStyleSup">123</span>I-<span class="elsevierStyleItalic">meta-iodobenzylguanidine</span> &#40;MIBG&#41; or <span class="elsevierStyleItalic">beta-methyl-iodophenylpentadecanoic acid</span> &#40;BMIPP&#41; uptake abnormalities&#44; with abnormal distribution of cellular receptors or modulators &#40;mainly adrenergic&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">34&#44;35</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Endomyocardial biopsy</span><a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">5</span></a>&#58; data from small studies which have used electron microscopy optics and immunohistochemistry show that there has been a slight increase of reversible connective tissue lesions and the like as observed by catecholamine concentrations in pheochromocytoma or in subarachnoid haemorrhage&#44; namely&#58; contractile and cytoskeletal protein separation&#44; contractile cell material reduces and moves to the periphery&#44; a rounded nucleus is observed&#44; there is cellular oedema with contraction and the typical &#8220;contraction bands&#8221; appear&#46;</p></li></ul></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Aetiology</span><p id="par0115" class="elsevierStylePara elsevierViewall">Associated with multiple causes or triggers &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; the final cause remains partially unclear&#59; we could be facing a &#8220;catchall&#8221; with multiple diseases that share phenotypic expression&#46; The researchers who initially described the disease suggest that it could be due to a multivessel spasm&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">1&#44;2&#44;7</span></a> This theory&#44; along with others&#44; such as coronary variations &#40;large and recurrent anterior descending CAD&#41;&#44; ventricular outflow tract obstruction&#44; myocarditis&#44; evanescent intracoronary thrombi&#44; have become obsolete&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">24</span></a> Microcirculation abnormalities and metabolic disorders detected in certain tests are yet to be explained&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">35</span></a> However&#44; the influence of catecholamines remains as the most accepted hypothesis&#44; especially adrenaline and noradrenaline in the genesis of the syndrome&#46; Similar to what happens in subarachnoid haemorrhage or pheochromocytoma&#44;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">5&#44;18</span></a> it seems that patients suffer myocardial stunning caused by sympathetic hypertonia&#44; even due to direct catecholaminergic lesion&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">26</span></a> Lyon et al&#46; reported that the etiopathogenic mechanism would be a kind of &#8216;defensive&#8217; action by the beta-adrenergic receptors which&#44; in order to protect the underlying muscle from an adrenergic hyperstimulation that could kill the cell&#44; change their function to inhibitory&#44; so that the muscle would temporarily stop moving&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">36</span></a> At this point there is still no conclusive and clear theory to explain all phenomena present in this disease&#46; Large numbers of receptors and modulator molecules associated with the same could be involved&#44; the real meaning of which we are only beginning to understand&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">37</span></a> The hormonal influence is also clear&#44; since most patients are postmenopausal women&#46; Also&#44; the questionable possibility of a familial form &#40;2 sisters&#8217; syndrome&#41; has been considered in some isolated cases&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">38</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Prognosis</span><p id="par0120" class="elsevierStylePara elsevierViewall">The disease is generally benign and usually involves a good long-term prognosis&#44; clearly much better than when compared with coronary syndromes without ST elevation&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">4&#44;7&#44;22</span></a> This is consistent with the conclusions of many studies already published&#46; As a summary&#44; it appears to be a transient myocardial stunning condition&#44; which then reaches a complete or <span class="elsevierStyleItalic">ad integrum recovery</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">39&#8211;42</span></a> However&#44; it should be noted that it is usually accompanied by acute complications&#44; such as heart failure&#44; and that secondary forms involve a worse prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">22&#44;24&#44;43</span></a> A hospital mortality of 0&#8211;8&#37; has been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">7</span></a> Patients with advanced stages of heart failure &#40;Killip&#41; &#40;III&#8211;IV&#41; during their hospital stay experience a worse long term progression&#44; likely similar to those over 65 years of age&#44; because of their greater frailty and comorbidities&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">24</span></a> The recurrence rate is low&#59; although it varies with the series&#44; it is close to 3&#37;&#44; with chest pain recurrence being the most common &#40;but without clear new segmental abnormalities&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Treatment</span><p id="par0125" class="elsevierStylePara elsevierViewall">As there are no solid data available from clinical studies&#44; it is recommended that the initial management is similar to that applied in acute coronary syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">7&#44;8</span></a> As for chronic cardiac pump failure&#44; it usually requires diuretic therapy and&#44; in some cases&#44; the need of some mechanical support has been reported&#46; Levosimendan calcium sensitizer might be the preferable inotropic agent&#44; although the experience available is limited&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">44</span></a> This is probably better than the use of catecholamines due to the very genesis of the disease&#44; but certainly should be contraindicated in cases where left ventricle outflow tract obstruction is observed&#44; which is not uncommon to manifest with hypotension and variable degrees of mitral regurgitation&#44; even causing cardiogenic shock&#46; These cases of obstruction usually experience significant improvements with volume and the use of intravenous beta blockers&#44; which paradoxically raises their blood pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">24</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Antithrombotic treatment is controversial and totally empirical&#44; possibly benefiting from acute phase infarction treatment&#44; with anticoagulation agents if an intraventricular thrombus is detected &#40;until resolution&#44; seen in 100&#37; of cases&#41;&#46; Taking into account the PLATAKO study results&#44; the long-term treatment should probably be individualized&#44; given patient comorbidities&#44; evaluating the need for aspirin at low doses&#44; depending on the patient profile&#44; and prescribing beta-blockers in those cases where it may be advisable&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusions</span><p id="par0135" class="elsevierStylePara elsevierViewall">We are faced with an interesting disease&#44; whose diagnosis is increasingly common today and&#44; although it generally carries a good prognosis with a low rate of recurrence&#44; it is necessary to treat with extra care and stratify the patient&#39;s risk profile as it is not free of complications in the acute phase&#44; sometimes even death&#44; especially in the secondary forms&#44; male and elderly or frail people&#46; Still&#44; we continue with many unanswered questions&#44; both in terms of aetiology as well as in terms of what would be the optimal management of these patients&#46; With this in mind&#44; the RETAKO registry was started in 2012 on the Takotsubo syndrome&#46; It has already recruited more than 400 patients thanks to the collaboration of more than 20 hospitals across the country&#46; The study&#44; currently underway&#44; aims to bring together researchers interested in the disorder and answer some of the questions related to this enigmatic disease&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interests</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Takotsubo syndrome&#44; apical ballooning or &#8220;broken heart&#8221; syndrome&#44; is a growing diagnostic entity which clinically mimics an acute coronary syndrome&#46; Included into the stress cardiomyopathy group of cardiopathies&#44; this condition is characterized by the absence of potentially responsible coronary lesions&#44; while displaying a transient abnormal ventricular motion&#44; usually affecting various coronary territories&#46; It is generally observed in postmenopausal women and frequently seen in the presence of a stressful situation&#44; both physical and emotional&#46; With a prevalence of 1&#46;2&#37; among patients undergoing a cardiac catheterization with a suspected diagnosis of acute coronary syndromes&#44; Takotsubo syndrome usually has a good prognosis&#46; However&#44; complications can occur in the acute phase&#44; generally heart failure&#44; which can even lead to death&#46; In this review we discuss the latest available information on this disease and present it in a practical and useful way for the attending physician&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El s&#237;ndrome de Takotsubo&#44; <span class="elsevierStyleItalic">apical balloning</span> o s&#237;ndrome del &#171;coraz&#243;n roto&#187;&#44; es una entidad de diagn&#243;stico creciente que mimetiza cl&#237;nicamente un s&#237;ndrome coronario agudo&#46; Englobado en el grupo de las miocardiopat&#237;as de estr&#233;s&#44; se caracteriza por la ausencia de lesiones coronarias potencialmente responsables del cuadro y una parad&#243;jica alteraci&#243;n en la motilidad ventricular de car&#225;cter transitorio&#44; que suele interesar varios territorios coronarios&#46; Se observa generalmente en mujeres posmenop&#225;usicas y se describe con frecuencia la presencia de una situaci&#243;n estresante&#44; tanto f&#237;sica como emocional&#46; Con una incidencia aproximada del 1&#44;2&#37; de aquellos s&#237;ndromes coronarios agudos sometidos a cateterismo&#44; a pesar de conllevar generalmente un buen pron&#243;stico&#44; ocasionalmente presenta en la fase aguda complicaciones&#44; generalmente insuficiencia cardiaca&#44; que pueden conducir incluso al fallecimiento de los enfermos&#46; En la presente revisi&#243;n nos planteamos repasar la &#250;ltima informaci&#243;n disponible y presentarla de un modo pr&#225;ctico y &#250;til al cl&#237;nico&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; N&#250;&#241;ez-Gil IJ&#44; Mej&#237;a-Renter&#237;a HD&#44; Mart&#237;nez-Losas P&#46; Actualizaci&#243;n pr&#225;ctica en s&#237;ndrome de Takotsubo&#46; Med Clin &#40;Barc&#41;&#46; 2016&#59;146&#58;212&#8211;217&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Typical systolic shape ventriculography image &#40;&#8220;octopus trap pot&#8221; shape or Takotsubo&#41;&#46; The arrows show the affected area&#46; &#40;B&#41; Image equivalent to the above but of a patient with atypical shape&#44; predominantly midventricular&#46; In this case the apex is normally contracted&#46; The arrows indicate the dyskinetic area&#46;</p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Transient abnormalities in left ventricular contractility &#40;dyskinesia&#47;akinesia or hypokinesia&#41;&#44; with or without apical involvement&#59; extending beyond a particular coronary artery&#59; occasionally triggered by a stressful situation&#44; but not always&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">New electrocardiographic changes &#40;ST elevation and&#47;or T-wave inversion&#41; and slight troponin elevation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Absence of myocarditis&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Takotsubo syndrome diagnostic criteria used in the RETAKO National Registry &#40;based on those modified by Mayo Clinic&#44; 2008&#41;&#46;</p>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Strong arguments with family members&#44; neighbours&#44; work colleagues&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Public presentations &#40;doctors&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Legal issues&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Surprise party&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Economic loss&#44; gambling&#44; business&#44; redundancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Change of residence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Casual fall with inability to stand up &#40;common in the elderly&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Non-cardiac surgery of any kind&#46; Post-anaesthetic recovery&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Important adjuvant disease&#44; e&#46;g&#46; asthma attack or sepsis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Severe pain&#58; e&#46;g&#46; reno-ureteral fractures or crisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Withdrawal of opioids and other addictive drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nortriptyline overdose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pulmonary embolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Addiction to cocaine&#44; amphetamines or other betamimetics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Stress tests&#44; such as exercise test&#44; pharmacological tests &#40;dobutamine&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Epileptic seizures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cardiac arrest recovery &#40;treatment with epinephrine&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Some triggers associated with stress cardiomyopathy&#46; Sometimes several triggers can be associated &#40;e&#46;g&#46;&#44; physical and mental stress&#41;&#46; Some patients do not show any of these &#8220;triggers&#8221;&#46;</p>"
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      "titulo" => "References"
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                    0 => array:1 [
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