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Original Contribution
July 20, 2011

Clinical Characteristics and Cardiovascular Magnetic Resonance Findings in Stress (Takotsubo) Cardiomyopathy.

Author Affiliations

Author Affiliations: Departments of Internal Medicine/Cardiology (Drs Eitel, Desch, Schuler, and Thiele) and Diagnostic and Interventional Radiology (Dr Gutberlet), Heart Center, University of Leipzig, Leipzig, Germany; Departments of Cardiac Sciences and Radiology, Stephenson Cardiovascular Magnetic Resonance Centre at the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada (Drs Eitel, Carbone, Strohm, and Friedrich); Working Group of Cardiovascular Magnetic Resonance, Charité University Medicine Berlin, Experimental and Clinical Research Center, and Department of Cardiology and Nephrology, HELIOS Klinikum Berlin-Buch, Berlin, Germany (Drs von Knobelsdorff-Brenkenhoff and Schulz-Menger); Department of Internal Medicine II, University of Ulm, Ulm, Germany (Dr Bernhardt); Department of Radiological Sciences, University of Rome, Sapienza, Rome, Italy (Drs Carbone and Francone); Center for Cardiology and Cardiovascular Surgery, University of Hamburg-Eppendorf, Hamburg, Germany (Dr Muellerleile); and Division of Cardiology, Department of Heart and Lung, Azienda Ospedaliero University of Parma, Parma, Italy (Dr Aldrovandi).

JAMA. 2011;306(3):277-286. doi:10.1001/jama.2011.992

Context Stress cardiomyopathy (SC) is a transient form of acute heart failure triggered by stressful events and associated with a distinctive left ventricular (LV) contraction pattern. Various aspects of its clinical profile have been described in small single-center populations, but larger, multicenter data sets have been lacking so far. Furthermore, it remains difficult to quickly establish diagnosis on admission.

Objectives To comprehensively define the clinical spectrum and evolution of SC in a large population, including tissue characterization data from cardiovascular magnetic resonance (CMR) imaging; and to establish a set of CMR criteria suitable for diagnostic decision making in patients acutely presenting with suspected SC.

Design, Setting, and Patients Prospective study conducted at 7 tertiary care centers in Europe and North America between January 2005 and October 2010 among 256 patients with SC assessed at the time of presentation as well as 1 to 6 months after the acute event.

Main Outcome Measures Complete recovery of LV dysfunction.

Results Eighty-one percent of patients (n = 207) were postmenopausal women, 8% (n = 20) were younger women (aged ≤50 years), and 11% (n = 29) were men. A stressful trigger could be identified in 182 patients (71%). Cardiovascular magnetic resonance imaging data (available for 239 patients [93%]) revealed 4 distinct patterns of regional ventricular ballooning: apical (n = 197 [82%]), biventricular (n = 81 [34%]), midventricular (n = 40 [17%]), and basal (n = 2 [1%]). Left ventricular ejection fraction was reduced (48% [SD, 11%]; 95% confidence interval [CI], 47%-50%) in all patients. Stress cardiomyopathy was accurately identified by CMR using specific criteria: a typical pattern of LV dysfunction, myocardial edema, absence of significant necrosis/fibrosis, and markers for myocardial inflammation. Follow-up CMR imaging showed complete normalization of LV ejection fraction (66% [SD, 7%]; 95% CI, 64%-68%) and inflammatory markers in the absence of significant fibrosis in all patients.

Conclusions The clinical profile of SC is considerably broader than reported previously. Cardiovascular magnetic resonance imaging at the time of initial clinical presentation may provide relevant functional and tissue information that might aid in the establishment of the diagnosis of SC.