Letter by Madias Regarding Article, “Three Recurrent Episodes of Apical-Ballooning Takotsubo Cardiomyopathy in a Man”
To the Editor:
The contribution by Cattaneo et al,1 published ahead of print on December 15, 2015 in Circulation, about the 66-year-old man who experienced 3 recurrent episodes of takotsubo syndrome (TTS) in the course of 3 years, is unique, because, as the authors stated, the 3 well-documented episodes of classic apical-ballooning TTS involved the same midventricular and apical myocardial territories, and they occurred in a man. Otherwise, recurrence of TTS in women with 2 successive episodes has been frequently reported,2 and recurrence with 3 episodes has been documented.3 Indeed, a report with 4 recurrent episodes of TTS has been published.4 One wonders whether the frequent reports of women with unexplainable self-limited bouts of chest pain and shortness of breath before or after a documented episode of TTS represent occurrences of milder atypical episodes of TTS.5 Only liberal use of transthoracic echocardiography with a very low threshold of application, and using even handheld echocardiographic devices (with their recognized limitations), may shed some light as to the nature of these episodes. An even more feasible way of deciphering the puzzling concerns of patients in the clinic may be the use of smartphone technology by the patients to frequently transmit their ECG, which could be evaluated by cardiologists for the presence of the ECG hallmarks of TTS (ST-segment elevations, T-wave inversions, low-amplitude QRS complexes, and QTc prolongation).5 Some of these episodes that some patients are reporting are more frequent with cold weather, and it is of interest that this patient had the first episode of TTS while fishing very early in the morning (? temperature) at high altitude, and the third episode while again fishing in the morning in cold weather (? altitude). In reference to the second recurrent episode of TTS, described as not having a clear precipitant,1 do the authors know whether the patient was at a high altitude and the weather was cold at the inception of his illness?
John E. Madias, MD, FACC, FAHA
Icahn School of Medicine at Mount Sinai
New York, NY
- © 2016 American Heart Association, Inc.