Transient left ventricular dysfunction with apical ballooning (tako-tsubo cardiomyopathy) in Germany

A peculiar type of an acute coronary syndrome is characterised by acute onset of chest pain, STsegment changes, elevated troponin I levels and a transient balloon-like apical left ventricular dysfunction, but without significant coronary artery disease. We sought to assess this syndrome in German patients.

A total of 22 females and 1 male with acute transient left ventricular dysfunction were identified during an interval of 2 years and were investigated clinically and angiographically. All patients presented without obstructive coronary artery disease. In 16 patients (70%) ST-segment elevations were observed mimicking acute myocardial infarction, whereas the remaining patients (30%) revealed only negative T waves. Deep negative Twaves were characteristically seen during the course of recovery in all patients. Elevated troponin I levels>2.0 microg/l (upper level of normal) were measured in all patients (mean 18+/-26.5 microg/l, range from 2.2-135.7 microg/l). Creatine kinase rose up to a mean of 282+/-236 IU/l (upper level of normal 180 U/l). Emotional or physical stress situations associated with the onset of the symptoms were observed in 16 patients (70%). Other suspected trigger factors were gastrointestinal infection and in one case a surgical intervention. In four patients a trigger factor could not be identified. Left ventriculography showed an ejection fraction of 53+/-15%. After an interval of 7+/-2 days after the first angiogram, ejection fraction had increased from 48+/-11% to 64+/-11% in eight controlled patients by repeated ventriculography. Coronary spasm with a lumen reduction>75% could be provoked using acetylcholine in 10 of 17 tested patients (59%) with reproduction of the symptoms. Within 14 days the LV dysfunction returned to normal in all patients. The ECG abnormalities disappeared completely as early as 3 months (74%) and were not seen in any patient after 6 months.

Tako-tsubo cardiomyopathy is not exclusively a Japanese or Northern American phenomenon. Despite increased patient reports the exact underlying cause and pathophysiology of this syndrome remain unclear. However, despite the initial dramatic presentation of this disease the prognosis is good.