Letter by Alla and Kaushik Regarding Article, "Three Recurrent Episodes of Apical-Ballooning Takotsubo Cardiomyopathy in a Man".

To the Editor: We read with great interest the article published by Cattaneo et al regarding recurrent episodes of apical-ballooning takotsubo cardiomyopathy in a 66-year-old man. Based on the absence of obstructive coronary artery disease by coronary angiography, mild troponin elevation, and extensive regional wall motion abnormalities with the classic apical-ballooning appearance on echocardiography, the authors rightly conclude this to be a case of recurrent stress cardiomyopathy (SCMP). In this regard, we would like to draw the authors’ and readers’ attention to the following 3 issues: (1) Was urine drug screening done in this patient? (2) The authors state that this is possibly the first published report of 3 episodes of stress cardiomyopathy in the same patient. (3) What should the role of repeat coronary angiography be in patients with recurrent SCMP? We have previously reported a case of a 59-year-old woman with recurrent episodes of stress cardiomyopathy and a different morphological appearance during each of the episodes. Between 2008 and 2012, our patient had 5 hospitalizations for stress cardiomyopathy (4 at the time of publication and 1 subsequently) with complete recovery of left ventricular function between the episodes. Of these episodes, 3 had the morphological appearance of classical apical ballooning, 1 was consistent with the reverse takotsubo cardiomyopathy (apical hyperkinesis and basal hypokinesis), and 1 was a midcavitary variant (midwall hypokinesis with sparing of apical and basal segments). As in the current report, there was no obstructive coronary artery disease, no late gadolinium enhancement on cardiac MRI, and 24-hour urine fractionated catecholamines and metanephrines were normal in our patient. Interestingly, our patient had history of cannabis abuse and her episodes of stress cardiomyopathy coincided with episodes of excess use and were associated with hyperemesis. Given our experience and other reports of SCMP associated with recreational drug use, we ask the authors whether their patient had a toxicology screen. We would suggest that a toxicology screen be done in patients with SCMP, particularly in those without obvious stressors. Second, the authors state that the current report is the first documented case with 3 episodes of SCMP. Aside from our own experience, others have previously reported multiple recurrences of SCMP. Although the morphological pattern of SCMP appears to vary during each recurrence, the precipitating events appear to be identical. Finally, in the current patient, coronary angiography was performed during all the admissions. It is currently recommended that obstructive coronary artery disease be excluded before the diagnosis of SCMP, preferably with angiography. However, in light of the emerging reports of multiple recurrences of SCMP in some patients, the relative risks and benefits of repeat angiography during every admission have to be carefully weighed. In our patient, who had 5 episodes, coronary angiography was performed only twice without any long-term adverse outcomes. The presence or absence of concomitant coronary artery disease, time interval from previous angiography, ECG changes in comparison with previous episodes, and the availability of alternative diagnostic tools like cardiac computed tomography angiography could potentially guide the physician in making this decision.