Takotsubo Cardiomyopathy and Coronary Artery Disease: A Meaningful Coincidence?

S ince its initial description , Takotsubo cardiomyopathy has generated much debate and interest. Over the past 25 years, much progress has been made in understanding this syndrome. While the clinical presentation and characteristics have been well described and agreed upon, the etiology is a bit more of a debate. At present, the most commonly accepted theory on the pathophysiology of Takotsubo syndrome (TTS) centers on excess catecholaminergic state and enhanced sympathetic activity. However, there is still some thought that TTS may represent an aborted myocardial infarction or the results of plaque rupture and transient ischemia and myocardial stunning. The Mayo criteria for TTS rely on the “absence of significant obstructive coronary artery disease (CAD) or angiographic evidence of plaque rupture.” Since then, there have been multiple case series, challenging the notion that coronary artery disease necessarily excludes the diagnosis of TTS. It is now increasingly accepted that the 2 conditions are not mutually exclusive, but can exist coincidently. In their current single-center study, Eitel et al try to shed some light on the causal association, or lack of it, between ACS with vulnerable plaque and TTS. For the first time, they describe the optical coherence tomography (OCT) findings in a patient population with TTS. Of note, the present study reiterates a significant prevalence of atherosclerotic plaques in these patients with TTS. Previously the prevalence of CAD in patients with TTS was noted to range between 10% and 61% in prior studies. In a prior retrospective cohort of patients with TTS, coronary atherosclerosis was present in the majority (61%) of patients. In addition, 29% had luminal stenosis severity greater than 50% in at least 1 epicardial vessel. The clinical characteristics of TTS were recently reviewed in the International Takotsubo Registry, a consortium of 26 centers in Europe and the United States including 1750 patients with Takotsubo cardiomyopathy. In the International Takotsubo Registry there was significant coexistence of coronary disease occurring in approximately 15% of patients.