Deleterious effects of catecholamine administration in acute heart failure caused by unrecognized Takotsubo cardiomyopathy
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The potential life-threatening consequences of catecholamine use for emergency circulatory support in Takotsubo cardiomyopathy-related acute heart failure is a major challenge in cardiovascular emergences. In their recent work in BMC Cardiovascular Disorders Ansari U. et al. demonstrated the harmful effects of catecholamines on the outcome of patients with Takotsubo cardiomyopathy. Concerning this matter we emphasize the usefulness of speckle-tracking-derived echocardiography for early recognition of an acute phase of a Takotsubo syndrome in order to avoid the deleterious effects of a catecholamine therapy in patients with Takotsubo-associated acute heart failure.
KeywordsAcute heart failure Catecholamines Etiopathogenesis Diagnosis Myocardial infarction Speckle-tracking echocardiography Takotsubo cardiomyopathy
Extracorporeal membrane oxygenation
Left ventricular outflow tract
Systolic anterior movement
Circumferential wall stress
We read with great interest the publication by Ansari U. et al. , in which the authors report on the clinical outcomes associated with catecholamine use in patients with Takotsubo cardiomyopathy, also known as the Takotsubo syndrome (TTS). The special value of this large and comprehensive study is that it convincingly demonstrated the harmful effects of catecholamine therapy on the outcome of hemodynamically unstable patients with TTS.
Although the etiopathogenesis of TTS is still under debate, the role of catecholamines appears central to the pathophysiology of TTS. There is increasing evidence that the reversible change in left ventricular (LV) shape (apical ballooning) associated with potentially life-threatening LV dysfunction, which characterize the acute phase of TTS reflect an uncommon myocardial response to sympathetic stimulation [2, 3, 4] Patients with TTS reveal abnormal catecholamine dynamics during stress, as well as significant differences in myocardial β-adrenoreceptor (β-AR) regional distribution and sensitivity in comparison with healthy controls [2, 3]. There are also studies which suggest a genetic predisposition for altered catecholamine susceptibility and β-adrenergic signalling in TTS .
Catecholamines are still the first-line therapeutics in cardiogenic shock following acute myocardial infarction (MI), but are absolutely contraindicated in TTS patients, regardless of the severity of hemodynamic compromise. The potentially life-threatening consequences of catecholamine use for emergency circulatory support if the underlying cause of acute LV dysfunction is unrecognized TTS are therefore the main problem that can derive from diagnostic errors [2, 4, 5].
Transthoracic echocardiography can be useful for early distinction between TTS and acute apical MI if attention is focused on regional myocardial function using the advantages of strain imaging.
In patients with life-threatening acute HF, before coronary angiography becomes possible, echocardiography including also STE can identify a highly probable acute phase of TTS and in such patients, if absolutely necessary, any administration of cathecholamines should be continuously monitored by echocardiography and immediately stopped if the signs for TTS become more evident.
MD wrote the manuscript, and RH was involved in critically reviewing the manuscript and made appropriate corrections. Both authors approved the final manuscript.
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