European Heart Journal Advance Access originally published online on May 23, 2006
European Heart Journal 2006 27(13):1523-1529; doi:10.1093/eurheartj/ehl032
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Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review
1 Department of Clinical Medicine, University of Insubria, Varese, Italy
2 Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
Received 1 February 2006; revised 12 April 2006; accepted 27 April 2006; online publish-ahead-of-print 23 May 2006.
* Corresponding author: Dr Eva Lonn, Hamilton Health Sciences Corporation, General Site, 237 Barton Street East, Hamilton, ON, Canada L8L 2X2. Tel: +1 905 526 0970; fax: +1 905 527 5380.E-mail address: lonnem{at}mcmaster.ca
Aims To clarify the major features of the apical ballooning syndrome, we performed a systematic review of the existing literature.
Methods and results Review of all relevant case series using the MEDLINE and EMBASE databases resulted in the identification of 14 studies. These studies suggest that the apical ballooning syndrome accounts for 
2.0% of ST-segment elevation infarcts, with most cases described in post-menopausal women. The most common clinical presentations are chest pain and dyspnoea, reported in 67.8 and 17.8% of the patients, respectively. Cardiogenic shock (4.2% of the patients) and ventricular fibrillation (1.5%) were not infrequent. ST-segment elevation was reported in 81.6% of the patients, T wave abnormalities in 64.3%, and Q waves in 31.8%. Cardiac biomarkers were usually mildly elevated, as reported in 86.2% of the patients. Typically, patients had left ventricular (LV) dysfunction on admission, with mean ejection fraction ranging from 20 to 49%. However, over a period of days to weeks, all patients experienced dramatic improvement in LV function. The onset of symptoms was often preceded by emotional (26.8%) or physical stress (37.8%). Norepinephrine concentration was elevated in 74.3% of the patients. Prognosis was generally excellent, with full recovery in most patients. In-hospital mortality was 1.1%. Only 3.5% of the patients experienced a recurrence.
Conculsion Clinicians should consider this syndrome in the differential diagnosis of patients presenting with chest pain, especially in post-menopausal women with a recent history of emotional or physical stress.
Key Words: Left ventricular apical ballooning syndrome • Acute coronary syndrome • Takotsubo cardiomyopathy • Left ventricular dysfunction
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