European Heart Journal Advance Access originally published online on May 17, 2006
European Heart Journal 2006 27(12):1509-1510; doi:10.1093/eurheartj/ehl021
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Tako-tsubo syndrome: a form of spontaneous aborted myocardial infarction?
Cardiovascular Institute
Mount Sinai School of Medicine
One Gustave L. Levy Place
New York
10029 NY
USA
Tel: +1 212 241 5282
Fax: +1 212 426 6962
E-mail address: ibanez_borja{at}yahoo.es
Cardiovascular Institute
Mount Sinai School of Medicine
One Gustave L. Levy Place
New York
10029 NY
USA
Fundación Jiménez Díaz-Capio
Madrid
Spain
Fundación Jiménez Díaz-Capio
Madrid
Spain
We read with great interest the article by Verheugt et al.1 on aborted myocardial infarction. We agree with the fact that after the onset of acute coronary syndrome (ACS), the best scenario would be the spontaneous or mechanical abortion of the myocardial infarct. This myocardial infarct abortion could also induce wall motion abnormalities that may recover within hours or days. We want to highlight those cases of spontaneous myocardial abortion because of auto-thrombolysis and raise the question whether we could diagnose an aborted myocardial infarction when the thrombus responsible for the event has been completely lysed.
Tako-tsubo syndrome (also named transient left ventricular apical ballooning) presents with all the signs and symptoms of myocardial infarction, slight or no enzymatic release, and apical left ventricular akinesia that recovers within the first 2 weeks.2 These patients present on angiography (usually in the subacute phase and under the state-of-the-art antithrombotic–anticoagulant therapy) with no significant coronary artery stenosis. Because of the latter, ACS as the cause of the syndrome has usually been ruled out.3 Could tako-tsubo also represent spontaneous myocardial infarct abortion? Could it be in this population the balance between coronary thrombosis and endogenous fibrinolysis (eventually modulated by vasoconstriction) falls on the fibrinolysis side and, therefore, no thrombus is seen on angiography? This hypothesis becomes more plausible when it has been reported in tako-tsubo patients that disrupted eccentric atherosclerotic plaques of the left anterior descending have been visualized by IVUS, but were not visible by contrast angiography.4 Could the transient akinesia seen in these patients be the result of stunned myocardium? This phenomenon may be related to multiple episodes of occlusion–reperfusion, which makes the myocardium more prone to stunning. During episodes of ischaemia, regional left ventricular wall motion abnormalities develop in the region of ischaemia because myocytes cease contracting within seconds of the onset of acute ischaemia. After relief of ischaemia (e.g. by rapid lysis of a thrombus), the post-ischaemic but viable myocardium requires hours to days before the function is fully restored, as in the tako-tsubo syndrome. The length of time for the function to return is dependent on the number and duration of the ischaemic episodes. Charlat et al.5 showed that after a 15 min coronary artery occlusion, 48 h of reperfusion was needed for full recovery of systolic function, something that is common among tako-tsubo apical ballooning patients.
Therefore, we believe that the tako-tsubo syndrome patients could represent the paradigm of myocardial infarct abortion secondary to spontaneous thrombus autolysis. Hence, they could represent the ideal population to study the mechanisms leading to spontaneous thrombus autolysis and also deserves mention in your review. In addition, we would highly suggest the use of a technique that visualizes the entire vessel wall (not just the lumen, like contrast angiography does), such as IVUS or OCT, to explore the presence of disrupted plaques in patients with AMI and normal coronary arteries.
References
- Verheugt FW, Gersh BJ, Armstrong PW. (2006) Aborted myocardial infarction: a new target for reperfusion therapy. Eur Heart J 27:901–904.
[Abstract/Free Full Text] - Ibanez B, Navarro F, Farre J, Marcos-Alberca P, Orejas M, Rabago R, Rey M, Romero J, Iniguez A, Cordoba M. (2004) Tako-tsubo syndrome associated with a long course of the left anterior descending coronary artery along the apical diaphragmatic surface of the left ventricle. Rev Esp Cardiol 57:209–216.[CrossRef][Medline]
- Kurisu S, Sato H, Kawagoe T, Ishihara M, Shimatani Y, Nishioka K, Kono Y, Umemura T, Nakamura S. (2002) Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction. Am Heart J 143:448–455.[CrossRef][Web of Science][Medline]
- Ibanez B, Navarro F, Cordoba M, Alberca P, Farre J. (2005) Tako-tsubo transient left ventricular apical ballooning: is intravascular ultrasound the key to resolve the enigma? Heart 91:102–104.
[Free Full Text] - Charlat ML, O'Neill PG, Hartley CJ, Roberts R, Bolli R. (1989) Prolonged abnormalities of left ventricular diastolic wall thinning in the ‘stunned’ myocardium in conscious dogs: time course and relation to systolic function. J Am Coll Cardiol 13:185–194.[Abstract]
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