European Heart Journal Advance Access originally published online on October 26, 2006
European Heart Journal 2006 27(23):2907-2908; doi:10.1093/eurheartj/ehl346
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Apical ballooning syndrome, emotional stress and women
uli
Department of Medicine
University Hospital Split
Spinciceva 1
Split 21000
Croatia
Tel: +385 21 538 251
Fax: +385 21 556 031
E-mail address: viktor.culic{at}st.t-com.hr
In their systematic review, Gianni et al.1 described clinical characteristics of the transient left-ventricular apical ballooning syndrome or takotsubo cardiomyopathy. They found that the disease onset is preceded by emotional stress in 26.8% and physical stress in 37.8% of cases. However, two largest and most comprehensive studies in western populations strongly have pointed toward the striking female predominance, but also toward the importance of emotional stress as a possible external triggering event, observed in 86 and 100% of cases.2,3 In addition, another recent report that has not been included in this review has shown a marked increase in the incidence of apical ballooning syndrome in Niigata, Japan, associated with the earthquake, where 96% of patients were women.4
A similar sex discrepancy in triggering, with a greater likelihood of acute episodes of emotional stress preceding onset in women, has been seen for the acute myocardial infarction.5 Moreover, probably by representing protracted or re-iterated emotional stress, excess in risk of infarction in both sexes is associated with natural catastrophes or stressful mass events such as earthquakes and war threats (e.g. missile attacks), again more prominently among women.5 We have speculated5 that men and women respond differently to emotional stress or that there may be sex-specific pathophysiological mechanisms involved in triggering, as those suggested for apical ballooning syndrome.1–3 Furthermore, we have also previously observed a greater association of emotional stress with non-Q-wave than Q-wave myocardial infarction and proposed that transient vasospasm may be an important triggering mechanism associated with an emotional stress.6 Multiple vasospasm is one of the mechanisms postulated to underlay apical ballooning syndrome.1–4
Gianni et al.1 noted several putative explanations for the sex difference in pathophysiology of triggering of apical ballooning syndrome including sex hormones-related influence on the sympathetic neurohormonal axis and on coronary vasoreactivity, women's susceptibility to sympathetically mediated myocardial stunning, and post-menopausal alteration of endothelial function. However, further mechanisms may involve a sigmoid interventricular septum or a smaller left-ventricular outflow tract and reduced left-ventricular volumes predominantly found in women. In conclusion, in spite of data from the present review on the more frequent presence of physical stress before the onset of apical ballooning syndrome,1 there is evidence convincingly suggesting the pivotal role of emotional stress in triggering of this disorder that predominantly affects women. Still, the existence of such a phenomenon should be evaluated by controlled data (such as case-crossover methodology5), whereas eventual underlying pathophysiological mechanisms are yet to be fully clarified.
References
- Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. (2006) Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J 27:1523–1529.
[Abstract/Free Full Text] - Sharkey SW, Lesser JR, Zenovich AG, Maron MS, Lindberg J, Longe TF, Maron BJ. (2005) Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation 111:472–479.
- Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, Wu KC, Rade JJ, Bivalacqua TJ, Champion HC. (2005) Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 352:539–548.
[Abstract/Free Full Text] - Watanabe H, Kodama M, Aizawa Y, Tanabe N. (2005) Earthquakes and takotsubo cardiomyopathy. JAMA 294:2169–2170.
[Free Full Text] - uli V, Eterovi D, Miri D. (2005) Meta-analysis of possible external triggers of acute myocardial infarction. Int J Cardiol 99:1–8.[CrossRef][ISI][Medline]
- uli V, Miri D, Eterovi D. (2002) Different circumstances, timing, and symptom presentation at onset of Q wave versus non-Q wave acute myocardial infarction. Am J Cardiol 89:456–460.[CrossRef][ISI][Medline]
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  V. Culic Psychology, cardiology, and gender Eur. Heart J., August 16, 2008; (2008) ehn370v1. [Full Text] [PDF]
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