European Heart Journal Advance Access originally published online on October 26, 2006
European Heart Journal 2006 27(23):2908; doi:10.1093/eurheartj/ehl347
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Apical ballooning syndrome, emotional stress and women: reply
Department of Clinical Medicine
University of Insubria,
Varese
Italy
Department of Clinical Medicine
University of Insubria
Varese
Italy
Division of Cardiology
McMaster University
Hamilton General Hospital
237 Barton Street East
Hamilton
Ontario
Canada L8L 2X2
Tel: +1 905 6279710
E-mail address: lonnem{at}mcmaster.ca
In our systematic overview, we found that apical ballooning syndrome is preceded by an emotional stressor in 
27% of cases and by a physical stressor in 38%.1 
uli
suggests that emotional stress may be a more frequent trigger, especially in women. Indeed, in his meta-analysis of triggers of acute myocardial infarction (MI), uli2 observed a greater association between emotional stress and MI in women vs. men. However, this finding relates to MI in general and not to Takotsubo cardiomyopathy in particular. uli cites a couple of specific studies, conducted in western populations, which did indeed report a higher prevalence of emotional stressors as triggers for apical ballooning syndrome cases3,4 and a report from Japan linking the stress associated with earthquakes to this syndrome in Japan. We thank uli for drawing the readers' attention to the interesting report from Japan, which was not incorporated in our systematic overview, as it was published in brief as a research letter and did not meet the a priori criteria set for the inclusion of studies in our meta-analysis.
The ascertainment of triggers for cases of apical ballooning syndrome is difficult, often based on patients' recall, and we cannot exclude a more dominant role for emotional stressors. However, scientific rigour requires the careful consideration of the totality of the available evidence, rather than emphasis on specific reports. In our review, we attempted to capture all reliable and detailed studies reporting on this syndrome. It is possible that the role of emotional stress may differ in different populations [an emotional stressor was reported in 50 of 81 (63%) Caucasian patients, but only in 18 of 173 (9.3%) Japanese patients] and in women vs. men (we did not have access to individual patient data and could not analyse potential triggers in women and men separately).
uli suggests that multiple vasospasm may be an important, emotional-stress-mediated, trigger mechanism for this syndrome and that the presence of a sigmoid septum or a small left ventricular (LV) outflow tract, both leading to low LV volumes, may also be important underlying pathophysiological mechanisms. We believe this to be unlikely. In the published literature to date, only three of 212 evaluated patients (1.4%) experienced multivessel epicardial spasm during coronarography spontaneously and only 24 of 84 evaluated patients (28.6%) experienced multivessel epicardial spasm after infusion of a provocative agent. We identified no reports linking a sigmoid septum or a small LV outflow tract to the apical ballooning syndrome, and such conditions leading indeed to lower LV volumes may cause syncope, but would not be expected to trigger acute ischaemic events.
However, we fully agree that our current knowledge regarding the apical ballooning syndrome is scarce and that more research is needed to better understand this condition.
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] - uli
V, Eterovic D, Miric D. (2005) Meta-analysis of possible external triggers of acute myocardial infarction. Int J Cardiol 99:1–8.[CrossRef][Web of Science][Medline] - 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]
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