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J Am Coll Cardiol, 2001; 38:11-18
© 2001 by the American College of Cardiology Foundation
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CLINICAL STUDY

Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction

Kazufumi Tsuchihashi, MD, PhDa, Kenji Ueshima, MD, PhD{dagger}, Tatsuro Uchida, MD, PhD{ddagger}, Nobuhiro Oh-mura, MD, PhD§, Kazuo Kimura, MD, PhD||, Mafumi Owa, MD, PhD, Minoru Yoshiyama, MD, PhD#, Shunichi Miyazaki, MD, PhD**, Kazuo Haze, MD, PhD{dagger}{dagger}, Hisao Ogawa, MD, PhD{ddagger}{ddagger}, Takashi Honda, MD, PhD§§, Mamoru Hase, MDa, Ryu-ichi Kai, MD, PhD§, Isao Morii, MD, PhD** for the Angina Pectoris-Myocardial Infarction Investigations in Japan

a Second Department of Internal Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
{dagger} Second Department of Internal Medicine and Cardiology, Memorial Heart Center, Iwate Medical University School of Medicine, Morioka, Iwate, Japan
{ddagger} Division of Cardiovascular Medicine, Sendai Cardiovascular Center, Sendai, Japan
§ Department of Cardiovascular Medicine, Omiya Medical Center, Jichi Medical School, Omiya, Saitama, Japan
|| Department of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
First Department of Internal Medicine, Shinsyu University School of Medicine, Matsumoto, Nagano, Japan
# Division of Cardiology, Osaka City University School of Medicine, Osaka, Japan
** Division of Cardiology, National Cardiovascular Center, Suita, Osaka, Japan
{dagger}{dagger} Department of Cardiology, Osaka City General Hospital, Osaka, Japan
{ddagger}{ddagger} Department of Cardiovascular Medicine, Kumamoto University School of Medicine, Kumamoto, Japan
§§ Cardiovascular Center, Saiseikai Kumamoto Hospital, Kumamoto, Japan

Manuscript received November 15, 2000; revised manuscript received March 8, 2001, accepted March 26, 2001.

Reprint requests and correspondence: Dr. Kazufumi Tsuchihashi, Second Department of Internal Medicine, Sapporo Medical University School of Medicine, S-1, W-16, Chuo-ku, Sapporo 060-0061, Japan
tsuchiha{at}sapmed.ac.jp

OBJECTIVES

To determine the clinical features of a novel heart syndrome with transient left ventricular (LV) apical ballooning, but without coronary artery stenosis, that mimics acute myocardial infarction, we performed a multicenter retrospective enrollment study.

BACKGROUND

Only several case presentations have been reported with regard to this syndrome.

METHODS

We analyzed 88 patients (12 men and 76 women), aged 67 ± 13 years, who fulfilled the following criteria: 1) transient LV apical ballooning, 2) no significant angiographic stenosis, and 3) no known cardiomyopathies.

RESULTS

Thirty-eight (43%) patients had preceding aggravation of underlying disorders (cerebrovascular accident [n = 3], epilepsy [n = 3], exacerbated bronchial asthma [n = 3], acute abdomen [n = 7]) and noncardiac surgery or medical procedure (n = 11) at the onset. Twenty-four (27%) patients had emotional and physical problems (sudden accident [n = 2], death/funeral of a family member [n = 7], inexperience with exercise [n = 6], quarreling or excessive alcohol consumption [n = 5] and vigorous excitation [n = 4]). Chest symptoms (67%), electrocardiographic changes (ST elevation [90%], Q-wave formation [27%] and T-wave inversion [97%]) and elevated creatine kinase (56%) were found. After treatment of pulmonary edema (22%), cardiogenic shock (15%) and ventricular tachycardia/fibrillation (9%), 85 patients had class I New York Heart Association function on discharge. The LV ejection fraction improved from 41 ± 11% to 64 ± 10%. Transient intraventricular pressure gradient and provocative vasospasm were documented in 13/72 (18%) and 10/48 (21%) of the patients, respectively. During follow-up for 13 ± 14 months, two patients showed recurrence, and one died suddenly.

CONCLUSIONS

A novel cardiomyopathy with transient apical ballooning was reported. Emotional or physical stress might play a key role in this cardiomyopathy, but the precise etiologic basis still remains unclear.

Abbreviations and Acronyms
  AMI = acute myocardial infarction
  AP-MI = Angina Pectoris-Myocardial Infarction investigations
  CAG = coronary angiogram or coronary angiographic
  CK = creatine kinase
  ECG = electrocardiogram or electrocardiographic
  LV = left ventricle or left ventricular
  LVG = left ventriculography or left ventriculographic




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Neurohumoral Features of Myocardial Stunning Due to Sudden Emotional Stress
N. Engl. J. Med., February 10, 2005; 352(6): 539 - 548.
[Abstract] [Full Text] [PDF]

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 CirculationHome page
G. W. Dec
Recognition of the Apical Ballooning Syndrome in the United States
Circulation, February 1, 2005; 111(4): 388 - 390.
[Full Text] [PDF]

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 CirculationHome page
S. W. Sharkey, J. R. Lesser, A. G. Zenovich, M. S. Maron, J. Lindberg, T. F. Longe, and B. J. Maron
Acute and Reversible Cardiomyopathy Provoked by Stress in Women From the United States
Circulation, February 1, 2005; 111(4): 472 - 479.
[Abstract] [Full Text] [PDF]

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 ANN INTERN MEDHome page
K. A. Bybee, T. Kara, A. Prasad, A. Lerman, G. W. Barsness, R. S. Wright, and C. S. Rihal
Systematic Review: Transient Left Ventricular Apical Ballooning: A Syndrome That Mimics ST-Segment Elevation Myocardial Infarction
Ann Intern Med, December 7, 2004; 141(11): 858 - 865.
[Abstract] [Full Text] [PDF]

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 HeartHome page
L Pison, P De Vusser, and W Mullens
Apical ballooning in relatives
Heart, December 1, 2004; 90(12): e67 - e67.
[Abstract] [Full Text] [PDF]

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 QJMHome page
Y.J. Akashi, H. Musha, K. Nakazawa, and F. Miyake
Plasma brain natriuretic peptide in takotsubo cardiomyopathy
QJM, September 1, 2004; 97(9): 599 - 607.
[Abstract] [Full Text] [PDF]

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 JNMHome page
Y. J. Akashi, K. Nakazawa, M. Sakakibara, F. Miyake, H. Musha, and K. Sasaka
123I-MIBG Myocardial Scintigraphy in Patients with "Takotsubo" Cardiomyopathy
J. Nucl. Med., July 1, 2004; 45(7): 1121 - 1127.
[Abstract] [Full Text] [PDF]

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 Mayo Clin Proc.Home page
Y. J. Akashi, T. Tejima, H. Sakurada, H. Matsuda, K. Suzuki, K. Kawasaki, K. Tsuchiya, N. Hashimoto, H. Musha, M. Sakakibara, et al.
Left Ventricular Rupture Associated With Takotsubo Cardiomyopathy
Mayo Clin. Proc., June 1, 2004; 79(6): 821 - 824.
[Abstract] [PDF]

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 NEJMHome page
J. Ako, Y. Honda, P. J. Fitzgerald, I. A. Andrianakis, E. D. Papadomichelakis, A. N. Kotanidou, T. O. Cheng, E. Fossum, K. Nils-Einar, A. Mangschau, et al.
Conditions Associated with ST-Segment Elevation
N. Engl. J. Med., March 11, 2004; 350(11): 1152 - 1155.
[Full Text] [PDF]

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 J Am Coll CardiolHome page
M. Penas-Lado, R. Barriales-Villa, and J. Goicolea
Transient left ventricular apical ballooning and outflow tract obstruction
J. Am. Coll. Cardiol., September 17, 2003; 42(6): 1143 - 1144.
[Full Text] [PDF]

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 J Am Coll CardiolHome page
Y. Abe
Transient left ventricular apical ballooning and outflow tract obstruction: Reply
J. Am. Coll. Cardiol., September 17, 2003; 42(6): 1144 - 1144.
[Full Text] [PDF]

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 HeartHome page
Y Abe and M Kondo
Apical ballooning of the left ventricle: a distinct entity?
Heart, September 1, 2003; 89(9): 974 - 976.
[Full Text] [PDF]

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 HeartHome page
W J R Desmet, B F M Adriaenssens, and J A Y Dens
Apical ballooning of the left ventricle: first series in white patients
Heart, September 1, 2003; 89(9): 1027 - 1031.
[Abstract] [Full Text] [PDF]

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 J. Neurol. Neurosurg. PsychiatryHome page
M Oomura, T Yamawaki, H Oe, H Moriwaki, K Miyashita, H Naritomi, and Y Yasumura
Association of cardiomyopathy caused by autonomic nervous system impairment with the Miller Fisher syndrome
J. Neurol. Neurosurg. Psychiatry, May 1, 2003; 74(5): 689 - 690.
[Full Text]

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 J Am Coll CardiolHome page
Y. Abe, M. Kondo, R. Matsuoka, M. Araki, K. Dohyama, and H. Tanio
Assessment of clinical features in transient left ventricular apical ballooning
J. Am. Coll. Cardiol., March 5, 2003; 41(5): 737 - 742.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
S. Kurisu, I. Inoue, T. Kawagoe, M. Ishihara, Y. Shimatani, K. Nishioka, T. Umemura, S. Nakamura, M. Yoshida, and H. Sato
Myocardial perfusion and fatty acid metabolism in patients with tako-tsubo-like left ventricular dysfunction
J. Am. Coll. Cardiol., March 5, 2003; 41(5): 743 - 748.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
K. Tsuchihashi
Transient left ventricular apical ballooning without coronary artery stenosis: a form of stunning-like phenomenon? Reply
J. Am. Coll. Cardiol., February 20, 2002; 39(4): 741 - 742.
[Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
J. Ako, K. Kozaki, M. Yoshizumi, and Y. Ouchi
Transient left ventricular apical ballooning without coronary artery stenosis: a form of stunning-like phenomenon?
J. Am. Coll. Cardiol., February 20, 2002; 39(4): 741 - 741.
[Full Text] [PDF]

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 J Am Coll CardiolHome page
K. Tsuchihashi
Reply
J. Am. Coll. Cardiol., January 2, 2002; 39(1): 181 - 182.
[Full Text] [PDF]

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 J Am Coll CardiolHome page
V. J. Castro, C. Larrauri, and A. Bryce
Transient ischemia as a possible etiology for ventricular dysfunction
J. Am. Coll. Cardiol., January 2, 2002; 39(1): 181 - 181.
[Full Text] [PDF]


 
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