CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Rodolfo Citro, MD*,
Mario Previtali, MD,
Eduardo Bossone, MD and
Roberto Manfredini, MD
* Cardiology Department, A.O.U. San Giovanni di Dio e Ruggi d'Aragona, Salerno 84131, Italy (Email: rodolfocitro{at}tele2.it).
We thank Dr. Mansencal and colleagues for their comments on our study (1). They reviewed 51 cases of Tako-Tsubo cardiomyopathy (TTC) from 2008 to 2009 and did not replicate our findings. They found a peak onset of TTC in April and not in summer, and morning and afternoon were the preferred periods. The main limitation of epidemiological studies on TTC derives from the limited size of populations, so that very few cases may cause significant changes. As for seasonal variation, a further study from our Network, conducted on an enlarged population of 112 patients, confirmed the summer preference of onset of TTC for subjects either age <65 or  65 years (2). Moreover, a summer preference has been reported previously in a German single-center study (31 cases) (3), and more recently also confirmed for 70 patients included in an American registry (4). The existence of a main morning peak of occurrence was observed in a Japanese cohort of 50 cases (5). We do not suggest that our results are definitely conclusive. However, our study was conducted on one of the largest populations of TTC patients available in the literature to date (6), and first used a validated chronobiological method of analysis, focused on searching for underlying rhythmic reproducible patterns of occurrence, not only peaks of higher frequencies. Although the role of stress hormones remains controversial (7), the exposure to catecholamines and beta-receptor agonists could precipitate the clinical scenario of TTC (8). We agree with Dr. Mansencal and colleagues that stress events may play a pivotal role. Thus, their hypothesis that different types of stress may explain different results is certainly interesting, and deserves further in-depth studies on larger populations.
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1. Citro R, Previtali M, Bovelli D, et al. Chronobiological patterns of onset of Tako-Tsubo cardiomyopathy. a multicenter Italian study. J Am Coll Cardiol 2009;54:180-181.[Free Full Text]2. Manfredini R, Citro R, Previtali M, et al. The summer preference in the occurrence of Takotsubo cardiomyopathy is independent of age J Am Geriatr Soc 2009;57:1509-1511.[CrossRef][Web of Science][Medline] 3. Hertting K, Krause K, Härle T, Boczor S, Reimers J, Kucj KH. Transient left ventricular apical ballooning in a community hospital in Germany Int J Cardiol 2006;112:282-288.[CrossRef][Web of Science][Medline] 4. Regnante RA, Zuzek RW, Weinser SB, et al. Clinical characteristics and four-year outcomes of patients in the Rhode Island Takotsubo Cardiomyopathy Registry Am J Cardiol 2009;103:105-109. 5. Kurisu S, Inoue I, Kawagoe T, et al. Circadian variation in the occurrence of tako-tsubo cardiomyopathy: comparison with acute myocardial infarction Int J Cardiol 2007;115:270-271.[CrossRef][Web of Science][Medline] 6. Akashi YJ, Goldstein DS, Barbaro G, et al. Takotsubo cardiomyopathy Circulation 2008;118:2754-2762.[Free Full Text] 7. Madhavan M, Borlaug BA, Lerman A, Rihal CS, Prasad A. Stress hormone and circulating biomarker profile of apical ballooning syndrome (Takotsubo cardiomyopathy): insights into the clinical significance of B-type natriuretic peptide and troponin levels Heart 2009;95:1436-1441.[Abstract/Free Full Text] 8. Abraham J, Mudd JO, Kapur NK, Klein K, Champion HC, Wittstein IS. Stress cardiomyopathy after intravenous administration of catecholamines and beta-receptor agonists J Am Coll Cardiol 2009;53:1320-1325.[Abstract/Free Full Text]
Related Article
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Occurrence of Tako-Tsubo Cardiomyopathy and Chronobiological Variation
- Nicolas Mansencal, Rami El Mahmoud, and Olivier Dubourg
J. Am. Coll. Cardiol. 2010 55: 500-501.
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