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たこつぼ(型)心筋症/たこつぼ症候群

著者: 渡辺昌文 山形大学医学部 内科学第一講座(循環・呼吸・腎臓内科学)

監修: 伊藤浩 岡山大学循環器内科

著者校正/監修レビュー済:2021/10/06
患者向け説明資料

概要・推奨   

【概要】
  1. たこつぼ型心筋症は、左心室壁の一部が一過性に無収縮となる症候群である。無収縮となる領域は、冠状動脈の支配領域では説明がつかず、80%以上の症例で心尖部を中心とした領域である。冠動脈造影検査で無収縮の原因となる冠動脈病変は認められない。
  1. 1990年、佐藤らによって最初に報告され[1][2]、左室造影で、左室心尖部とその周囲が拡張したまま収縮しない様が、蛸壺の形を連想させることから、「たこつぼ心筋障害」または「たこつぼ心筋症」と呼ばれた。
  1. 河合らTakotsubo Cardiomyopathy Study GroupTCSG, 2007)による狭義の「たこつぼ心筋症」の診断基準[3]、より広義のMayo clinic criteria2008[4]Inter TKA Diagnostic Criteria2018[5]が代表的な診断基準である。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要とな ります。閲覧にはご契約が必要となります。閲覧にはご契
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契
  1. 予後は、必ずしも良好とはいえず、再発も稀ではない。
    【推奨】
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
渡辺昌文 : 特に申告事項無し[2021年]
監修:伊藤浩 : 講演料(第一三共,興和,アストラゼネカ,小野,ノバルティスファーマ),研究費・助成金など(興和,Canon),奨学(奨励)寄付など(第一三共,田辺三菱,小野薬品,興和,Boston,武田,ベーリンガーインゲルハイム,持田,バイエル),企業などが提供する寄付講座(日本メドトロニック)[2021年]

改訂のポイント:
  1. International Expert Consensus Document on Takotsubo Syndrome (Part I/II): Eur Heart J.2018 Jun 7;39(22) の内容を盛り込んだ。
  1. 定期レビューを行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. たこつぼ型心筋症は、1990年にわが国から初めて報告された。当初、主に日本で注目を集めたが、2000年代に入って、海外でもその存在が広く認識されるようになった。2006年には、アメリカ心臓病学会も、本症候群を、後天的心筋症に含めた。
  1. いずれの診断視診やガイドラインも主に経験に基づいて作成されている。近年、国際的な Registry による、病態解明の試みが行われており、次第にエビデンスが集まってきている。
疫学
  1. 高齢女性(女性90%、平均年齢67歳)に多くみられる。
  1. 発症前にストレスがあることが多く、心因性ストレスのみ(27.7%)、身体的ストレスのみ(36.0%)、両方のストレス(7.8%)の場合がある。ストレスが認められない(28.5%)こともある[6]
  1. 身体的ストレスの内容としては、急性呼吸不全(20.2%)、術後・骨折後(18.4%)、脳神経疾患(15.5%)、感染症(8.1%)などである[6]
  1. 心因性ストレスの内容としては、悲しみ・喪失感(22.1%)、パニック・恐怖・心配(22.1%)、対人摩擦(16.1%)、怒り・不満(15.8%)、経済・雇用問題(7.6%)などである[6]
  1. 心因性ストレスは、幸福なことでもきっかけとなる。ネガティブな場合に比べて、年齢が高めで、高血圧歴は少なく、midventricular type が多い[7]
  1. 病歴に、神経疾患や精神疾患が比較的多いことが報告されている。
  1. 強度の地震の際に本症候群の患者が増加したという複数の報告がある[8]
  1. COVID-19 感染時にも、見られるという報告がある。
  1. ごく軽症で、病院を受診しない患者がいることも予想される。また全身状態の悪い入院患者で発症した場合、心臓カテーテル検査などの侵襲的な検査は施行されず、本症の診断が確定しないこともあると考えられる。
 
病態
  1. たこつぼ型心筋症は、左心室壁の一部が一過性に無収縮となる症候群である。無収縮となる領域は、冠状動脈の支配領域では説明がつかず、80%以上の症例で心尖部を中心とした領域である。冠動脈造影検査では、無収縮の原因となる冠動脈病変は認められない。
  1. 発症機序は、主要な冠動脈の基質的病変が原因ではないことに異論はないが、真の発症機序は不明である。以下のような説が唱えられているが、いずれもコンセンサスを得られていない。診断基準の作成・予防・根本的な治療は困難である。
  1. 冠動脈多枝攣縮
  1. 自律神経異常 
  1. 冠動脈微小循環障害
問診・診察のポイント  
  1. 急性心筋梗塞との鑑別が重要である。冠動脈危険因子(高血圧、糖尿病、脂質異常、肥満、喫煙、虚血性心疾患の家族歴など)についての問診、病歴の聴取など、急性心筋梗塞の可能性を検討する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: K Dote, H Sato, H Tateishi, T Uchida, M Ishihara
雑誌名: J Cardiol. 1991;21(2):203-14.
Abstract/Text Five patients with typical myocardial stunning were presented. They had chest pain and had electrocardiographic abnormalities matching the symptoms of acute myocardial infarction (AMI) but had no coronary artery stenoses on angiogram (CAG). The prevalence of cases with these clinical manifestations was 1.2% among 415 consecutive AMI patients who were examined invasively. The electrocardiographic abnormalities varied; ST elevations were observed in 4 patients, R waves decreased transiently in one, and Q waves developed in one patient. Typical left ventriculogram (LVG) was akinesis in the apical, diaphragmatic and/or anterolateral segments, but hyperkinesis in the basal segments. This akinesis was transient and resolved in 7 days. CAG revealed diffuse multi-vessel spasms in 2 patients, which were also observed in additional 2 patients after ergonovine administration. The intracoronary administration of nitroglycerin disclosed no coronary artery stenoses in any of the patients.

PMID 1841907  J Cardiol. 1991;21(2):203-14.
著者: Sachio Kawai, Akira Kitabatake, Hitonobu Tomoike, Takotsubo Cardiomyopathy Group
雑誌名: Circ J. 2007 Jun;71(6):990-2.
Abstract/Text BACKGROUND: It is important to differentiate takotsubo cardiomyopathy from other types of transient ventricular dysfunction. These guidelines, resulting from a workshop sponsored by the Ministry of Health, Labour, and Welfare, Idiopathic Cardiomyopathy Research Committee, outline the steps necessary for diagnosis of takotsubo cardiomyopathy.
METHODS AND RESULTS: The survey was conducted by mailing a questionnaire to the researchers of the 203 institutions that had made presentations on this disease at scientific meetings of the Japanese Circulation Society from November 1989 to October 2002. The questionnaires were sent and collected on January 10, 2003. Based on the results of the questionnaire, the first edition of the guidelines for diagnosis of takotsubo cardiomyopathy was prepared and evaluated at the 2003 group meeting of the Research Committee. Out of 33 researchers in Japan who had published research papers on this disease, 21 responded to the request and provided their opinions. The guidelines were revised and were approved at the 2004 group meeting.
CONCLUSIONS: This summary provides standard guidelines for patients with takotsubo cardiomyopathy.

PMID 17527002  Circ J. 2007 Jun;71(6):990-2.
著者: Abhiram Prasad, Amir Lerman, Charanjit S Rihal
雑誌名: Am Heart J. 2008 Mar;155(3):408-17. doi: 10.1016/j.ahj.2007.11.008. Epub 2008 Jan 31.
Abstract/Text Apical ballooning syndrome (ABS) is a unique reversible cardiomyopathy that is frequently precipitated by a stressful event and has a clinical presentation that is indistinguishable from a myocardial infarction. We review the best evidence regarding the pathophysiology, clinical features, investigation, and management of ABS. The incidence of ABS is estimated to be 1% to 2% of patients presenting with an acute myocardial infarction. The pathophysiology remains unknown, but catecholamine mediated myocardial stunning is the most favored explanation. Chest pain and dyspnea are the typical presenting symptoms. Transient ST elevation may be present on the electrocardiogram, and a small rise in cardiac troponin T is invariable. Typically, there is hypokinesis or akinesis of the mid and apical segments of the left ventricle with sparing of the basal systolic function without obstructive coronary lesions. Supportive treatment leads to spontaneous rapid recovery in nearly all patients. The prognosis is excellent, and a recurrence occurs in <10% of patients. Apical ballooning syndrome should be included in the differential diagnosis of patients with an apparent acute coronary syndrome with left ventricular regional wall motion abnormality and absence of obstructive coronary artery disease, especially in the setting of a stressful trigger.

PMID 18294473  Am Heart J. 2008 Mar;155(3):408-17. doi: 10.1016/j.ahj.・・・
著者: Jelena-Rima Ghadri, Ilan Shor Wittstein, Abhiram Prasad, Scott Sharkey, Keigo Dote, Yoshihiro John Akashi, Victoria Lucia Cammann, Filippo Crea, Leonarda Galiuto, Walter Desmet, Tetsuro Yoshida, Roberto Manfredini, Ingo Eitel, Masami Kosuge, Holger M Nef, Abhishek Deshmukh, Amir Lerman, Eduardo Bossone, Rodolfo Citro, Takashi Ueyama, Domenico Corrado, Satoshi Kurisu, Frank Ruschitzka, David Winchester, Alexander R Lyon, Elmir Omerovic, Jeroen J Bax, Patrick Meimoun, Guiseppe Tarantini, Charanjit Rihal, Shams Y-Hassan, Federico Migliore, John D Horowitz, Hiroaki Shimokawa, Thomas Felix Lüscher, Christian Templin
雑誌名: Eur Heart J. 2018 Jun 7;39(22):2032-2046. doi: 10.1093/eurheartj/ehy076.
Abstract/Text Takotsubo syndrome (TTS) is a poorly recognized heart disease that was initially regarded as a benign condition. Recently, it has been shown that TTS may be associated with severe clinical complications including death and that its prevalence is probably underestimated. Since current guidelines on TTS are lacking, it appears timely and important to provide an expert consensus statement on TTS. The clinical expert consensus document part I summarizes the current state of knowledge on clinical presentation and characteristics of TTS and agrees on controversies surrounding TTS such as nomenclature, different TTS types, role of coronary artery disease, and etiology. This consensus also proposes new diagnostic criteria based on current knowledge to improve diagnostic accuracy.

PMID 29850871  Eur Heart J. 2018 Jun 7;39(22):2032-2046. doi: 10.1093/・・・
著者: Christian Templin, Jelena R Ghadri, Johanna Diekmann, L Christian Napp, Dana R Bataiosu, Milosz Jaguszewski, Victoria L Cammann, Annahita Sarcon, Verena Geyer, Catharina A Neumann, Burkhardt Seifert, Jens Hellermann, Moritz Schwyzer, Katharina Eisenhardt, Josef Jenewein, Jennifer Franke, Hugo A Katus, Christof Burgdorf, Heribert Schunkert, Christian Moeller, Holger Thiele, Johann Bauersachs, Carsten Tschöpe, Heinz-Peter Schultheiss, Charles A Laney, Lawrence Rajan, Guido Michels, Roman Pfister, Christian Ukena, Michael Böhm, Raimund Erbel, Alessandro Cuneo, Karl-Heinz Kuck, Claudius Jacobshagen, Gerd Hasenfuss, Mahir Karakas, Wolfgang Koenig, Wolfgang Rottbauer, Samir M Said, Ruediger C Braun-Dullaeus, Florim Cuculi, Adrian Banning, Thomas A Fischer, Tuija Vasankari, K E Juhani Airaksinen, Marcin Fijalkowski, Andrzej Rynkiewicz, Maciej Pawlak, Grzegorz Opolski, Rafal Dworakowski, Philip MacCarthy, Christoph Kaiser, Stefan Osswald, Leonarda Galiuto, Filippo Crea, Wolfgang Dichtl, Wolfgang M Franz, Klaus Empen, Stephan B Felix, Clément Delmas, Olivier Lairez, Paul Erne, Jeroen J Bax, Ian Ford, Frank Ruschitzka, Abhiram Prasad, Thomas F Lüscher
雑誌名: N Engl J Med. 2015 Sep 3;373(10):929-38. doi: 10.1056/NEJMoa1406761.
Abstract/Text BACKGROUND: The natural history, management, and outcome of takotsubo (stress) cardiomyopathy are incompletely understood.
METHODS: The International Takotsubo Registry, a consortium of 26 centers in Europe and the United States, was established to investigate clinical features, prognostic predictors, and outcome of takotsubo cardiomyopathy. Patients were compared with age- and sex-matched patients who had an acute coronary syndrome.
RESULTS: Of 1750 patients with takotsubo cardiomyopathy, 89.8% were women (mean age, 66.8 years). Emotional triggers were not as common as physical triggers (27.7% vs. 36.0%), and 28.5% of patients had no evident trigger. Among patients with takotsubo cardiomyopathy, as compared with an acute coronary syndrome, rates of neurologic or psychiatric disorders were higher (55.8% vs. 25.7%) and the mean left ventricular ejection fraction was markedly lower (40.7±11.2% vs. 51.5±12.3%) (P<0.001 for both comparisons). Rates of severe in-hospital complications including shock and death were similar in the two groups (P=0.93). Physical triggers, acute neurologic or psychiatric diseases, high troponin levels, and a low ejection fraction on admission were independent predictors for in-hospital complications. During long-term follow-up, the rate of major adverse cardiac and cerebrovascular events was 9.9% per patient-year, and the rate of death was 5.6% per patient-year.
CONCLUSIONS: Patients with takotsubo cardiomyopathy had a higher prevalence of neurologic or psychiatric disorders than did those with an acute coronary syndrome. This condition represents an acute heart failure syndrome with substantial morbidity and mortality. (Funded by the Mach-Gaensslen Foundation and others; ClinicalTrials.gov number, NCT01947621.).

PMID 26332547  N Engl J Med. 2015 Sep 3;373(10):929-38. doi: 10.1056/N・・・
著者: Jelena R Ghadri, Annahita Sarcon, Johanna Diekmann, Dana Roxana Bataiosu, Victoria L Cammann, Stjepan Jurisic, Lars Christian Napp, Milosz Jaguszewski, Frank Scherff, Peter Brugger, Lutz Jäncke, Burkhardt Seifert, Jeroen J Bax, Frank Ruschitzka, Thomas F Lüscher, Christian Templin, InterTAK Co-investigators:
雑誌名: Eur Heart J. 2016 Oct 1;37(37):2823-2829. doi: 10.1093/eurheartj/ehv757. Epub 2016 Mar 2.
Abstract/Text AIMS: Takotsubo syndrome (TTS) is typically provoked by negative stressors such as grief, anger, or fear leading to the popular term 'broken heart syndrome'. However, the role of positive emotions triggering TTS remains unclear. The aim of the present study was to analyse the prevalence and characteristics of patients with TTS following pleasant events, which are distinct from the stressful or undesirable episodes commonly triggering TTS.
METHODS AND RESULTS: Takotsubo syndrome patients with preceding pleasant events were compared to those with negative emotional triggers from the International Takotsubo Registry. Of 1750 TTS patients, we identified a total of 485 with a definite emotional trigger. Of these, 4.1% (n = 20) presented with pleasant preceding events and 95.9% (n = 465) with unequivocal negative emotional events associated with TTS. Interestingly, clinical presentation of patients with 'happy heart syndrome' was similar to those with the 'broken heart syndrome' including symptoms such as chest pain [89.5% (17/19) vs. 90.2% (412/457), P = 1.0]. Similarly, electrocardiographic parameters, laboratory findings, and 1-year outcome did not differ. However, in a post hoc analysis, a disproportionate higher prevalence of midventricular involvement was noted in 'happy hearts' compared with 'broken hearts' (35.0 vs. 16.3%, P = 0.030).
CONCLUSION: Our data illustrate that TTS can be triggered by not only negative but also positive life events. While patient characteristics were similar between groups, the midventricular TTS type was more prevalent among the 'happy hearts' than among the 'broken hearts'. Presumably, despite their distinct nature, happy and sad life events may share similar final common emotional pathways, which can ultimately trigger TTS.

© The Author 2016. Published by Oxford University Press on behalf of the European Society of Cardiology.
PMID 26935270  Eur Heart J. 2016 Oct 1;37(37):2823-2829. doi: 10.1093/・・・
著者: Tatsuo Aoki, Jun Takahashi, Yoshihiro Fukumoto, Satoshi Yasuda, Kenta Ito, Satoshi Miyata, Tsuyoshi Shinozaki, Kanichi Inoue, Tetsuo Yagi, Tatsuya Komaru, Yoshiaki Katahira, Atsushi Obata, Tetsuya Hiramoto, Hiroyasu Sukegawa, Kazunori Ogata, Hiroaki Shimokawa
雑誌名: Circ J. 2013;77(2):490-3. doi: 10.1253/circj.cj-12-1594. Epub 2013 Jan 18.
Abstract/Text BACKGROUND: We reported an increased occurrence of cardiovascular diseases (CVDs) after the Great East Japan Earthquake by examining ambulance records, but it had to be confirmed by cardiologists.
METHODS AND RESULTS: We enrolled patients admitted to the cardiology department of the 10 hospitals in the disaster area from 4 weeks prior to 15 weeks after March 11 in the years 2008-2011 (n=14,078). The weekly occurrence of several CVDs, including heart failure (HF), pulmonary thromboembolism (PTE) and infectious endocarditis (IE), was sharply and significantly increased after the Earthquake.
CONCLUSIONS: The Disaster caused significantly increases in the occurrence of HF, PTE and IE.

PMID 23328448  Circ J. 2013;77(2):490-3. doi: 10.1253/circj.cj-12-1594・・・
著者: Jelena R Ghadri, Victoria L Cammann, Stjepan Jurisic, Burkhardt Seifert, L Christian Napp, Johanna Diekmann, Dana Roxana Bataiosu, Fabrizio D'Ascenzo, Katharina J Ding, Annahita Sarcon, Elycia Kazemian, Tanja Birri, Frank Ruschitzka, Thomas F Lüscher, Christian Templin, InterTAK co-investigators
雑誌名: Eur J Heart Fail. 2017 Aug;19(8):1036-1042. doi: 10.1002/ejhf.683. Epub 2016 Dec 7.
Abstract/Text AIMS: Clinical presentation of takotsubo syndrome (TTS) mimics acute coronary syndrome (ACS) and does not allow differentiation. We aimed to develop a clinical score to estimate the probability of TTS and to distinguish TTS from ACS in the acute stage.
METHODS AND RESULTS: Patients with TTS were recruited from the International Takotsubo Registry ( www.takotsubo-registry.com) and ACS patients from the leading hospital in Zurich. A multiple logistic regression for the presence of TTS was performed in a derivation cohort (TTS, n = 218; ACS, n = 436). The best model was selected and formed a score (InterTAK Diagnostic Score) with seven variables, and each was assigned a score value: female sex 25, emotional trigger 24, physical trigger 13, absence of ST-segment depression (except in lead aVR) 12, psychiatric disorders 11, neurologic disorders 9, and QTc prolongation 6 points. The area under the curve (AUC) for the resulting score was 0.971 [95% confidence interval (CI) 0.96-0.98] and using a cut-off value of 40 score points, sensitivity was 89% and specificity 91%. When patients with a score of ≥50 were diagnosed as TTS, nearly 95% of TTS patients were correctly diagnosed. When patients with a score ≤31 were diagnosed as ACS, ∼95% of ACS patients were diagnosed correctly. The score was subsequently validated in an independent validation cohort (TTS, n = 173; ACS, n = 226), resulting in a score AUC of 0.901 (95% CI 0.87-0.93).
CONCLUSION: The InterTAK Diagnostic Score estimates the probability of the presence of TTS and is able to distinguish TTS from ACS with a high sensitivity and specificity.
TRIAL REGISTRATION: NCT0194762.

© 2016 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.
PMID 27928880  Eur J Heart Fail. 2017 Aug;19(8):1036-1042. doi: 10.100・・・
著者: Jelena-Rima Ghadri, Ilan Shor Wittstein, Abhiram Prasad, Scott Sharkey, Keigo Dote, Yoshihiro John Akashi, Victoria Lucia Cammann, Filippo Crea, Leonarda Galiuto, Walter Desmet, Tetsuro Yoshida, Roberto Manfredini, Ingo Eitel, Masami Kosuge, Holger M Nef, Abhishek Deshmukh, Amir Lerman, Eduardo Bossone, Rodolfo Citro, Takashi Ueyama, Domenico Corrado, Satoshi Kurisu, Frank Ruschitzka, David Winchester, Alexander R Lyon, Elmir Omerovic, Jeroen J Bax, Patrick Meimoun, Guiseppe Tarantini, Charanjit Rihal, Shams Y-Hassan, Federico Migliore, John D Horowitz, Hiroaki Shimokawa, Thomas Felix Lüscher, Christian Templin
雑誌名: Eur Heart J. 2018 Jun 7;39(22):2047-2062. doi: 10.1093/eurheartj/ehy077.
Abstract/Text The clinical expert consensus statement on takotsubo syndrome (TTS) part II focuses on the diagnostic workup, outcome, and management. The recommendations are based on interpretation of the limited clinical trial data currently available and experience of international TTS experts. It summarizes the diagnostic approach, which may facilitate correct and timely diagnosis. Furthermore, the document covers areas where controversies still exist in risk stratification and management of TTS. Based on available data the document provides recommendations on optimal care of such patients for practising physicians.

PMID 29850820  Eur Heart J. 2018 Jun 7;39(22):2047-2062. doi: 10.1093/・・・
著者: Masami Kosuge, Toshiaki Ebina, Kiyoshi Hibi, Satoshi Morita, Jun Okuda, Noriaki Iwahashi, Kengo Tsukahara, Tatsuya Nakachi, Masayoshi Kiyokuni, Toshiyuki Ishikawa, Satoshi Umemura, Kazuo Kimura
雑誌名: J Am Coll Cardiol. 2010 Jun 1;55(22):2514-6. doi: 10.1016/j.jacc.2009.12.059.
Abstract/Text
PMID 20510222  J Am Coll Cardiol. 2010 Jun 1;55(22):2514-6. doi: 10.10・・・
著者: K Tsuchihashi, K Ueshima, T Uchida, N Oh-mura, K Kimura, M Owa, M Yoshiyama, S Miyazaki, K Haze, H Ogawa, T Honda, M Hase, R Kai, I Morii, Angina Pectoris-Myocardial Infarction Investigations in Japan
雑誌名: J Am Coll Cardiol. 2001 Jul;38(1):11-8. doi: 10.1016/s0735-1097(01)01316-x.
Abstract/Text 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: Thirt-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.

PMID 11451258  J Am Coll Cardiol. 2001 Jul;38(1):11-8. doi: 10.1016/s0・・・
著者: Ingo Eitel, Florian von Knobelsdorff-Brenkenhoff, Peter Bernhardt, Iacopo Carbone, Kai Muellerleile, Annachiara Aldrovandi, Marco Francone, Steffen Desch, Matthias Gutberlet, Oliver Strohm, Gerhard Schuler, Jeanette Schulz-Menger, Holger Thiele, Matthias G Friedrich
雑誌名: JAMA. 2011 Jul 20;306(3):277-86. doi: 10.1001/jama.2011.992.
Abstract/Text CONTEXT: Stress cardiomyopathy (SC) is a transient form of acute heart failure triggered by stressful events and associated with a distinctive left ventricular (LV) contraction pattern. Various aspects of its clinical profile have been described in small single-center populations, but larger, multicenter data sets have been lacking so far. Furthermore, it remains difficult to quickly establish diagnosis on admission.
OBJECTIVES: To comprehensively define the clinical spectrum and evolution of SC in a large population, including tissue characterization data from cardiovascular magnetic resonance (CMR) imaging; and to establish a set of CMR criteria suitable for diagnostic decision making in patients acutely presenting with suspected SC.
DESIGN, SETTING, AND PATIENTS: Prospective study conducted at 7 tertiary care centers in Europe and North America between January 2005 and October 2010 among 256 patients with SC assessed at the time of presentation as well as 1 to 6 months after the acute event.
MAIN OUTCOME MEASURES: Complete recovery of LV dysfunction.
RESULTS: Eighty-one percent of patients (n = 207) were postmenopausal women, 8% (n = 20) were younger women (aged ≤50 years), and 11% (n = 29) were men. A stressful trigger could be identified in 182 patients (71%). Cardiovascular magnetic resonance imaging data (available for 239 patients [93%]) revealed 4 distinct patterns of regional ventricular ballooning: apical (n = 197 [82%]), biventricular (n = 81 [34%]), midventricular (n = 40 [17%]), and basal (n = 2 [1%]). Left ventricular ejection fraction was reduced (48% [SD, 11%]; 95% confidence interval [CI], 47%-50%) in all patients. Stress cardiomyopathy was accurately identified by CMR using specific criteria: a typical pattern of LV dysfunction, myocardial edema, absence of significant necrosis/fibrosis, and markers for myocardial inflammation. Follow-up CMR imaging showed complete normalization of LV ejection fraction (66% [SD, 7%]; 95% CI, 64%-68%) and inflammatory markers in the absence of significant fibrosis in all patients.
CONCLUSIONS: The clinical profile of SC is considerably broader than reported previously. Cardiovascular magnetic resonance imaging at the time of initial clinical presentation may provide relevant functional and tissue information that might aid in the establishment of the diagnosis of SC.

PMID 21771988  JAMA. 2011 Jul 20;306(3):277-86. doi: 10.1001/jama.2011・・・
著者: Ahmad A Elesber, Abhiram Prasad, Ryan J Lennon, R Scott Wright, Amir Lerman, Charanjit S Rihal
雑誌名: J Am Coll Cardiol. 2007 Jul 31;50(5):448-52. doi: 10.1016/j.jacc.2007.03.050. Epub 2007 Jul 16.
Abstract/Text OBJECTIVES: This study sought to assess the long-term prognosis of patients with apical ballooning syndrome (ABS).
BACKGROUND: Apical ballooning syndrome is a recently described acute cardiac syndrome of uncertain etiology and prognosis.
METHODS: We retrospectively identified 100 unselected patients with a confirmed diagnosis of ABS by angiography. Recurrences of ABS and mortality were recorded.
RESULTS: Over a mean follow-up of 4.4 +/- 4.6 years, 31 patients continued to have episodes of chest pain and 10 patients had recurrence of ABS, for a recurrence rate of 11.4% over the first 4 years. Seventeen patients died in 4.7 +/- 4.8 years of follow-up. There was no difference in survival or in cardiovascular survival to an age- and gender-matched population.
CONCLUSIONS: The recurrence rate for ABS was 11.4% over 4 years after initial presentation. Recurrence of chest pain is common. Four-year survival was not different from that in an age-matched and gender-matched population.

PMID 17662398  J Am Coll Cardiol. 2007 Jul 31;50(5):448-52. doi: 10.10・・・
著者: Kuljit Singh, Kristin Carson, Zafar Usmani, Gagandeep Sawhney, Ranjit Shah, John Horowitz
雑誌名: Int J Cardiol. 2014 Jul 1;174(3):696-701. doi: 10.1016/j.ijcard.2014.04.221. Epub 2014 Apr 26.
Abstract/Text AIM: Takotsubo cardiomyopathy (TTC) is a disorder of myocardial inflammation induced by high catecholamine levels and is associated with acute complications. In the long-term TTC is associated with a risk of single or multiple recurrences, but risk of such occurrences is not clear. We performed a systematic review and meta-analysis to identify and consolidate the evidence on the incidence and clinical correlates of cases of TTC recurrence.
METHODS: A comprehensive search of four major databases (EMBASE, OVID Medline, PubMed and Google Scholar) was performed from their inception to first week of Jan 2014. We included original research studies, recruiting ≥ 5 participants, with ≥ 3 months follow-up, published in English language that reported data on recurrence in patients with TTC.
RESULTS: Out of 298 studies searched, 31 cohorts (1664 TTC patients) were included in the analyses. Out of 74 cases of recurrence, with a mean follow-up of 24.5 months (95% CI, 19.3 to 33 months), extensive recurrence data were available for 23 cases. Cumulative incidence of recurrence was approximately 5% at 6 years. Annual rate of recurrence was approximately 1.5%. Furthermore, 14% of cases had recurrent chest pain and 11% reported dyspnea without definite evidence of recurrent TTC. Discharge medications at index admission included β-adrenoceptor antagonists (BB) in 66.8% and ACE inhibitors (ACEi) and ARB in 67.4%. Recurrence rate was independent of clinic utilization of BB prescription, but inversely correlated (r=-0.45, p=0.016) with ACEi/ARB prescription. Patients with severe TTC at index admission were noted to have more recurrences.
CONCLUSIONS: (1) TTC is associated with only 1-2% annual recurrence rate but substantially greater frequency of ongoing symptoms. (2) ACEi/ARB rather than BB may reduce risk of recurrence.

Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
PMID 24809923  Int J Cardiol. 2014 Jul 1;174(3):696-701. doi: 10.1016/・・・
著者: Manuel Almendro-Delia, Iván J Núñez-Gil, Manuel Lobo, Mireia Andrés, Oscar Vedia, Alessandro Sionis, Ana Martin-García, María Cruz Aguilera, Eduardo Pereyra, Irene Martín de Miguel, José A Linares Vicente, Miguel Corbí-Pascual, Xavier Bosch, Oscar Fabregat Andrés, Alejandro Sánchez Grande Flecha, Alberto Pérez-Castellanos, Javier López Pais, Manuel De Mora Martín, Juan María Escudier Villa, Roberto Martín Asenjo, Marta Guillen Marzo, Ferrán Rueda Sobella, Álvaro Aceña, José María García Acuña, Juan C García-Rubira, RETAKO Investigators
雑誌名: JACC Heart Fail. 2018 Nov;6(11):928-936. doi: 10.1016/j.jchf.2018.05.015. Epub 2018 Oct 10.
Abstract/Text OBJECTIVES: This study sought to describe the incidence, determinants, and prognostic impact of cardiogenic shock (CS) in takotsubo syndrome (TTS).
BACKGROUND: TTS can be associated with severe hemodynamic instability. The prognostic implication of CS has not been well characterized in large studies of TTS.
METHODS: We analyzed patients with a definitive TTS diagnosis (modified Mayo criteria) who were recruited for the National RETAKO (Registry on Takotsubo Syndrome) trial from 2003 to 2016. Cox and competing risk regression models were used to identify factors associated with mortality and recurrences.
RESULTS: A total of 711 patients were included, 81 (11.4%) of whom developed CS. Male sex, QTc interval prolongation, lower left ventricular ejection fraction at admission, physical triggers, and presence of "a significant" left intraventricular pressure gradient, were associated with CS (C index = 0.85). In-hospital complication rates, including mortality, were significantly higher in patients with CS. Over a median follow-up of 284 days (interquartile range: 94 to 929 days), CS was the strongest independent predictor of long-term, all-cause mortality (hazard ratio [HR]: 5.38; 95% confidence interval [CI]: 2.60 to 8.38); cardiovascular (CV) death (sub-HR: 4.29; 95% CI: 2.40 to 21.2), and non-CV death (sub-HR: 3.34; 95% CI: 1.70 to 6.53), whereas no significant difference in the recurrence rate was observed between groups (sub-HR: 0.76; 95% CI: 0.10 to 5.95). Among patients with CS, those who received beta-blockers at hospital discharge experienced lower 1-year mortality compared with those who did not receive a beta-blocker (HR: 0.52; 95% CI: 0.44 to 0.79; pinteraction = 0.043).
CONCLUSIONS: CS is not uncommon and is associated with worse short- and long-term prognosis in TTS. CS complicating TTS may constitute a marker of underlying disease severity and could identify a masked heart failure phenotype with increased vulnerability to catecholamine-mediated myocardial stunning.

Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
PMID 30316938  JACC Heart Fail. 2018 Nov;6(11):928-936. doi: 10.1016/j・・・
著者: Wataru Mitsuma, Makoto Kodama, Masahiro Ito, Komei Tanaka, Takao Yanagawa, Noboru Ikarashi, Kanako Sugiura, Shinpei Kimura, Nobue Yagihara, Takeshi Kashimura, Koichi Fuse, Satoru Hirono, Yuji Okura, Yoshifusa Aizawa
雑誌名: Am J Cardiol. 2007 Jul 1;100(1):106-9. doi: 10.1016/j.amjcard.2007.02.062. Epub 2007 May 15.
Abstract/Text This study aimed to clarify detailed and serial electrocardiographic findings in patients with Takotsubo cardiomyopathy from onset to recovery. Nine consecutive women aged 65 to 84 years (mean 74) with Takotsubo cardiomyopathy were investigated. Standard 12-lead electrocardiograms were recorded during hospitalization and ST-segment elevation and T-wave inversion were manually measured daily in each patient. All 9 patients had 4 phases found electrocardiographically. Phase 1 was characterized by ST-segment elevation immediately after onset. Subsequently, T-wave inversion was observed from days 1 to 3 (phase 2), then inverted T waves improved transiently from days 2 to 6 (phase 3). After this phase, giant inverted T waves with QT prolongation appeared and persisted > or =2 months until recovery (phase 4). Serum creatine kinase levels were increased only at onset. Left ventricular wall motion abnormalities evaluated using echocardiography improved gradually after phase 3 in all patients. Second T-wave inversions (phase 4) were significantly deeper than those of the first one (phase 2; p <0.05). In conclusion, 4 electrocardiographic phases in patients with Takotsubo cardiomyopathy were shown. This observation may be helpful to understand the pathophysiologic process of Takotsubo cardiomyopathy.

PMID 17599450  Am J Cardiol. 2007 Jul 1;100(1):106-9. doi: 10.1016/j.a・・・

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