Cardiomyopathy
Emotional, Neurohormonal, and Hemodynamic Responses to Mental Stress in Tako-Tsubo Cardiomyopathy

https://doi.org/10.1016/j.amjcard.2015.02.064Get rights and content

Tako-Tsubo cardiomyopathy (TTC) is characterized by apical ballooning of the left ventricle and symptoms and signs mimicking acute myocardial infarction. The high catecholamine levels in the acute phase of TTC and common emotional triggers suggest a dysregulated stress response system. This study examined whether patients with TTC show exaggerated emotional, neurohormonal, and hemodynamic responses to mental stress. Patients with TTC (n = 18; mean age 68.3 ± 11.7, 78% women) and 2 comparison groups (healthy controls, n = 19; mean age 60.0 ± 7.6, 68% women; chronic heart failure, n = 19; mean age 68.8 ± 10.1, 68% women) performed a structured mental stress task (anger recall and mental arithmetic) and low-grade exercise with repeated assessments of negative emotions, neurohormones (catecholamines: norepinephrine, epinephrine, dopamine, hypothalamic-pituitary-adrenal axis hormones: adrenocorticotropic hormone [ACTH], cortisol), echocardiography, blood pressure, and heart rate. TTC was associated with higher norepinephrine (520.7 ± 125.5 vs 407.9 ± 155.3 pg/ml, p = 0.021) and dopamine (16.2 ± 10.3 vs 10.3 ± 3.9 pg/ml, p = 0.027) levels during mental stress and relatively low emotional arousal (p <0.05) compared with healthy controls. During exercise, norepinephrine (511.3 ± 167.1 vs 394.4 ± 124.3 pg/ml, p = 0.037) and dopamine (17.3 ± 10.0 vs 10.8 ± 4.1 pg/ml, p = 0.017) levels were also significantly higher in patients with TTC compared with healthy controls. In conclusion, catecholamine levels during mental stress and exercise were elevated in TTC compared with healthy controls. No evidence was found for a dysregulated hypothalamic-pituitary-adrenal axis or hemodynamic responses. Patients with TTC showed blunted emotional arousal to mental stress. This study suggests that catecholamine hyper-reactivity and not emotional hyper-reactivity to stress is likely to play a role in myocardial vulnerability in TTC.

Section snippets

Methods

From January 2012 to April 2014, 56 patients (18 patients with TTC, 19 healthy controls, and 19 HF control patients) participated in the study. Patients with TTC were identified from the echocardiography patient database belonging to the Elisabeth Tweesteden Hospital, Tilburg, The Netherlands. Patients who were admitted with a diagnosis of TTC in the preceding 5 years were approached by a cardiologist for participation in the study. The diagnosis of TTC was based on the Mayo Clinic diagnostic

Results

Characteristics of the study sample are listed in Table 1. Patients with TTC were on average older compared with the healthy control group and, thus, less likely to be used. Age and gender were adjusted for multivariable analyses. As listed in Table 1, patients with TTC were also more likely to have hypertension and use β-adrenergic blocking agents, ACE inhibitors, antiplatelet medication, and lipid-lowering medication. Patients with TTC did not differ from patients with HF on any of the

Discussion

Patients with TTC showed higher norepinephrine and dopamine levels during mental stress and exercise compared with healthy controls, suggesting sympathetic neurohormonal hyper-reactivity. Responses of the HPA axis and hemodynamic reactivity were not elevated in TTC. The emotional responses to mental stress were not exaggerated in TTC, and the results even showed a blunted arousal response compared with healthy controls. These findings provide preliminary evidence of hyper-reactivity of the

Acknowledgment

Dounya Schoormans, PhD is acknowledged for assistance with the cortisol assays.

References (26)

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