2024, Number 4
Takotsubo syndrome in a cruise ship port, a single center experience
Full text
10.35366/118791
Language: English
References: 7
Page: 145-150
PDF size: 399.86 Kb.
ABSTRACT
Introduction: Takotsubo syndrome is an infrequent problem characterized by transitory apical dilatation and ballooning of the left ventricle, frequently resulting from mental or physical stress; it mimics other acute cardiac problems. There are few publications about these conditions in vacation centers, especially on cruise ships. Results: the paper describes 15 patients from a vacation center with high cruise ship volume, from 2014 through 2023, nine of them on Killip-Kimbal class 3-4; the average ejection fraction of all patients was 36%. All the patients had negative coronary angiography or non-significant stenosis, and all of them had complete recovery before leaving the hospital, on Killip-Kimball class 1 and 58% average left ventricle ejection fraction. Discussion and conclusion: the present TS single-center experience at a top vacation cruise line center offers significant insight into travelers' triggers, demographic characteristics, and illness management. Post-menopause, women are especially vulnerable to the syndrome. TS usually shows ST-segment but is distinguished from acute coronary syndromes by the early return of ventricular function, conditions observed in our patients. Echocardiography, coronary angiography, and electrocardiography are vital for distinguishing myocardial infarction from TS. Supportive therapy and identifying and correcting triggering variables are part of the management; this care may include intravenous and device-based ventricular support.INTRODUCTION
Takotsubo syndrome (TS) consists of sudden functional deterioration and deformity of the left ventricle, typically with apical segment dyskinesis and ballooning, with the preservation of the basal segment's mobility. It frequently results after a mental or physical stressing condition, especially in women, under complex pathophysiological aspects such as paradoxical adrenergic-load triggered myocardial microvascular dysfunction, stress-triggered altered neuronal activity, metabolic derangements, and epigenetics.1,2
This kind of cardiomyopathy mimics other acute cardiac problems, especially myocardial infarction, and myocarditis, with all the possible heart failure spectrum up to cardiogenic shock, cardiac arrest, and death, being sometimes unrecognized and making particular diagnostic challenges, with its final clinical diagnostic feature, the complete or almost complete quick left ventricle function and shape recovery.
The mental stress triggering TS might result from a sad personal catastrophe, extreme joy, physical trauma, or general disease; nonetheless, sometimes, there is a lack of stress. The present paper discloses our experience of TS in patients who attended a hospital located in a port that receives cruise-ship travelers. Up to these cases, there is only one published case of a woman suffering from TS on a cruise ship.3
TS, which primarily affects postmenopausal women, represents 1-2% of all suspected cases of acute coronary syndrome. While most patients with TS recover fully, complications can occasionally result in significant morbidity and mortality.4
MATERIAL AND METHODS
Our private hospital attends to the local population, destination tourists, and cruise ship travelers. The current paper is a case report resulting from the retrospective review of our patients considered with a diagnosis of TS, based on the occurrence of sudden myocardial infarction symptoms and heart failure, with echocardiography-tailored transitory segmental akinesia with angiography-confirmed lack of significant coronary stenosis and documented clinical and echocardiography recovery before discharge. Our experience includes a small case number from a low-volume heart service, with results expressed as case presentations with an average of the numerical variables.
RESULTS
We gathered data from 12 women and two men –one of them is a ship crew member– with TS between 2014 and 2023. Their average age was 61.8 years, with an average hospital stay of 4.9 days and an average body mass index of 29.5. Ten patients were from cruise ships, three were tourists, and one was a local patient. Nine patients were on Killip-Kimbal class 3-4 and five class 1-2, with an average class of 2.7.
The average ejection fraction at admission was 36%; seven patients started with chest pain, 12 had dyspnea, three had delirium, three patients needed mechanical invasive ventilation, while four on cardiogenic shock received intravenous amines, none of them had mechanical cardiac support. Only three patients had initial ST elevation, two had left bundle branch block, 12 had troponin I, and 12 had proBNP elevation. We found three patients with mental stress before the event, and eight had physical trauma: three during snorkeling, one on scuba diving, one during beach gaming, one after intense diarrhea, one after severe bladder retention, and one during abdominal sepsis. Four patients had a history of depression, one of them after melanoma.
All the patients had coronary angiography, eleven catheter-based and three by computed tomography; 12 had coronaries without significant and two with borderline stenosis; nine catheterized patients had TIMI-3 and two TIMI-2 flow. All the patients left the hospital (four by air-ambulance transfer, ten to home) on Killip-Kimbal class 1; the discharge ejection-fraction average was 58.4%.
Table 1 shows the patients' origin and demographics. Table 2 shows the basal patient's characteristics, and Table 3 displays the diagnostic angiography and outcomes; Figure 1 displays the Killip-Kimbal class progress and Figure 2 the ejection fraction; Figure 3 shows an example of the echocardiographic in one of our patients, showing the characteristic apical ballooning on dotted lines and the typical basal contractility shown by the arrows.
DISCUSSION
The present TS single-center experience at a top vacation cruise line center offers significant insight into travelers' triggers, demographic characteristics, and illness management. Any major changes in circumstances that are stressful for the person might also serve as triggers for the beginning of TS; significant atmosphere changes caused by lengthy overseas travels, together with physical and psychological history, may significantly contribute to TS.5
Post-menopause, women are especially vulnerable to the syndrome due to hormonal fluctuations that intensify stress responses and endothelial impairment, possibly after the expected estrogen levels decline with consequent morbid changes in autonomic regulation and endothelial function, impairing the cardiovascular stress response.6
Myocardial stunning, microvascular dysfunction, and catecholamine surges are all implicated in the pathophysiology of TS, possibly for dysregulation of the hypothalamic-pituitary-adrenal axis, which leads to increased sympathetic response and, in turn, left ventricular dysfunction.7
TS usually shows ST-segment elevation, dyspnea, and chest discomfort that resembles myocardial infarction, as well as presenting with any degree of heart failure, including cardiogenic shock, but distinguished from acute coronary syndromes by the early return of ventricular function, conditions observed in our patients.
Echocardiography, coronary angiography, and electrocardiography are vital for distinguishing myocardial infarction from TS. Supportive therapy and identifying and correcting triggering variables are part of the management; this care may include intravenous and device-based ventricular support.
Even though the majority of patients restore their ventricular function on their own in a matter of days to weeks, persistent psychological stress could increase the chance of recurrence worth preventive strategies for TS recurrence, including neurohormonal therapies that target the sympathetic nervous system. In our patient list, we do not describe another three patients who came for cardiological assessment due to TS preexistence.
CONCLUSIONS
In conclusion, this single-center experience underscores the need for heightened vigilance in diagnosing and managing TS, particularly in high-stress settings like sea travel, warranting further research to explore the long-term outcomes of TS and the efficacy of stress management interventions in preventing recurrence.
REFERENCES
AFFILIATIONS
1 The Clinics of the Heart, Cozumel, Quintana Roo México.
2 COSTAMED. Quintana Roo, Mexico.
3 Universidad Anáhuac Cancun. Cancun, Quintana Roo, Mexico.
4 Zulekha Hospital Dubai. Dubai, United Arab Emirates.
Declaration of confidentiality and patients consent: the authors confirm that they have complied with the relevant workplace protocols for the use of patient data. Additionally, the authors attest that no form of generative artificial intelligence was employed in the preparation of this manuscript or in the creation of figures, graphs, tables, or their corresponding captions or legends.
Clinical trial registration and approval number: this is a retrospective observational experience, not a clinical trial.
Funding: no funding.
Declaration of interests: the authors declare no conflict of interest.
Acknowledgement: the authors want to thank the staff of COSTAMED and The Clinics of the Heart, the Universidad Anahuac social service program, and the mentor/mentee program of the Society for Cardiovascular Angiography and Interventions (SCAI).
CORRESPONDENCE
Rafael Moguel Ancheita. E-mail: cathboss@gmail.comReceived: 10/15/2024. Accepted: 11/28/2024