Takotsubo cardiomyopathy (TCM) is a transient wall motion abnormality of the left ventricular apex associated with emotional or physical stress. In the setting of diabetic ketoacidosis (DKA), it is thought to be caused by the compound effect of a catecholamine surge and the noxious effect of acidosis and ketones leading to myocardial stunning. In this report, the first of its kind in the Middle East, we describe the case of a 71-year-old comatose patient, who was being treated for DKA and hypernatremia and was incidentally diagnosed with TCM. We also review 15 case reports of DKA-induced TCM published to date in the literature, many of which had an atypical presentation and good outcomes. Furthermore, we discuss possible risk factors for TCM in our case and supporting literature. It is recommended to maintain increased vigilance and attempt early identification of such conditions in acutely ill patients to prevent life-threatening complications.

Diabetic ketoacidosis (DKA) is one of the hyperglycemic emergencies seen in patients with poorly controlled diabetes mellitus. One of the potential cardiovascular complications of this hyperglycemic crisis, not that well documented in the literature, is takotsubo cardiomyopathy (TCM) also known as stress-induced cardiomyopathy or \"broken heart syndrome\". It is a reversible condition where the heart muscle becomes suddenly weakened and stunned, which is mostly known to develop in patients who have suffered a stressful life event or are undergoing an acute illness. We present an interesting case of a 45-year-old female with a history of poorly controlled diabetes mellitus who presented with significant hyperglycemia and laboratory results concerning DKA. The patient was also complaining of new-onset chest pain on arrival. Further workup revealed elevated troponin, severely reduced ejection fraction, and echocardiographic findings concerning TCM.  The coexistence of DKA and TCM is rare but clinically significant. This case emphasizes the value of clinical vigilance in patients with this hyperglycemic crisis and encourages us to always consider stress-induced cardiomyopathy as a potential complication. Further research is needed to better elucidate the exact mechanisms linking DKA and stress-induced cardiomyopathy. This will help improve outcomes and prevent recurrence in this vulnerable patient population.

UNASSIGNED: The role of acute mechanical circulatory support (aMCS) in patients with stress-induced cardiomyopathy (SIC) complicated by cardiogenic shock (CS) is not well studied. Here, we describe the incidence and outcomes of aMCS use in SIC-CS using a large national database.
UNASSIGNED: Using the Nationwide Readmissions Database from January 2016 to November 2019, we identified patients hospitalized with SIC who received isolated intra-aortic balloon pump (IABP), microaxial flow pump (Impella, Abiomed), or extracorporeal membrane oxygenation (ECMO) during the index hospitalization.
UNASSIGNED: A total of 902 among 94,709 hospitalizations for SIC (1.0%) required aMCS during the index hospitalization: 611 had IABP (67.7%), 189 had Impella (21.0%) and 102 had ECMO (11.3%). Patients with ECMO or Impella had higher in-hospital mortality rates than those with IABP (37.3% vs 29.1% vs 18.5%, respectively). There was an increased adjusted risk of in-hospital death with Impella (adjusted odds ratio [aOR], 1.98; 95% CI, 1.12-3.49) and ECMO (aOR, 4.15; 95% CI, 1.85-9.32) vs IABP. Impella was associated with an increased adjusted risk of 30-day readmission compared to IABP (aOR, 2.53; 95% CI, 1.16-5.51). Patients with ECMO or Impella had a higher incidence of renal replacement therapy and vascular/bleeding complications compared to those who received IABP.
UNASSIGNED: In this nationwide analysis using an administrative database, patients who received ECMO and Impella showed higher rates of in-hospital mortality, renal replacement therapy, and vascular/bleeding complications compared to those who received IABP. Patients with more comorbidities may receive more aggressive hemodynamic support which may account for observed mortality differences. Future prospective studies with objective and universal characterization of baseline clinical and hemodynamic characteristics of patients with CS secondary to SIC are needed.

An acute, transient episode of left ventricular dysfunction characterizes Takotsubo syndrome. It represents about 2% of all cases of acute coronary syndrome (ACS), and occurs predominantly in postmenopausal women, generally following a significant physical or emotional stressor. It can be diagnosed based on clinical symptoms and the absence of coronary artery disease on angiography. Ventriculography remains the gold standard for the diagnosis. Despite its transitory characteristic Takotsubo syndrome should not be considered a benign condition since complications occur in almost half of the patients, and the mortality rate reaches 4-5%. Lately, it has been revealed that Takotsubo syndrome can also lead to permanent myocardial damage due to the massive release of catecholamines that leads to myocardial dysfunction. Different mechanisms have been advanced to explain this fascinating syndrome, such as plaque rupture and thrombosis, coronary spasm, microcirculatory dysfunction, catecholamine toxicity, and activation of myocardial survival pathways. Here are still several issues with Takotsubo syndrome that need to be investigated: the complex relationship between the heart and the brain, the risk of permanent myocardial damage, and the impairment of cardiomyocyte. Our review aims to elucidate the pathophysiology and the mechanisms underlying this complex disease to manage the diagnostic and therapeutic algorithms to create a functional synergy between physicians and patients.

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Takotsubo syndrome (TTS) is a clinical condition characterized by temporary regional wall motion anomalies and dysfunction that extend beyond a single epicardial vascular distribution. Various pathophysiological mechanisms, including inflammation, microvascular dysfunction, direct catecholamine toxicity, metabolic changes, sympathetic overdrive-mediated multi-vessel epicardial spasms, and transitory ischemia may cause the observed reversible myocardial stunning. Despite the fact that TTS usually has an acute coronary syndrome-like pattern of presentation, the absence of culprit atherosclerotic coronary artery disease is often reported at coronary angiography. However, the idea that coronary artery disease (CAD) and TTS conditions are mutually exclusive has been cast into doubt by numerous recent studies suggesting that CAD may coexist in many TTS patients, with significant clinical and prognostic repercussions. Whether the relationship between CAD and TTS is a mere coincidence or a bidirectional cause-and-effect is still up for debate, and misdiagnosis of the two disorders could lead to improper patient treatment with unfavourable outcomes. Therefore, this review seeks to provide a profound understanding of the relationship between CAD and TTS by analyzing potential common underlying pathways, addressing challenges in differential diagnosis, and discussing medical and procedural techniques to treat these conditions appropriately.

Chronic starvation and its associated metabolic derangements are known to have dangerous cardiovascular implications in the long term, but less is known about the cardiovascular consequences of acute starvation, such as in the context of a hunger strike. This case describes a patient who presented with signs and symptoms of acute coronary syndrome which began two weeks into a hunger strike and was ultimately found to have stress cardiomyopathy with complete resolution on subsequent imaging.

Takotsubo cardiomyopathy (TCM) is a form of non-ischemic cardiomyopathy that can present with signs of heart failure and volume overload; it often mimics acute coronary syndrome. It is characterized by stress-induced transient left ventricular (LV) dysfunction. Echocardiography classically demonstrates LV apical ballooning and akinesis in typical TCM, although other less common variants exist. Patients typically present with one variant. A 32-year-old woman with a past medical history of alcohol use disorder, anxiety, and hypertension presented to the hospital with chest pain, shortness of breath, nausea, vomiting, and diarrhea. She was diagnosed with cardiogenic shock in the setting of a newly identified LV ejection fraction (EF) of 24% on echocardiogram with findings consistent with typical apical TCM. Ischemic workup was unremarkable, and she was medically managed with clinical improvement and subsequent recovery of cardiac function. Four months later, the patient presented with similar symptoms at which time she was found to have a recurrence of heart failure with reduced LV EF; echocardiography showed reverse TCM. Patients with TCM who develop a recurrence typically maintain the same variant. The recurrence of TCM in a single patient with different anatomical variants is rare and poorly understood. We presented a case of a patient with alcohol use disorder who developed a recurrence of TCM with two anatomical variants. Further studies are necessary to investigate the predictors of recurrence and better understand the underlying mechanisms behind the different variants.

Stress-induced cardiomyopathy, commonly known as Takotsubo cardiomyopathy (TCM), is a clinical syndrome characterized by acute and transient ventricular systolic dysfunction that often presents with chest pain and may resemble an acute coronary syndrome. This case report discusses a complex clinical scenario involving an adult female with severe depression who attempted suicide through drug overdose, subsequently developing serotonin syndrome. Her clinical presentation was further complicated by the emergence of a unique lambda-shaped triangular QRS-ST-T waveform fusion ST-elevation electrocardiographic (ECG) pattern closely mimicking an anterolateral occlusive myocardial infarction. The study delves into the clinical implications of this unique ECG pattern in TCM, providing valuable insights into diagnosing and treating such complex cases. This case underscores the importance of recognizing diverse manifestations of TCM and its potential for severe cardiovascular complications.

UNASSIGNED: Liver transplantation (LT) is a strenuous event for the cardiovascular system. Cardiovascular events (CVE), including heart failure (HF), arrhythmias and myocardial ischemia, are important causes of peri- and post-liver transplantation morbidity and mortality.
UNASSIGNED: We describe the case of a 45-year-old male patient who developed heart failure with severely reduced ejection fraction (HFrEF) after receiving liver transplantation (LT) for end-stage post-alcoholic liver cirrhosis. Preoperative transthoracic echocardiography (TTE) demonstrated borderline left ventricular ejection fraction (LVEF) of 50% and diastolic dysfunction grade 2. On coronary angiography, the patient had no coronary stenoses. Persistent vasopressor need, increasing creatinine levels and progressive pleural effusion characterized the early postoperative period. TTE on postoperative day 6 revealed a new finding of a markedly reduced LVEF of 15%, accompanied by a discrete increase in hs-TnI and CK-MB without electrocardiographic (ECG) ST-T abnormalities. LVEF did not recover completely (EF 45%) during follow-up. The patient had a sudden death 4.5 months post-liver transplantation.
UNASSIGNED: Our case demonstrates that the risk of post-LT systolic dysfunction is not excluded by preoperative resting examinations within normal range and highlights the need for preoperative cardiac stress assessment (e.g. dobutamine echocardiography or stress cardiac magnetic resonance imaging) before LT. In addition, patients on a liver-transplant waiting list with cardiac dysfunction should be followed by a multidisciplinary team including a dedicated cardiology team experienced in managing liver-related cardiac pathology.