Emotional, neurohormonal and hemodynamic responses to mental stress in Tako-Tsubo cardiomyopathy

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.

Tako-Tsubo cardiomyopathy (TTC) is characterized by apical ballooning of the left ventricle (LV) and symptoms and signs mimicking acute myocardial infarction.1, 2 and 3 Emotional triggers are common in TTC,4 and the high catecholamine levels on admission1 suggest a dysregulated stress response system. This study examined emotional, neurohormonal, and hemodynamic responses to acute mental stress, comparing patients with TTC to healthy controls and cardiac patients with heart failure (HF). We investigated whether emotional, neurohormonal (catecholamines and hypothalamic-pituitary-adrenal [HPA]-related measures adrenocorticotropic hormone [ACTH] and cortisol), and hemodynamic (LV function, blood pressure, and heart rate [HR]) responses to a structured mental stress task are exaggerated in patients with a history of TTC compared with healthy controls and patient controls with stable HF. We also examined potential response patterns to low-grade exercise challenge for comparison purposes.