Takotsubo syndrome (TTS) is an acute, profound but reversible heart failure syndrome, usually but not always triggered by physical or emotional stress. Although practically indistinguishable from an acute coronary syndrome upon clinical presentation, some characteristics of TTS, such as the involvement of a myocardial area that extends beyond a single coronary vessel territory, the complete recovery of ventricular function in days or weeks, and the absence of significant epicardial coronary artery disease, appear to make TTS a unique form of acute heart failure syndrome (1). To date, the exact pathogenic mechanism of this syndrome remains unclear, however several hypotheses including vascular, endocrine and gender related mechanisms as well as autonomic and central nervous system abnormalities involving catecholamine surges have been proposed, thus suggesting a multifactorial pathogenic background (2).

Cardiac magnetic resonance (CMR) is a first-line clinical modality for the assessment of TTS. In addition to comprehensive assessment of the myocardial functional and anatomical properties, including potential acute complications of the syndrome, CMR is uniquely suited to differentiating TTS from other forms of acute ventricular dysfunction associated with patent coronary arteries. In this setting CMR may have a major impact on both clinical management and risk stratification. The combination of the hallmark regional wall motion abnormalities with matching reversible myocardial oedema and no or subtle delayed enhancement may serve as a very useful set of diagnostic criteria in cases with myocardial infarction with non-obstructive coronary artery disease (MINOCA) (3), helping in particular in distinguishing TTS from embolism and myocarditis.

Although TTS is widely considered as a benign, reversible condition, its associated risk for major cardiac events in the acute and chronic phase is increasingly recognized (4). In fact, TTS represents an acute heart failure syndrome with substantial morbidity and mortality, comparable to patients with acute coronary syndromes (5). Defining the exact nature of the disease, and in particular whether myocardial tissue abnormalities in TTS represent a causative factor or a consequence of this disorder remains elusive and will largely determine the management of these patients. The implementation of CMR in the study of the disease is expected to offer further insight from an imaging perspective to the pathophysiological substrate of the disease. Further large-scale studies are required to elucidate the clinical and prognostic value of the CMR parameters, including the value of late gadolinium enhancement, an established marker of poorer prognosis in other ischemic and non- ischemic cardiomyopathies.

References

1. Lyon AR, Bossone E, Schneider B et al. Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology. European journal of heart failure 2016;18:8-27.
2. Pelliccia F, Kaski JC, Crea F, Camici PG. Pathophysiology of Takotsubo Syndrome. Circulation 2017;135:2426-2441.
3. Syed IS, Prasad A, Oh JK et al. Apical ballooning syndrome or aborted acute myocardial infarction? Insights from cardiovascular magnetic resonance imaging. The international journal of cardiovascular imaging 2008;24:875-82.
4. Ghadri JR, Cammann VL, Jurisic S et al. A novel clinical score (InterTAK Diagnostic Score) to differentiate takotsubo syndrome from acute coronary syndrome: results from the International Takotsubo Registry. European journal of heart failure 2016.
5. Templin C, Ghadri JR, Diekmann J et al. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. The New England journal of medicine 2015;373:929-38.