Original Article
Clinical Characteristics and Outcome of Apical Ballooning Syndrome in Auckland, New Zealand

https://doi.org/10.1016/j.hlc.2011.11.010Get rights and content

Background

Apical ballooning syndrome (ABS) mimics myocardial infarction but is characterised by transient left ventricular (LV) dysfunction without significant coronary artery obstruction.

Methods

We prospectively identified 100 consecutive patients presenting in the Auckland region between March 2004 and July 2010 and obtained clinical, laboratory, electrocardiography, echocardiography, coronary angiography and long-term follow-up data.

Results

Chest pain or dyspnoea were the most common presenting symptom, 95% were women (mean age 65 ± 11 years). An associated stressor was identified in two-thirds of patients, troponin was elevated in all patients, and one-third had ECG ST-elevation. There was a similar range of initial LV ejection fraction (EF), myocardial damage, LV recovery and prognosis in those with and without ST-elevation, and with and without identifiable stressors. One-quarter had a complicated in-hospital course. Lower admission LVEF, but not peak troponin level or ECG ST-elevation, was associated with a complicated in-hospital course. The mean follow-up was 3.0 ± 1.7 years. One patient died in hospital. Four died late after discharge, all from non-cardiac causes. Seven had recurrent ABS.

Conclusion

In this large, prospective, New Zealand ABS cohort a quarter of patients had a complicated in-hospital course, but almost all recovered, recurrence was infrequent and long-term prognosis dependent on associated non-cardiac disease.

Introduction

Apical ballooning syndrome (ABS) (also known as Tako-tsubo cardiomyopathy or stress-induced transient left ventricular dysfunction) is an increasingly recognised subset of the broader group of acute coronary syndromes (ACS) characterised by acute but rapidly reversible left ventricular (LV) dysfunction in the absence of obstructive coronary disease. Prevalence of ABS is reported to be 1–2.5% in patients presenting with acute coronary syndrome (ACS) and 12% of women presenting with anterior ST-elevation myocardial infarction (STEMI) [1], [2]. The condition tends to occur in postmenopausal women after a stressful event. The aetiology of ABS is currently poorly understood and likely to be complex but the association with stress and catecholamine surge has lead many investigators to suspect that this is primarily a neurohormonal phenomenon mediated via coronary vasomotion or directly affecting the LV myocardium [3], [4]. Although initially described in Japan, it has subsequently been reported in many countries around the world [5], [6], [7], [8].

This study describes the clinical presentation and outcome of patients with ABS in a large New Zealand cohort. We also explored whether any characteristics at admission (e.g. the presence of a precipitating stressor or ST elevation) identified a heterogeneous subgroups of patients with a more complicated in-hospital course.

Section snippets

Method

The study population was prospectively identified from the three major public hospitals in the Auckland region (Middlemore Hospital, Auckland City Hospital and North Shore Hospital) between March 2004 and July 2010. The cohort comprised 100 consecutive patients who fulfilled the diagnostic criteria of ABS proposed by the Mayo Clinic group [9]: (1) transient hypokinesis, akinesis, or dyskinesis in the left ventricular mid segments with or without apical involvement; regional wall motion

Results

One hundred consecutive patients with ABS (95 females, 5 males) were included in the study. The clinical characteristics of all patients are presented in Table 1. The mean age at presentation was 65 ± 11 years (median 66) and 95% were women. Seventy-five patients were European. Thirty-five patients had hypertension and 17 patients were on β-blockers before admission.

Discussion

To our knowledge, this cohort is the largest series of ABS patients published to date in Australasia and one of the largest internationally. Ninety-five percent of the cohort were women over 60 years of age, similar to that reported for Japanese [5], [11], [12], North American [13], [14], [15], [16], and European cohorts [17]. The distribution of patients by ethnicity was representative of the Auckland population without a predominance of a particular ethnic group.

Presentation was preceded by a

Conclusion

This prospective study represents the largest ABS cohort published to date in Australasia and also one of the largest internationally. Our clinical and echocardiographic findings support previously published series. Recurrence is infrequent and the long-term prognosis is good. Although the pathogenesis remains unclear, the similar age and gender distribution range of myocardial damage, LV recovery and prognosis, in those with and without ST elevation at admission, and with and without

Competing Interests

None.

References (24)

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