What is already known about this subject?
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Little is known about the underlying pathological mechanisms in patients with Takotsubo Syndrome (TTS). There are some recent studies demonstrating that there are specific alterations in neurological response and sympathetic activation after emotional stimuli in TTS patients suggesting the importance of the brain-heart interaction.
What does this study add?
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Decreased resilience scores were found in about 40% of TTS patients in the acute phase of this syndrome.
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This might reflect a decreased ability to cope with this event and may lead to the reminiscence of the TTS as a threatening adverse life event, which can additionally be seen in moderate to high levels of illness threatening in these patients.
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Moderate to low resilience scores in TTS patients are on the one hand additional trigger factors for the development of the TTS and on the other hand potential prognostic factors for the recovery from this syndrome.
How might this impact on clinical practice?
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As TTS seems to be accompanied by an activation of the sympathetic nervous system, decreased coping strategies in the acute phase of the syndrome might help to explain the pathomechanism of this syndrome. This may lead to improved therapeutic interventions, especially in the field of psychocardiology.
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Based on these findings, a multidisciplinary assessment of TTS patients with structured interviews by qualified psychologists addressing the involvement of emotional events in TTS patients with more accuracy has been initiated and is still ongoing.
Background
Methods
Design
Study sample
Clinical assessment
Psychosomatic assessment
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Brief Illness Perception Questionnaire (B-IPQ) to detect emotional and cognitive representations of illness or health threat [23]. For further interpretation the score of the B‑IPQ was divided into three groups: low level of threatening illness perception (scores from 0–27), moderate level of threatening illness perception (scores from 28–55) and high level of illness perception (scores > 55).
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PHQ‑9 depression scale from the Patient Health Questionnaire (PHQ) for detection of depressive disorders [24] designed to diagnose and grade depression disorders. The questionnaire focuses on the nine diagnostic DSM-IV criteria for depression disorders. All items score between 0 (not at all) and 3 (every day). As a measure for severity of depression the score ranges between 0 and 27. It has been shown to have reasonable sensitivity and specificity for patients with coronary artery disease [25, 26].
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PHQ-15 somatic symptom scale from PHQ for the analysis of somatic disorders [27]
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Panic module, anxiety module and the stress module from PHQ‑D for detection of panic or anxiety disorders [28]
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Brief resilience scale (RS-13) to detect the patients’ ability to cope with the experienced stress [29].
Inclusion criteria
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Transient WMA of the left ventricular segments extending beyond a single epicardial vascular distribution.
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New electrocardiographic changes (ST/T changes) and/or typical symptoms indicative for myocardial ischemia and/or release of specific myocardial necrosis marker.
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Absence of obstructive coronary disease.
Exclusion criteria
Patient involvement
Statistical analysis
Results
Clinical results and patient characteristics
Clinical assessment | |
Age (years) | 68.0 ± 11.4 (42–85) |
Cardiovascular risk factor | 85.2% |
AHT | 63.0% |
Hyperlipidemia | 63.0% |
Diabetes mellitus II | 25.9% |
Active smoker | 14.8% |
History of smoking | 14.8% |
Family history of CAD | 14.8% |
Symptoms | |
AP | 77.8% |
Dyspnea | 55.6% |
Nausea/vomiting | 14.8% |
ECG changes on admission | |
ST-segment elevation | 44.4% |
T wave inversion | 25.9% |
Pathological Q waves | 11.1% |
ST-segment depression | 7.4% |
Cardiovascular complications | 33.3% |
Type of TTS | |
Apical | 59.3% |
Combined | 29.6% |
Midventricular | 7.4% |
Basal | 3.7% |
Right ventricular involvement | 18.5% |
Regional wall motion abnormalities and echocardiographic assessment
Psychosomatic assessment
Psychosomatic assessment | |
B IPQ | 39.3 ± 10.8 (19–61) |
Consequences | 5.8 ± 2.7 (1–10) |
Timeline | 5.4 ± 3.5 (1–10) |
Personal control | 5.5 ± 2.4 (2–9) |
Treatment control | 6.4 ± 2.7 (1–9) |
Identity | 4.7 ± 2.6 (1–10) |
Concern | 5.6 ± 2.9 (1–10) |
Understanding | 6.3 ± 2.9 (2–10) |
Emotional response | 5.3 ± 3.1 (1–10) |
Support from surrounding | 67.8% ± 30.6 (5–10%) |
Impact of emotional stress | 58.8% ± 31 (5–100%) |
Level of illness threat | |
Moderate to high | 48.1% |
Low | 7.4% |
Educational level | |
Low | 51.9% |
High | 14.8% |
Resilience | 69.0 ± 16.6 (23–89) |
Resilience level | |
High | 37.0% |
Low to moderate | 40.7% |