Takotsubo cardiomyopathy and arrhythmic risk: the dark side of the moon

BACKGROUND: "Takotsubo" car- diomyopathy (TTC) is a clinical disorder usually triggered by intense emotional and/or physical stress, characterized by reversible severe local- ized left ventricular wall dyskinesia, transient changes of ST segment, without significant coro- nary artery stenoses, that can mimic acute my- ocardial infarction. STATE OF THE ART: Although TTC is well known to have a good mid- and long-term prog- nosis, arrhythmic risk is increasingly recognized and we could provide, in view of the available lit- erature, a mean for a prognostic stratification and some practical suggestions for management of these "vulnerable" patients. PERSPECTIVES: Further studies with random- ized trials will be needed to prove the optimal treatment of TTC CONCLUSIONS: TTC, generally considered a benign syndrome, should be reconsidered as a clinical condition at high risk for lethal arrhyth- mias in a subpopulation with QTc > 500 msec in acute phase. The studies about arrhythmias and TTC are based on case reports. TTC may pre- sent with sudden cardiac death: this results in a probable underestimate of the real arrhythmic risk. TTC is one of the causes of acquired long QT syndrome and could be a trigger able to un- mask latent silent or inapparent congenital long QT syndrome. All factors that can exacerbate QT prolongation should be promptly removed. In the case of marked bradycardia and/or TdP should be implant a temporary pacemaker. In most cas- es, due to the transient nature of the syndrome, it is reasonable to recommend only beta-blocker therapy at discharge, despite the absence of ran- domized trials. If there are high-risk factor for long QT syndrome (QTc post-TCM > 500 ms, pri- or syncope, previous cardiac arrests) thought should be given an indication to ICD implant.