the stress - induced cardiomyopathy ( scm ) is characterized by acute , reversible , and transient left ventricular ( lv ) systolic dysfunction mimicking acute coronary syndrome without significant stenosis on coronary angiogram.1)2 ) this syndrome was first described by satoh et al.3 ) and was named takotsubo - cardiomyopathy because its shape resembles the tako - tsubo ( japanese octopus trap).4 ) the majority of patients are postmenopausal women who present with acute emotional or physical stress.1)2 ) clinical features are acute onset chest pain or dyspnea , electrocardiographic st changes with t - wave inversion , elevated cardiac biomarkers , elevated b - type natruretic peptide ( bnp ) , apical or midventricular wall motion abnormality by echocardiography and favorable prognosis.1 ) the underlying etiology is unclear .
there are limited data for clinical manifestations and prognostic factors of scm in korea.5)6 ) therefore , we sought to clarify the clinical features and prognosis in scm .
we retrospectively reviewed and analyzed 39 patients diagnosed with scm from may , 2004 , to january , 2009 , in wonju christian hospital .
scm was diagnosed as : 1 ) no previous history of cardiac disease , 2 ) acute onset , 3 ) a regional wall motion abnormality , typically in the takotsubo or inverted takotsubo shape by echocardiography , and 4 ) no significant stenosis in the coronary angiogram .
we investigated baseline clinical characteristics , laboratory data , hospital course , complications , and clinical outcomes .
we defined st - elevation as deviation > 1 mm higher than the baseline in 2 contiguous leads .
we defined t - wave inversion as a change from the previous electrocardiogram ( ekg ) in 2 contiguous leads .
echocardiography was performed at admission and rechecked at discharge or improved symptoms . coronary angiography and left ventriculography were performed to evaluate coronary artery disease or lv systolic function .
shock was defined as systolic blood pressure < 90 mm hg with signs of end - organ hypoperfusion requiring the use of vasopressor agents .
cardiac biomarkers { creatinine kinase mb ( ck - mb ) fraction and troponin - i } , high sensitive c - reactive protein ( hs - crp ) , and bnp were collected at admission and cardiac biomarkers were rechecked until normalization .
after discharge , all patients were followed in an out - patient clinic to reevaluate symptoms , lv systolic function , and adverse events .
continuous data were summarized as meansd and were compared by student 's t - test .
multivariate logistic regression analysis was performed to determine the independent variables associated with the occurrence of adverse events .
past medical history was 10 ( 26% ) of hypertension , 3 ( 8% ) of diabetes mellitus , 5 ( 13% ) of chronic obstructive pulmonary disease , and 5 ( 13% ) current smokers .
the initial symptom were dyspnea ( n=18 , 46% ) , chest pain ( n=10 , 26% ) , mental change ( n=8 , 21% ) , collapse ( n=1 , 3% ) , fever ( n=1 , 3% ) and seizure ( n=1 , 3% ) .
the triggering factors of scm were medical illness ( n=23 , 59% ) , emotional stress ( n=6 , 15% ) , procedure - related ( n=3 , 8% ) , trauma ( n=3 , 8% ) , and food or drugs ( n=2 , 5% ) ( table 2 ) .
initial ekg presented t - wave inversion ( n=18 , 46% ) , st - elevation ( n=11 , 28% ) , st - depression ( n=2 , 5% ) , or non - specific findings ( n=6 , 15% ) .
we observed an increasing trend of scm in spring and winter but there was no statistical significance . the peak ck - mb fraction and troponin
i were 15.620.9 ng / ml ( reference range : < 5.0 ng / ml ) and 6.812.3 ng / ml ( reference range : < 0.78 ng / ml ) , respectively .
the bnp at admission was 745.4905.6 pg / ml ( reference range : < 100 pg / ml ) .
l ( reference range : < 5 mg / l ) and 23 patients ( 59% ) had elevated hs - crp at admission . in echocardiography , the mean lv ejection fraction ( ef ) was 4516% at admission and 6113% at discharge .
there were 3 cases of inverted takotsubo shape , 4 cases of transient lv outflow tract obstruction due to a hyperkinetic basal segment of lv , and 1 case of apical thrombus on the site of apical ballooning ( fig .
1 ) . the patient who developed apical lv thrombus had a distal embolization in the right common iliac artery , right external iliac artery , and left femoral artery .
she had anticoagulation therapy with warfarin and was discharged after 15 days without significant complications .
three patients ( 8% ) died due to pneumonia and 13 patients ( 33% ) experienced cardiogenic shock .
inotropic agents were administered to 10 patients ( 26% ) , and 9 patients ( 23% ) needed mechanical ventilation .
eleven patients ( 28% ) received an emergency coronary angiogram to rule out acute st - elevation myocardial infarction .
thirty - six patients were discharged after improvement of lv systolic function . during follow - up , there was no scm recurrence or sudden death .
the scm patients were divided into two groups according to the presence of cardiogenic shock or death : the adverse clinical event group ( n=15 ) versus the no event group ( n=24 ) .
these groups showed significantly different age ( 54.817.5 vs. 65.314.0 years ; p=0.046 ) , hospitalization ( 22.118.5 vs. 9.46.3 days ; p=0.020 ) , initial ef ( 34.915.5 vs. 50.613.8% ; p=0.003 ) , initial hs - crp ( 7680 vs. 2335
mg / l ; p=0.027 ) , initial qtc ( 477.463.1 vs. 532.969.5 msec ; p=0.018 ) , peak ck - mb fraction ( 2.81.1 vs. 2.00.9 ng / ml ; p=0.033 ) and peak troponin i ( 12.617.5 vs. 2.62.4 ng / ml ; p=0.045 ) ( table 3 ) .
multivariate logistic regression analysis ( adjusted for age , sex , and risk factors ) showed that hs - crp at admission was associated with an odds ratio ( or ) of 1.41 { 95% confidence interval ( ci ) 1.02 - 1.97 } for an adverse event .
the initial lvef was also significantly associated with an event ( or 0.89 , 95% ci 0.80 - 0.98 , p=0.024 ) .
past medical history was 10 ( 26% ) of hypertension , 3 ( 8% ) of diabetes mellitus , 5 ( 13% ) of chronic obstructive pulmonary disease , and 5 ( 13% ) current smokers .
the initial symptom were dyspnea ( n=18 , 46% ) , chest pain ( n=10 , 26% ) , mental change ( n=8 , 21% ) , collapse ( n=1 , 3% ) , fever ( n=1 , 3% ) and seizure ( n=1 , 3% ) .
the triggering factors of scm were medical illness ( n=23 , 59% ) , emotional stress ( n=6 , 15% ) , procedure - related ( n=3 , 8% ) , trauma ( n=3 , 8% ) , and food or drugs ( n=2 , 5% ) ( table 2 ) .
initial ekg presented t - wave inversion ( n=18 , 46% ) , st - elevation ( n=11 , 28% ) , st - depression ( n=2 , 5% ) , or non - specific findings ( n=6 , 15% ) .
we observed an increasing trend of scm in spring and winter but there was no statistical significance .
the peak ck - mb fraction and troponin i were 15.620.9 ng / ml ( reference range : < 5.0 ng / ml ) and 6.812.3 ng / ml ( reference range : < 0.78 ng / ml ) , respectively .
the bnp at admission was 745.4905.6 pg / ml ( reference range : < 100 pg / ml ) .
l ( reference range : < 5 mg / l ) and 23 patients ( 59% ) had elevated hs - crp at admission . in echocardiography , the mean lv ejection fraction ( ef ) was 4516% at admission and 6113% at discharge .
there were 3 cases of inverted takotsubo shape , 4 cases of transient lv outflow tract obstruction due to a hyperkinetic basal segment of lv , and 1 case of apical thrombus on the site of apical ballooning ( fig .
1 ) . the patient who developed apical lv thrombus had a distal embolization in the right common iliac artery , right external iliac artery , and left femoral artery .
she had anticoagulation therapy with warfarin and was discharged after 15 days without significant complications .
three patients ( 8% ) died due to pneumonia and 13 patients ( 33% ) experienced cardiogenic shock .
inotropic agents were administered to 10 patients ( 26% ) , and 9 patients ( 23% ) needed mechanical ventilation .
eleven patients ( 28% ) received an emergency coronary angiogram to rule out acute st - elevation myocardial infarction .
thirty - six patients were discharged after improvement of lv systolic function . during follow - up
the scm patients were divided into two groups according to the presence of cardiogenic shock or death : the adverse clinical event group ( n=15 ) versus the no event group ( n=24 ) .
these groups showed significantly different age ( 54.817.5 vs. 65.314.0 years ; p=0.046 ) , hospitalization ( 22.118.5 vs. 9.46.3 days ; p=0.020 ) , initial ef ( 34.915.5 vs. 50.613.8% ; p=0.003 ) , initial hs - crp ( 7680 vs. 2335
mg / l ; p=0.027 ) , initial qtc ( 477.463.1 vs. 532.969.5 msec ; p=0.018 ) , peak ck - mb fraction ( 2.81.1 vs. 2.00.9 ng / ml ; p=0.033 ) and peak troponin
i ( 12.617.5 vs. 2.62.4 ng / ml ; p=0.045 ) ( table 3 ) .
multivariate logistic regression analysis ( adjusted for age , sex , and risk factors ) showed that hs - crp at admission was associated with an odds ratio ( or ) of 1.41 { 95% confidence interval ( ci ) 1.02 - 1.97 } for an adverse event .
the initial lvef was also significantly associated with an event ( or 0.89 , 95% ci 0.80 - 0.98 , p=0.024 ) .
our study shows that elevated hs - crp levels and initial impairment of lv systolic function relate to poor clinical outcome .
elevated crp levels are found in scm patients and related to impaired lv systolic function with bnp release.7 ) enhanced production of acute - phase proteins in the liver by catecholamines may result from direct stimulation or may be mediated by cytokines such as tumor necrosis factor- or interleukin 6.8 ) pathologic findings of scm revealed the infiltration of inflammatory cells , including activated macrophages.9 ) collectively , our findings and previous reports suggest that systemic or local inflammatory processes may affect myocardial dysfunction and clinical outcomes in scm .
we had different gender - related differences , triggering factors , and initial symptoms than previous studies ( table 4 ) .
postmenopausal females predominate in scm due to estrogen deficiency after menopause . in animal models ,
postmenopausal females are more vulnerable to sympathetically mediated myocardial stunning.16 ) ovariectomised female rats with estradiol supplementation had significantly less stress - induced ventricular dysfunction , suggesting that estrogen possibly downregulates myocardial adrenoreceptors .
new animal models propose that estrogen ( via immunoreactive estrogen receptors in the central sympathetic neurons ) directly attenuates the hypothalamo - sympathoadrenal axis , and also gives rise to cardioprotective substances such as atrial natruretic peptide , and heat shock protein 70.17)18 ) we found a lower percentage of women ( female 69% ) with scm , and physical stress was more common than emotional stress .
another scm study has mostly male patients ( 65% ) and lv apical ballooning developed in a considerable number of patients with severe physical stress who were admitted to the medical intensive care unit.19 ) hahn et al.20 ) also showed that the triggering factors were physical stress ( 69% ) rather than emotional stress .
thus , scm also occurs in men after physical stress , and inflammation ( high crp ) , leading to the development and poor clinical outcome for scm regardless of gender difference .
previous studies have reported that chest pain is a more frequent symptom than dyspnea.1)2)20 ) but , our study showed that dyspnea was more frequent at initial presentation .
the patients with dyspnea showed longer hospitalization than patients with chest pain ( 1818 vs. 108 days ) .
and dyspnea group showed an elevated bnp level ( 9661,118 vs. 779773 pg / ml ) , higher hs - crp level ( 5377 vs. 2229
mg / l ) and decreased initial lvef ( 4217 vs. 5015% ) , but none significant .
the discrepancy between our data and previous reports is unclear , but could relate to the small sample size and wide range of standard deviation .
there are 3 cases of inverted takotsubo type , 4 cases of transient lv outflow obstruction type , and 1 case of apical thrombus ( fig .
variations in regional wall motion in transient lv apical ballooning , transient mid - ventricular ballooning , and other entities involving excess catecholamines relate more to differences in the anatomic location of cardiac adrenergic receptors , the degree of excess sympathetic activity , or individual differences.21 ) transient severe lv dysfunction can cause serious complication such as cerebrovascular attack , renal infarct , and peripheral arterial obstruction that originates from an lv apical thrombus .
our study is restricted to a single center experience and it can not represent general characteristics of the korea population .
so , a multicenter prospective study needs to reveal the clinical characteristics and outcomes in korean patients with scm . in our single center experience ,
the major triggering factor of scm is physical stress due to medical illness or a procedure .
elevated hs - crp and decreased lvef at admission were independent risk factors for death or cardiogenic shock in patients with scm .
in our single center experience , the major triggering factor of scm is physical stress due to medical illness or a procedure .
elevated hs - crp and decreased lvef at admission were independent risk factors for death or cardiogenic shock in patients with scm .
 background and objectivesstress - induced cardiomyopathy ( scm ) is characterized by a transient left ventricular ( lv ) dysfunction due to emotional and physical stress . 
 there are limited data about the clinical characteristics in korean patients . 
 we sought to clarify the clinical features and prognosis in patients with scm.subjects and methodswe reviewed 39 cases diagnosed with scm in a tertiary hospital . 
 the scm was diagnosed as : 1 ) no previous history of cardiac disease , 2 ) acute onset , 3 ) regional wall motion abnormality , typically in the takotsubo or inverted takotsubo shape by echocardiography , and 4 ) no significant stenosis in the coronary angiogram . 
 we evaluated clinical characteristics , biomarkers , and prognosis.resultsmean age was 61.316.1 years ( female 69% ) . 
 the triggering factors were physical stress in 32 patients ( 82% ) and emotional stress in 5 patients ( 13% ) . 
 the initial symptom was dyspnea ( n=18 , 46% ) rather than chest pain ( n=10 , 26% ) . 
 an initial electrocardiogram ( ekg ) presented t - wave inversion ( n=18 , 46% ) , st - elevation ( n=11 , 28% ) , and st - depression ( n=2 , 5% ) . 
 multivariate logistic regression analysis showed that initial high sensitive c - reactive protein ( hs - crp ) { odds ratio ( or ) 1.41 , 95% confidence interval ( ci ) ; 1.02 - 1.97 } and initial left ventricular ejection fraction ( lvef ) ( or 0.89 , 95% ci ; 0.80 - 0.98 ) were significantly associated with death or cardiogenic shock , respectively.conclusionthe major triggering factor of scm is physical stress due to illness or surgical procedures , and the first manifestation is dyspnea rather than chest pain . 
 elevated hs - crp and decreased lvef at admission were independent risk factors for death or cardiogenic shock . 
Introduction
Subjects and Methods
Results
Clinical manifestations
Laboratory and imaging findings
Prognosis
Discussion
Conclusions