takotsubo cardiomyopathy ( tc ) is a cardiomyopathy characterized by typical wall motion abnormalities of the left ventricle whose most frequently resembles the  takotsubo  used by japanese for catching octopuses .
it mimics an acute coronary syndrome , but the coronary angiography typically reveals the absence of an obstructive atherosclerotic disease and the echocardiographic segmental wall abnormalities typically occur beyond the territory of perfusion of a coronary single vessel .
the causes are still unclear and the syndrome may be thought as a neurogenic disorder due to an acute physical and emotional stress with excessive sympathetic activity and abnormal catecholamine release .
tc is currently considered a quite benign condition , with a complete recovery in few days or weeks .
however , the recurrence , once thought to be rare , has been increasingly reported worldwide . in a recently published review of literature
, it has been evidenced in a significant heterogeneity among studies with an annual recurrence of roughly 1.5% .
cumulative incidence of recurrent events increased from 1.2% in the first six months to nearly 5% in six years .
unfortunately , the relatively small number of recurrences has still now precluded the identification of predictors of outcome .
interestingly , medical therapy ( ace - i and arb rather than b - blockers ) discontinuation may have an impact in the risk of recurrence .
both precocious ( one year ) and very late ( about 10 years ) repeated episodes have been previously described with the possibility of variable patterns of left ventricular region involvement .
she reported chronic stress related to the handicap of her daughter and frequent family quarrels . upon admission , she was symptomatic for typical chest pain .
the admission electrocardiogram showed negative t - waves in v4-v6 leads [ figure 1 ] , and markers of myocardial necrosis were mildly elevated ( maximum i troponin : 1.5 ng / dl ) .
transthoracic echocardiogram revealed apical and mid - segment akinesis with hyperkinesia of basal segments and a moderately impaired systolic function ( ejection fraction 45% ) [ figure 2 ] .
the patient underwent coronary angiography that revealed a non - significant stenosis of the anterior descending artery .
the left ventriculogram confirmed our suspicion [ figure 3 ] . before discharge , we assessed diffuse negative t - waves on electrocardiogram and normalization of segmental kinesis on transthoracic echocardiogram .
after the discharge , the patient discontinued medical therapy with -blockers , ace inhibitors and mineral receptor antagonist , for symptomatic hypotension .
transthoracic echocardiogram showed a typical apical ballooning pattern [ figure 2 ] , maximum troponin i was 0.11 ng / dl .
given the previous medical history and recent detection of non - significant coronary lesions , coronary angiography was not repeated , and the patient was conservatively treated and her hospital course was uncomplicated .
. electrocardiogram registered upon admission ( upper panel ) and before discharge ( lower panel ) transthoracic echocardiogram recorded during the second in - hospital admission and showing apical akinesis , with basal segments hyperkinesis ( left systolic frame , right diastolic frame ) coronary angiography showing non - significant atherosclerotic lesions and ventriculography showing apical ballooning of the left ventricle
the reaction to psychological stress is well - characterized but its link with cardiovascular disease risk is less established .
epidemiological data show that chronic stress predicts the occurrence of coronary artery disease ; in addition , short - term emotional stress can act as a trigger of cardiac events in people with advanced atherosclerosis .
an acute emotional or physical stress is typical of tc , even if not always detectable .
the influence of chronic stress and psychiatric illness in the pathogenesis of tc is far less studied . in some studies ,
high - anxiety trait is a common finding but it is not significantly more frequent than in control patients with myocardial infarction .
moreover , a high - anxiety trait seems to be neither associated with a worse outcome nor a predictor of tc . in other studies ,
patients with tc and chronic stress may have a higher catecholamine response to minor stressful situations and decreased inhibition of catecholamine with longer cardiac stimulation .
we report an unusual case of tc in a woman suffering from chronic emotional stress with a very early ( one month ) recurrence .
an acute , physical or emotional , trigger event was not detectable in both cases .
it is possible to suppose that , in predisposed subjects , chronic stress by increasing sympathetic activity may be considered not only a trigger for tc , but also a negative prognostic factor for early recurrence .
future studies may demonstrate an increased prevalence of psychiatric disorders or chronic stress in patients with tc and , on the other hand , a high prevalence of tc in patients with psychiatric diseases .
 takotsubo cardiomyopathy ( tc ) is characterized by transient systolic dysfunction of the apical and middle segments of the left ventricle , accompanied by electrocardiographic abnormalities and mild elevation of cardiac biomarker levels in the absence of obstructive coronary artery disease . 
 the following case is of a woman suffering from chronic emotional stress with a very early recurrence . 
 an acute trigger event was not detectable in both cases . 
 it is possible to suppose that , in predisposed subjects , chronic stress by increasing sympathetic activity may be considered not only a trigger for tc , but also a negative prognostic factor for early recurrence . 
INTRODUCTION
CASE REPORT
CONCLUSIONS