Takotsubo syndrome in the absence of an overt stressor: A glimpse into its mechanistic and clinical aspects

n the clinical setting, takotsubo syndrome (TS) is well known to be associated with adrenergic discharge mostly attributable to various emotional and physical triggers (1, 2). A recently published article by Taghavi et al. (1) has reported an interesting case of TS in the absence of an apparent stressor. This form of TS might be termed as “spontaneous TS” and might potentially mimic other cardiovascular conditions including myocarditis clinically (1). Accordingly, a few comments were made on this interesting case particularly emphasizing on its mechanistic and clinical implications: First, evolution of “spontaneous TS” might be related to certain mechanical factors regardless of existing stressors particularly in patients with preexisting hypertensive heart disease or hypertrophic cardiomyopathy (HCM) (2, 3). That is, sudden increases in midventricular gradient (MVG) (possibly due to abrupt physiological changes) might elicit myocardial stunning in the left ventricular (LV) apical segments (leading to an apical ballooning pattern) possibly as a consequence of excessive myocardial wall tension in these segments (2). Therefore, the evolution of TS in this case (1) seemed possible to have a potential mechanical basis (2, 3). In this case, right ventricular (RV) dysfunction on initial echocardiogram might have been a secondary pathology (rather than direct TS involvement) associated with substantial LV morphological changes induced by the TS episode. Accordingly, we wonder whether the severity of left ventricular hypertrophy was also assessed along with resting and provoked MVG (if any) values in the patient.