Left anterior descending artery length and coronary atherosclerosis in apical ballooning syndrome (Takotsubo/stress induced cardiomyopathy)

doi:10.1016/j.ijcard.2009.06.018

International Journal of Cardiology

Volume 145, Issue 1, 5 November 2010, Pages 112-115

https://doi.org/10.1016/j.ijcard.2009.06.018 Get rights and content

Abstract

Background

A proposed etiology of apical ballooning syndrome (ABS) is a spontaneously aborted anterior myocardial infarction (MI) in patients with a long “wrap around” left anterior descending artery (LAD) rather than it being a unique cardiomyopathy. The aim of this study was to evaluate whether patients with ABS have a higher frequency of “wrap around” LAD.

Methods

A retrospective analysis of the coronary anatomy and presence of coronary artery disease (CAD) by angiography was performed among 97 ABS patients, and compared to a matched control group with anterior ST-elevation MI. LAD length was graded: type 1 – does not supply the left ventricular (LV) apex, type 2 – the LAD and right coronary both supply the apex, type 3 – supplies the entire apex, and type 4 – supplies the apex and > 25% of the inferior wall (wrap around).

Results

ABS patients had lower ejection fractions at presentation (41% ± 14% vs 47% ± 13%, p = 0.001). There was no difference in the frequency of the 4 types of LAD between ABS (7%, 11%, 55%, 27%) and controls (3%, 13%, 51%, 33%), p = 0.45. In ABS, there was no difference in the mean LV ejection fraction (32.7%, 38.8%, 42.9%, 41.1%, respectively, p = 0.39), or wall motion score index at presentation in the 4 LAD groups. The prevalence of angiographic CAD in ABS was 84%.

Conclusions

ABS patients do not have a higher frequency of “wrap around” LAD. This fact, together with a greater magnitude of LV dysfunction at presentation, supports that cardiomyopathy is not due to spontaneously aborted anterior MI.

Introduction

Apical ballooning syndrome (ABS) is an increasingly diagnosed reversible cardiomyopathy [1], [2]. It has been proposed that ABS is not a clinically distinct entity, but rather a manifestation of a spontaneously aborted myocardial infarction (MI) [3], [4], [5]. However, the regional wall motion abnormality in ABS extends beyond the distribution of a single coronary artery [2], [6], [7], [8]. The proponents of the aborted MI hypothesis account for this fact by suggesting that ABS occurs in patients who have a left anterior descending artery (LAD) that “wraps around” the apex and supplies the inferior wall of the left ventricle. The hypothesis has been derived from data from a single case series of eleven patients [9] and warrants validation in other cohorts of ABS. Thus, the aim of our study was to test the hypothesis that patients with ABS have a higher frequency of a “wrap around” LAD.

Section snippets

Materials and methods

We conducted a retrospective case-control study among ninety-seven consecutive, prospectively identified ABS patients, based on the Mayo Clinic diagnostic criteria [2]. Ninety-seven patients with an anterior STEMI undergoing successful primary percutaneous coronary intervention to the proximal or mid-LAD, matched for age, gender, and event date served as the control population. The study was approved by the Mayo Clinic Institutional Review Board and all patients consented to the use of their

Results

Table 1 summarizes the baseline characteristics of ABS patients and controls. The length of the LAD, measured as types I–IV were similar in the two groups (p = 0.45) (Table 2). The prevalence of any angiographic CAD was high in ABS (84%), but only thirteen (13%) patients had obstructive disease. The obstructive lesions were located in the LAD or diagonal branches (n = 7), circumflex artery (n = 4), and the right coronary artery (n = 2). Ejection fraction at presentation was lower and wall motion score

Discussion

The major findings of this study are that patients with ABS: 1) do not have a higher prevalence of a “wrap around” LAD, 2) have greater left ventricular systolic dysfunction at presentation compared to patients with anterior STEMI, and 3) have a high prevalence (84%) of CAD detected by angiography, but this is non-obstructive in the majority of cases.

Our study demonstrates that while the LAD supplied the entire apex of the left ventricle in 55% of the patients, a “wrap around” LAD was present

Acknowledgements

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [15].

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Letter to the EditorLeft anterior descending artery length and coronary atherosclerosis in apical ballooning syndrome (Takotsubo/stress induced cardiomyopathy)

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

Am Heart J

Mayo Clin Proc

Am J Cardiol

J Am Coll Cardiol

Rev Esp Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Letter to the Editor
Left anterior descending artery length and coronary atherosclerosis in apical ballooning syndrome (Takotsubo/stress induced cardiomyopathy)