Takotsubo Syndrome in Patients With Acute Coronary Syndrome or Myocarditis

Stress cardiomyopathy/Takotsubo syndrome (TTS) is a transient cardiac condition characterized by sudden and reversible left ventricular dysfunction, typically triggered by emotional or physical stress. The international TTS (InterTAK) score predicts the probability of suffering from TTS. However, the diagnostic algorithm includes three mutually exclusive diagnoses: acute coronary syndrome (ACS), TTS, and acute infectious myocarditis. Thus, we propose to include the conditions in which TTS is associated with ACS or myocarditis. While TTS is commonly associated with non-ischemic stressors, recent evidence has indicated that TTS can be found in patients with ACS. Nonetheless, in some cases, ACS may trigger rather than exclude TTS. Additionally, TTS could also prompt plaque ruptures in coronary arteries. Meanwhile, infections and conditions that cause myocarditis can also produce physical stress that may trigger TTS. Furthermore, TTS has been reported after confirmed viral myocarditis. This opinion article explores the intricate relationships between (i) TTS and ACS, and (ii) TTS and myocarditis, delving into the related pathophysiologies and diagnostic challenges. However, further research is required to elucidate the mechanisms that link TTS with these conditions.