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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the paper by Menezes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> entitled &#8220;A rare case of concomitant stress &#40;takotsubo&#41; cardiomyopathy and acute myocardial infarction&#8221; published in the July 2015 issue of the <span class="elsevierStyleItalic">Journal</span>&#46; They presented a rare adult case of concomitant stress cardiomyopathy and myocardial infarction&#46; We congratulate the authors for their successful clinical management of the case&#46; If we may&#44; we have a few comments&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Takotsubo cardiomyopathy &#40;TC&#41; or stress cardiomyopathy is characterized by transient left ventricular &#40;LV&#41; wall motion changes&#44; which usually occur after a stressful event&#44; with excellent long-term prognosis despite the fact that TC can very rarely result in fatal arrhythmias or ventricular rupture&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#8211;5</span></a> The diagnosis of TC is currently established according to the Mayo Clinic diagnostic criteria&#44; which consist of &#40;1&#41; typical wall-motion changes&#59; &#40;2&#41; no obstruction or acute plaque rupture of a coronary artery&#59; &#40;3&#41; new ECG changes or mild elevation of cardiac troponin&#59; and &#40;4&#41; no evidence of myocarditis or pheochromocytoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Ahtarovski et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> described two stages of LV recovery in TC&#46; The first stage involves rapid systolic recovery in 4&#8211;6 days with diastolic dysfunction&#46; In the second stage there is delayed but complete diastolic recovery with almost normal LV systolic function&#46; Although LV systolic dysfunction in TC is completely reversible by three months&#44; diastolic impairment requiring treatment in symptomatic patients despite preserved ejection fraction may still be evident&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4&#44;5</span></a> Therefore&#44; cardiologists should consider a possible discordance between echocardiographic recovery and the patient&#39;s symptoms&#46; We think that it would have been helpful to present the patient&#39;s clinical symptoms and status of diastolic function during the clinical follow-up in this case report&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Recently&#44; Daniel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> have reported that psychiatric disorders were more prevalent in patients with TC and myocardial infarction with normal coronary arteries than in those with myocardial infarction with normal coronary arteries and no TC&#46; Therefore&#44; a patient with TC might be referred to a psychiatrist for evaluation of a possible psychiatric disorder regardless of a recent history of physical or emotional stress&#46;</p></span>"
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Vol. 35. Issue 6.
Pages 385 (June 2016)
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Vol. 35. Issue 6.
Pages 385 (June 2016)
Letter to the Editor
Open Access
Delayed diastolic recovery and more prevalent psychiatric disorders in Takotsubo cardiomyopathy
Recuperação diastólica tardia e alteração psiquiátrica mais prevalente na miocardiopatia da Takotsubo
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Mustafa Gulgun
Corresponding author
mustafagulgun@yahoo.com

Corresponding author.
, Muzaffer Kursat Fidanci, Alparslan Fatih Genc
Pediatric Cardiology, Gulhane Military Medical Academy, Ankara, Turkey
Related content
Miguel Nobre Menezes, Doroteia Silva, Ana G. Almeida, Fausto J. Pinto, Dulce Brito
Miguel Nobre Menezes, Doroteia Silva, Ana Gomes Almeida, Fausto José Pinto, Dulce Brito
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To the Editor,

We read with great interest the paper by Menezes et al.1 entitled “A rare case of concomitant stress (takotsubo) cardiomyopathy and acute myocardial infarction” published in the July 2015 issue of the Journal. They presented a rare adult case of concomitant stress cardiomyopathy and myocardial infarction. We congratulate the authors for their successful clinical management of the case. If we may, we have a few comments.

Takotsubo cardiomyopathy (TC) or stress cardiomyopathy is characterized by transient left ventricular (LV) wall motion changes, which usually occur after a stressful event, with excellent long-term prognosis despite the fact that TC can very rarely result in fatal arrhythmias or ventricular rupture.1–5 The diagnosis of TC is currently established according to the Mayo Clinic diagnostic criteria, which consist of (1) typical wall-motion changes; (2) no obstruction or acute plaque rupture of a coronary artery; (3) new ECG changes or mild elevation of cardiac troponin; and (4) no evidence of myocarditis or pheochromocytoma.1,4

Ahtarovski et al.5 described two stages of LV recovery in TC. The first stage involves rapid systolic recovery in 4–6 days with diastolic dysfunction. In the second stage there is delayed but complete diastolic recovery with almost normal LV systolic function. Although LV systolic dysfunction in TC is completely reversible by three months, diastolic impairment requiring treatment in symptomatic patients despite preserved ejection fraction may still be evident.4,5 Therefore, cardiologists should consider a possible discordance between echocardiographic recovery and the patient's symptoms. We think that it would have been helpful to present the patient's clinical symptoms and status of diastolic function during the clinical follow-up in this case report.

Recently, Daniel et al.4 have reported that psychiatric disorders were more prevalent in patients with TC and myocardial infarction with normal coronary arteries than in those with myocardial infarction with normal coronary arteries and no TC. Therefore, a patient with TC might be referred to a psychiatrist for evaluation of a possible psychiatric disorder regardless of a recent history of physical or emotional stress.

References
[1]
M. Nobre Menezes, D. Silva, A.G. Almeida, et al.
A rare case of concomitant stress (takotsubo) cardiomyopathy and acute myocardial infarction.
Rev Port Cardiol, 34 (2015), pp. 499
e1–3
[2]
M. Biteker, N.E. Duran, T. Gökdeniz, et al.
Takotsubo cardiomyopathy mimicking acute high lateral myocardial infarction.
Anadolu Kardiyol Derg, 10 (2010), pp. E2-E3
[3]
S. Nóbrega, D. Brito.
The “broken heart syndrome”: state of the art.
Rev Port Cardiol, 31 (2012), pp. 589-596
[4]
M. Daniel, C. Ekenbäck, S. Agewall, et al.
Risk factors and markers for acute myocardial infarction with angiographically normal coronary arteries.
Am J Cardiol, 116 (2015), pp. 838-844
[5]
K.A. Ahtarovski, K.K. Iversen, T.E. Christensen, et al.
Takotsubo cardiomyopathy, a two-stage recovery of left ventricular systolic and diastolic function as determined by cardiac magnetic resonance imaging.
Eur Heart J Cardiovasc Imaging, 15 (2014), pp. 855-862
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