Letter to the Editor
Takotsubo cardiomyopathy and chronic obstructive pulmonary disease
Miocardiopatia Takotsubo e doença pulmonar obstrutiva crónica
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(March 2014 issue of the <span class="elsevierStyleItalic">Portuguese Journal of Cardiology</span>) of a 56-year-old male with chronic obstructive pulmonary disease (COPD) who developed stress-induced cardiomyopathy associated with ipratropium bromide use, administered in the context of an acute exacerbation of COPD.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Although this timely and interesting case report provides important information, we would like to share some thoughts.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Acute COPD exacerbation and acute respiratory failure (hypoxemic and/or hypercapnic) have been described<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> as potential physical triggers of takotsubo cardiomyopathy (TCM). In a study by Sharkey et al., <a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> acute respiratory failure and COPD exacerbation were among the most prevalent physical triggers.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Hypoxemia and hypercapnia can induce sympathetic nerve stimulation; the effect of hypoxemia alone can produce a longer-lasting sympathetic activation than hypercapnia, however if both occur simultaneously the result may be a significant increase in sympathetic activity with concomitant increase in catecholamine release,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a> which has been widely implicated in the etiology of TCM.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Acidosis has been associated with high levels of catecholamine release and may have negative inotropic effects secondary to decreasing calcium release from the sarcoplasmic reticulum. Acidosis-induced cardiomyocyte injury has been reported.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a> Inhaled beta 2 agonists used in acute asthma and COPD exacerbation have also been implied as potential triggers of TCM.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Rarely, paradoxical bronchospasm may occur in the setting of inhaled ipratropium; however, this should be carefully distinguished from inadequate response and from transient nocturnal desaturation in COPD.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">This patient had hypercapnia and respiratory acidosis and used inhaled salbutamol. We wonder why COPD exacerbation itself (especially in the context of a left paratracheal consolidation suggesting community-acquired pneumonia, which could potentially add hypoxia to this clinical scenario) was not considered the most likely trigger of TCM instead of a rare paradoxical reaction to an anticholinergic drug.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Natural history and expansive clinical profile of stress (tako tsubo) cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S.W. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 3 | 9 |
| 2024 October | 48 | 28 | 76 |
| 2024 September | 53 | 27 | 80 |
| 2024 August | 53 | 28 | 81 |
| 2024 July | 29 | 26 | 55 |
| 2024 June | 28 | 28 | 56 |
| 2024 May | 29 | 22 | 51 |
| 2024 April | 24 | 25 | 49 |
| 2024 March | 25 | 21 | 46 |
| 2024 February | 28 | 20 | 48 |
| 2024 January | 32 | 29 | 61 |
| 2023 December | 24 | 29 | 53 |
| 2023 November | 41 | 24 | 65 |
| 2023 October | 25 | 17 | 42 |
| 2023 September | 25 | 22 | 47 |
| 2023 August | 17 | 11 | 28 |
| 2023 July | 26 | 8 | 34 |
| 2023 June | 20 | 12 | 32 |
| 2023 May | 27 | 22 | 49 |
| 2023 April | 20 | 6 | 26 |
| 2023 March | 25 | 19 | 44 |
| 2023 February | 29 | 19 | 48 |
| 2023 January | 25 | 11 | 36 |
| 2022 December | 25 | 26 | 51 |
| 2022 November | 32 | 23 | 55 |
| 2022 October | 27 | 15 | 42 |
| 2022 September | 31 | 44 | 75 |
| 2022 August | 31 | 41 | 72 |
| 2022 July | 24 | 27 | 51 |
| 2022 June | 20 | 32 | 52 |
| 2022 May | 29 | 21 | 50 |
| 2022 April | 37 | 26 | 63 |
| 2022 March | 26 | 30 | 56 |
| 2022 February | 31 | 28 | 59 |
| 2022 January | 29 | 21 | 50 |
| 2021 December | 18 | 30 | 48 |
| 2021 November | 24 | 21 | 45 |
| 2021 October | 38 | 35 | 73 |
| 2021 September | 24 | 25 | 49 |
| 2021 August | 34 | 31 | 65 |
| 2021 July | 21 | 27 | 48 |
| 2021 June | 17 | 10 | 27 |
| 2021 May | 29 | 28 | 57 |
| 2021 April | 30 | 28 | 58 |
| 2021 March | 44 | 7 | 51 |
| 2021 February | 55 | 23 | 78 |
| 2021 January | 24 | 11 | 35 |
| 2020 December | 31 | 8 | 39 |
| 2020 November | 34 | 9 | 43 |
| 2020 October | 14 | 2 | 16 |
| 2020 September | 65 | 6 | 71 |
| 2020 August | 21 | 5 | 26 |
| 2020 July | 42 | 3 | 45 |
| 2020 June | 23 | 7 | 30 |
| 2020 May | 34 | 1 | 35 |
| 2020 April | 38 | 2 | 40 |
| 2020 March | 33 | 5 | 38 |
| 2020 February | 69 | 13 | 82 |
| 2020 January | 30 | 8 | 38 |
| 2019 December | 22 | 1 | 23 |
| 2019 November | 39 | 2 | 41 |
| 2019 October | 31 | 4 | 35 |
| 2019 September | 26 | 8 | 34 |
| 2019 August | 26 | 8 | 34 |
| 2019 July | 38 | 11 | 49 |
| 2019 June | 20 | 8 | 28 |
| 2019 May | 35 | 5 | 40 |
| 2019 April | 15 | 13 | 28 |
| 2019 March | 37 | 13 | 50 |
| 2019 February | 58 | 14 | 72 |
| 2019 January | 22 | 10 | 32 |
| 2018 December | 18 | 10 | 28 |
| 2018 November | 53 | 7 | 60 |
| 2018 October | 118 | 13 | 131 |
| 2018 September | 66 | 14 | 80 |
| 2018 August | 63 | 6 | 69 |
| 2018 July | 25 | 4 | 29 |
| 2018 June | 35 | 7 | 42 |
| 2018 May | 41 | 10 | 51 |
| 2018 April | 32 | 3 | 35 |
| 2018 March | 41 | 6 | 47 |
| 2018 February | 28 | 2 | 30 |
| 2018 January | 42 | 4 | 46 |
| 2017 December | 57 | 3 | 60 |
| 2017 November | 29 | 8 | 37 |
| 2017 October | 15 | 20 | 35 |
| 2017 September | 30 | 7 | 37 |
| 2017 August | 26 | 19 | 45 |
| 2017 July | 19 | 9 | 28 |
| 2017 June | 34 | 15 | 49 |
| 2017 May | 23 | 8 | 31 |
| 2017 April | 31 | 2 | 33 |
| 2017 March | 23 | 11 | 34 |
| 2017 February | 18 | 2 | 20 |
| 2017 January | 21 | 1 | 22 |
| 2016 December | 25 | 5 | 30 |
| 2016 November | 27 | 2 | 29 |
| 2016 October | 31 | 9 | 40 |
| 2016 September | 19 | 6 | 25 |
| 2016 August | 5 | 1 | 6 |
| 2016 July | 6 | 3 | 9 |
| 2016 June | 15 | 5 | 20 |
| 2016 May | 10 | 0 | 10 |
| 2016 April | 18 | 1 | 19 |
| 2016 March | 20 | 5 | 25 |
| 2016 February | 38 | 11 | 49 |
| 2016 January | 29 | 9 | 38 |
| 2015 December | 25 | 8 | 33 |
| 2015 November | 21 | 3 | 24 |
| 2015 October | 29 | 5 | 34 |
| 2015 September | 36 | 7 | 43 |
| 2015 August | 25 | 8 | 33 |
| 2015 July | 33 | 8 | 41 |
| 2015 June | 5 | 2 | 7 |
| 2015 May | 25 | 7 | 32 |
| 2015 April | 18 | 7 | 25 |
| 2015 March | 15 | 5 | 20 |
| 2015 February | 18 | 4 | 22 |
| 2015 January | 23 | 8 | 31 |
| 2014 December | 52 | 13 | 65 |
| 2014 November | 48 | 10 | 58 |
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