Letter to the Editor

Takotsubo Syndrome + Coronary Artery Disease Vs Takotsubo Syndrome + Acute Coronary Syndromes

John E. Madias, MD


John E. Madias, MD


Dear Editors:

The contribution by Rawasia et al published in the June, 2014 issue of the Journal of Invasive Cardiology,1 about an 80-year-old woman who suffered an episode of Takotsubo syndrome (TTS) and was found to have multivessel coronary artery disease (CAD) at coronary arteriography, highlights an issue for which the cardiology community at large, and the invasive cardiology community in particular, should start feeling very comfortable about: namely, that TTS can coincide with CAD, from single vessel to multivessel, and from mild coronary artery irregularities at coronary arteriography to obstructive CAD. The authors have emphasized this point by citing the literature showing coincidence of TTS in a sizeable proportions of patients presenting with TTS.1 The original, and subsequently revised, Mayo Clinic diagnostic criteria of TTS have been superseded by vast experience on this enigmatic disease, and more realistic criteria have been recently proposed.2 

What the non-invasive and invasive cardiology communities should start feeling comfortable about is that acute coronary syndromes and TTS can coincide, with probably the former triggering the latter. Indeed, this has been occasionally reported,3 and if clinicians and investigators develop the right mindset, we all may soon “see” frequent occurrence of milder forms of TTS in patients with ACS.3,4 To this effect, we should start scrutinizing by serial echocardiography the emergence and natural course of regional contraction abnormalities, in myocardial territories extending beyond that of a single coronary vessel (sometimes even contralateral), in patients presenting with ACS.3,4  


  1. Rawasia WF, Pachika A, Ikram S. Diagnostic dilemma: Takotsubo cardiomyopathy versus acute coronary syndrome. J Invasive Cardiol. 2014;26(6):E82-E84.
  2. Madias JE. Why the current diagnostic criteria of Takotsubo syndrome are outmoded: a proposal for new criteria. Int J Cardiol. 2014;174(3):468-470. Epub 2014 Apr 29.
  3. Tota F, Ruggiero M, Sassara M, et al. Subacute stent thrombosis and stress-induced cardiomyopathy: trigger or consequence? Am J Cardiovasc Dis. 2013;3(3):175-179.        
  4. Madias JE. Forme fruste cases of Takotsubo syndrome: a hypothesis. Eur J Intern Med. 2014;25(4):e47. 

From the Icahn School of Medicine at Mount Sinai, New York, New York, and the Division of Cardiology, Elmhurst Hospital Center, Elmhurst, New York.

Address for correspondence: John E. Madias, MD, FACC, FAHA, Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY 11373. Email: madiasj@nychhc.org