Letter to the Editor Major depression as a potential trigger for Tako Tsubo cardiomyopathy Christopher B. Behrens a , Holger M. Nef a, ⁎ , Pirmin Hilpert a , Helge Möllmann a , Christian Troidl b , Michael Weber a , Christian Hamm a , Albrecht Elsässer a a Kerckhoff Heart Center, Department of Cardiology, D-61231 Bad Nauheim, Germany b Max-Planck-Institute for Heart and Lung Research, D-61231 Bad Nauheim, Germany Received 20 May 2008; accepted 15 November 2008 Available online 18 December 2008 Abstract Tako-Tsubo cardiomyopathy (TTC) is characterized by the sudden onset of severe left ventricular contractile dysfunction following profound emotional or physical stress. The underlying pathomechanism still remains to be elucidated. In this case we present a, to date, unique case of a female patient suffering from an episode of major depression who shows characteristic features of TTC. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Tako-Tsubo cardiomyopathy; Depression; Catecholamines 1. Case report A 41-year old female patient presenting sudden onset of dyspnoe and hyperventilation was admitted suspected of having an acute coronary syndrome. Arterial hypertension could be assessed as a cardiovascular risk factor. Patient's history revealed an acute episode of major depression according to DSM-IV criteria and multiple episodes of non-specific syncopes during the past two years. The patient did not describe an exceptional stressful event prior to the onset of afflictions, but reported suffering from long term demanding personal circumstances. Upon admission a 12-lead electrocardiogram (ECG) showed T wave inversion in leads II, III, aVF, and V4–6, as well as R wave loss in leads V1–3. Laboratory data showed a significantly elevated serum level of troponin I (0.79 ng/mL). Additionally, creatinine kinase (CK) (92 U/L) and CK-MB (65 U/L) was slightly increased. Emergency coronary angiography could exclude an obstructive coronary heart disease (stenosis N 50% lumen diameter, Fig. 1). Laevocardiography showed a markedly reduced left ventricular function (EF 22%) with wall motion abnormalities. The contractile pattern showed the typical features observed in tako-tsubo cardiomyopathy (TTC) with apical akinesia and a hyper-contractile base (Fig. 2). This could be confirmed by means of echocardiography. Consecutively performed echocardiographic measure- ments revealed a complete functional recovery within 12 days under treatment of beta-blocker, ACE-inhibitor and loop-diuretic. Endomyocardial biopsies taken from the left ventricle septum five days after admission showed partial myocardial hypertrophy and slight amount of interstitial fibrosis. For further therapy of the major depression the patient was referred to a psychiatric clinic. 2. Discussion TTC is characterized by transient left ventricular contractile dysfunction with precedent physical or emotional stress [1]. First described in 1991 by Dote et al. [2], several variant forms of this phenomenon have recently been International Journal of Cardiology 140 (2010) e40 – e42 www.elsevier.com/locate/ijcard ⁎ Corresponding author. Kerckhoff Heart Center, Department of Cardiology, Benekestr. 2-8, D-61231 Bad Nauheim, Germany. Tel.: +49 6032 996 0; fax: +49 6032 996 2827. E-mail address: holger.nef@mpi-bn.mpg.de (H.M. Nef). 0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.11.075