Letter to the Editor Les liaisons dangereuses: Tako-Tsubo syndrome after an adulterous intercourse in an elderly male Natale Daniele Brunetti ⁎, Luisa De Gennaro, Michele Correale, Pier Luigi Pellegrino, Andrea Cuculo, Matteo Di Biase Cardiology Department, University of Foggia, Foggia, Italy abstract article info Article history: Received 25 May 2009 Accepted 30 May 2009 Available online 28 June 2009 Keywords: Tako-Tsubo syndrome Elderly male Emotional distress We report the case of an 81-year-old man who presented with chest pain after an adulterous intercourse with a young woman. At echocardiography a typical apical ballooning phenomenon was detectable and com- pletely reversed after one week. Coronary angiography did not show significant coronary atherosclerosis. © 2009 Elsevier Ireland Ltd. All rights reserved. 1. Background Tako-Tsubo syndrome (TTS) is characterized by acute onset of chest symptoms, ECG changes with elevated cardiac markers mimicking acute myocardial infarction, left ventricular wall motion abnormalities in the apical region with preserved function of base, and normal coro- nary arteries [1]. It typically follows stressful triggers, which could be either emotional or physical [2,3], and usually affects elderly women [1]. Catecholamine excess has been proposed in the determinism of TTS [4], although the exact mechanism has not been completely de- scribed yet. 2. Case report We report the case of a 81-year-old man, referred for chest pain 12 h after an adulterous intercourse with a young woman. He was a smoker, with neither history of heart disease nor other cardiovascular risk factors; he was not receiving any drug therapy. Systolic arterial blood pressure at admission was 115/80 mmHg, and physical examination was unremarkable. Resting ECG showed sinus rhythm (66 bpm) and negative T waves in DI-aVL leads (Fig. 1). Chest radiography showed no sign of pulmonary congestion, with a mildly enlarged cardiac transverse diameter. Cholesterol, troponin and creatinine levels were normal. Unexpectedly, at the first echocardiography examination, a severe systolic dysfunction (30% left ventricular ejection fraction (LVEF)), with apical dyskinesis and basal hyperkinesis (typical apical balloon- ing) was found (Fig. 2). Further ECG examinations showed new onset deep negative T waves in all anterior leads (V1–V6, DI-AVL) (Fig. 3). The patient immediately underwent coronary angiography that, how- ever, was not able to show any sign of significant coronary atheroscle- rosis, with no need of coronary angioplasty. The patient recovered within a week, when LVEF was documented as normal at echocardiography (Fig. 4), with a mild increase in cir- culating troponin I levels (peak 1.25 ng/ml). At discharge, ECG was still presenting negative T waves in anterior leads, even though less mark- edly deep, and blood pressure 130/80 mmHg. The patient was asymptomatic at 6-month follow-up. 3. Discussion To our knowledge, this is one of the first cases reporting acute tran- sient systolic dysfunction in an old man after an adulterous inter- course. Previous cases of TTS associated with sexual intercourses were reported, although in a younger woman and not in an adulterous “liaison” [5]. TTS is described as less frequent in male than in female gender [1,6], although estrogen seems to attenuate the emotional stress- induced cardiac responses in the animal model of TTS [7]. However, what we are reporting is not the first case of TTS described in an elderly male [1]. There is a body of literature linking Tako-Tsubo phenomenonwith emotional stress; depression [8], a fall [9], even emotional impact of an automobile accident [10] were identified as a potential trigger of a TTS. In our case report, the stressful trigger was represented by an adulterous intercourse. The mechanism hypothesized to be responsible for acute systolic dysfunction after a stressful trigger was acute catecholamine release. Kume et al. documented increased local release of norepinephrine International Journal of Cardiology 149 (2011) e113–e117 ⁎ Corresponding author. Tel.: +39 3389112358; fax: +39 0881745424. E-mail address: nd.brunetti@unifg.it (N.D. Brunetti). 0167-5273/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2009.05.059 Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard