Abstract
De Giorgi et al 1 reviewed the association between Takotsubo cardiomyopathy (TC) and various infectious etiologies. However, the authors did not describe any report suggesting an association between viral myopericarditis and TC.
There is increasing evidence suggesting an association between viral myopericarditis and TC. 2 –4 Myopericarditis may either precede the stress-induced cardiomyopathy or develop as one of its complications. When myopericarditis is the primary pathology, it has been suggested that an intense perimyocardial inflammation-induced chest discomfort may trigger an exaggerated sympathetic stimulation or somatic stress resulting in a reversible left ventricular dysfunction/TC. 2,5 Alternatively, in cases where TC is the initial stressor, pericarditis may result from an extension of myocardial inflammation to the overlying epicardium suggesting an inflammatory hypothesis to TC. 2,5 In these instances, findings on imaging are often disproportionate to credibly explain the regional dysfunction caused by myopericarditis and thus support the coexistence of these 2 conditions.
Due to an increased understanding of stress-induced cardiomyopathy, its diagnostic criteria have evolved with time. In fact, previously proposed criteria by various medical societies, 6,7 which emphasized excluding patients with myocarditis or myopericarditis from the diagnosis of TC now appear to be outdated and modified versions have been recently proposed. 7 Recent studies suggest that these 2 entities can coexist and are not mutually exclusive. Cardiac magnetic resonance imaging may be useful in such clinical scenarios where the delayed gadolinium enhancement—not plausible to explain the segmental wall-motion abnormalities—will be suggestive of myopericarditis and TC association. 5
When exploring the infectious etiopathogenesis for stress-induced cardiomyopathy, viral myopericarditis is a differential diagnosis to consider. This association can have diagnostic and therapeutic implications, especially the cautionary use of anticoagulants and glycoprotein IIb/IIIa inhibitors when TC and myopericarditis association is suspected to prevent life-threatening complications such as hemorrhagic tamponade. 2,5