Enhanced external counterpulsation for some patients with Takotsubo syndrome

Management of Takotsubo syndrome (TTS) is nonspecific, empiric, and supportive, aiming at alleviation of symptoms and complications of afflicted patients [1]. Following the establishment that obstructive coronary artery disease is not its cause, and the finding of the characteristic left ventricular contraction abnormalities by contrast ventriculography or 2-D echocardiography, clinicians respond to the array of patient clinical problems, as they do for patients with acute myocardial infarction, or acute coronary syndromes. Thus, chest pain, atrial and ventricular arrhythmias, atrioventricular or intraventricular conduction abnormalities, lung congestion, peripheral edema, pericarditis, intracardiac thrombus, systemic andpulmonaryembolization, cardiac rupture, etc, are managed, as done routinely. Since TTS emerges in association with an intense adrenergic surge, interest in employing βblockers is found in the literature [2], although concern has been traditionally expressed for using such therapeutic agents in the presence of depressed left ventricular function and/orhypotension [3]. The interest for using β-blockers is stronger for patients with TTS and evidence for intense basal myocardial hyperkinesis, or left intraventricular pressure gradients, although some of such patients have also manifest hypotension, and this should be of concern to the clinicians [3]. Following the realization that TTS most probably is an epinephrine-mediated “neuromechanical” condition engendered by a transient, reversible alteration in the function of β-2 adrenegric receptors, from cardiostimulatory to cardioinhibitory [4], concern about employing β-blockers has been further increased, since such agents were not helpful, but even harmful, in relevantTTS animal experiments [4].Device-based therapy, as opposed to pharmacological therapies, has been occasionally employed and found to be beneficial, exemplified by the use of intraaortic balloon conterpulsation (IABC) [5], although somehave expressed reservation about its use in patients with TTS who have left ventricular outflow tract obstruction [6]. IABC is invasive, and not devoid of significant, primarily vascular, complications, andshouldbeusedwith caution, considering that thebulk of patients with TTS eventually, after an occasionally stormy early clinical course, are restored to their previous health status. This leads one to think in turn about enhanced external counterpulsation (EECP),which consists of three pneumatic cuffs applied to each of the patient's legs (at the level of calves, lower thighs, and upper thighs [or buttocks]), that are sequentially inflated and deflated, synchronized with the diastolic and systolic components of the cardiac cycle correspondingly, a noninvasive therapeutic modality currently used in patients with chronic angina, and chronic and acute heart failure [7–9]. EECP ameliorates hypotension, improves left ventricular function, lung congestion, and cardiogenic shock [7–9]. Accordingly for patients with TTS presenting, or subsequently developing, severe pulmonary congestion, marked left ventricular dysfunction, hypotension, or cardiogenic shock, EECPmaybe a good therapeutic choice. Indeed the device can be rapidly applied and evaluated about its usefulness, even in very sick patients, individuals withproblematicperipheral vascular access, orperipheral arterial disease [10], or even as an interim therapy, in patients on whom IABC is contemplated. Intense clinical assessment and monitoring with echocardiography can be implemented before, and immediately after application of the EECP, and the device's implementation promptly discontinued with impunity, if the desired therapeutic effects in the patients' symptoms, blood pressure, and the left ventricular ejection fraction, regional wall motion abnormalities, and particularly left intraventricular pressure gradient, are not met. An additional issue to be dealt with is that currently not many cardiovascular centers have the EECP device, or have experience with it, but this is not a reason not to acquire it and become adept in its implementation, considering the current paucity of specific therapeutic modalities for themanagement of patients with TTS in need for additional to the usually employed supportive therapies.