Cardiac takotsubo syndrome in association with cerebral, renal, gastrointestinal, vascular, and perhaps total body, “takotsubo” syndrome?

Finsterer and Stöllberger, in their insightful article, published in the May 15, 2017 issue of the Journal [ ], refer to 7 cases (6 previously published, and one new of their own) of transient global amnesia (TGA), in association with takotsubo syndrome (TTS), as having suffered a “cerebral takotsubo”. This suggestion echos my strong belief in the past few years, that it is counterintuitive to consider that there is only a selective cardiac affliction (i.e., TTS), engendered by an exclusive brain-heart connection [ ], with all the other body organ systems being immune to the injurious effects of an aroused autonomic nervous system. Accordingly we should start exploring (and feeling comfortable about it) the existence of cerebral, gastrointestinal, genitourinary, vascular, or in an all inclusive conceptualization, total body “takotsubo syndrome” (“TTS”). Indeed some hints of “TTS” involving other organs or organ systems have been already shown in some published reports of TTS. As an example one could consider the evidence of transient kidney injury, occasionally expressed not only as a transient elevation of creatinine, but as a pathological state requiring transiently renal replacement therapy [ , ]. Of course, in such a scenario one should be cautious to distinguish between a renal “TTS” from transient renal injury (i.e., prerenal cause) due to hemodynamic decompensation and cardiogenic shock, stemming from cardiac TTS. Similarly hints for gastrointestinal “TTS” have been shown in patients with gastrointestinal symptoms and signs revealing gastrointestinal dysfunction (e.g., abdominal pain, nausea, vomiting, abdominal bloating, exacerbation of gastroesophageal regurgitation disorder) in association with TTS, which need to be closely evaluated and ascribed to specific gastrointerstinal pathologies. For example the so-called cannabinoid hyperemesis syndrome [ ], in association with TTS could qualify for gastrointestinal “TTS”. Of course one should be cognizant of the possibility of TTS emerging in the setting of exacerbation of chronically existing gastrointestinal pathology [ ]. A vascular “TTS” has been indirectly described by reference to vascular dilatation, with associated hypotension, and low or normal left ventricular diastolic pressure, in the presence of a maximally reduced left ventricular ejection fraction [ ].