Reduced Estrogen in Menopause May Predispose Women to Takotsubo Cardiomyopathy

Background: Takotsubo cardiomyopathy (apical ballooning syndrome) has been reported with increased frequency, most commonly in postmenopausal women. Despite the gender disparity, no clear link between estrogen and its possible cardioprotective effects has been shown.

Objectives: We present a case series of takotsubo cardiomyopathy in women and examine the prevalence of estrogen replacement therapy (ERT), in addition to conducting a systematic literature review on this topic.

Methods: Consecutive cases of takotsubo cardiomyopathy were identified at our institution, Cleveland Clinic Florida, from January 2006 to December 2008, and patient-level data were extracted for analysis. For the literature review, we searched the MEDLINE database from January 1990 to March 2008 for English-language publications, using the terms apical ballooning syndrome, takotsubo, and stress cardiomyopathy, and identified case reports and series of takotsubo cardiomyopathy. Articles describing female patients and their medication use at time of presentation were included in the study.

Results: Eighteen cases of takotsubo cardiomyopathy were identified at our institution, all in postmenopausal women except for 2 who were still menstruating. Of the 16 postmenopausal cases, none were taking ERT at time of presentation. From the literature review, >400 publications were queried, of which 296 were recognized as case reports or series, with 7 articles meeting all of our inclusion criteria. From these reports, 13 women were identified, none of whom were taking ERT at time of presentation.

Conclusions: Lack of estrogen replacement in the postmenopausal state may predispose women to takotsubo cardiomyopathy. Further studies are needed to establish the link more firmly.