{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T01:46:21Z","timestamp":1789695981429,"version":"4.0.1"},"reference-count":30,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"7","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Circ: Cardiovascular Imaging"],"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND:<\/jats:title>\n                    <jats:p>The pathogenesis of Takotsubo syndrome (TTS) is poorly understood, but differences in outcome depending on the triggering factor imply differences in the pathophysiology. Beyond the established trigger-based InterTAK (International Takotsubo Registry) classification, the newly proposed distinction between primary and secondary TTS aims to differentiate emotionally primed heart dysfunction from TTS driven by direct myocardial injury. To explore these potential differences, we utilized cardiovascular magnetic resonance imaging to assess left ventricular function, myocardial edema, and myocardial injury across the InterTAK classification and between primary and secondary TTS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS:<\/jats:title>\n                    <jats:p>For this multicenter cohort study, 110 patients (95% women, age 66\u00b112 years) from the InterTAK registry were included who received cardiovascular magnetic resonance 3 (interquartile range, 2\u20135) days after symptom onset. Cardiovascular magnetic resonance included assessment of myocardial function, edema (T2-weighted spin-echo and T2-mapping when available), and late gadolinium enhancement.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS:<\/jats:title>\n                    <jats:p>\n                      No significant differences were observed in left ventricular volumes, function, or mass across the 3 InterTAK groups or between primary and secondary TTS. Patients with emotional triggers exhibited significantly larger myocardial edema (72% versus 60% for physical triggers;\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      &lt;0.01), supported by higher T2-mapping values in a subset of 22 patients with T2-mapping. In multivariable regression, only emotional trigger (\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      &lt;0.01) and the absence of coronary artery disease (\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      =0.04) were independently associated with the extent of myocardial edema. Secondary TTS showed a higher prevalence of focal or patchy late gadolinium enhancement (primary 19%, secondary 54%;\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      &lt;0.01). In multivariable logistic regression, secondary TTS (\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      &lt;0.01) and early cardiovascular magnetic resonance (\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      =0.02) were associated with the presence of any late gadolinium enhancement.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS:<\/jats:title>\n                    <jats:p>TTS due to emotional stress is associated with larger myocardial edema, and secondary TTS exhibited late gadolinium enhancement more frequently, indicative of direct myocardial damage. These findings suggest that emotionally primed heart dysfunction and direct myocardial injury contribute to TTS pathophysiology to varying extents, influenced by both the triggering factor and preexisting conditions.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1161\/circimaging.125.019335","type":"journal-article","created":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T09:07:25Z","timestamp":1782896845000},"update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["CMR Reveals the Influence of Trigger and Classification on the Myocardial Tissue Response in Takotsubo Syndrome"],"prefix":"10.1161","volume":"19","author":[{"given":"Alexander","family":"Gotschy","sequence":"first","affiliation":[{"name":"Department of Cardiology, University Hospital Zurich, University of Zurich, Switzerland (A.G., V.L.C., V.S., R.S., F.R., R.M., J.R.G.)."},{"name":"Institute for Biomedical Engineering, University and ETH Zurich, Switzerland (A.G., S.K., R.M.)."},{"name":"Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Switzerland (A.G., M.K., R.M.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Victoria L.","family":"Cammann","sequence":"additional","affiliation":[{"name":"Department of Cardiology, University Hospital Zurich, University of Zurich, Switzerland (A.G., V.L.C., V.S., R.S., F.R., R.M., J.R.G.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Victor","family":"Schweiger","sequence":"additional","affiliation":[{"name":"Department of Cardiology, University Hospital Zurich, University of Zurich, Switzerland (A.G., V.L.C., V.S., R.S., F.R., R.M., J.R.G.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rabea","family":"Schlenker","sequence":"additional","affiliation":[{"name":"Department of Cardiology, University Hospital Zurich, University of Zurich, Switzerland (A.G., V.L.C., V.S., R.S., F.R., R.M., J.R.G.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Davide","family":"Di Vece","sequence":"additional","affiliation":[{"name":"Internal Medicine B, University Medicine Greifswald, Germany (D.D.V., J.R.G., C.T.)."},{"name":"DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald, Germany (D.D.V., C.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mihaly","family":"K\u00e1rolyi","sequence":"additional","affiliation":[{"name":"Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Switzerland (A.G., M.K., R.M.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thanh H.","family":"Nguyen","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Basil Hetzel Institute, Queen Elizabeth Hospital, University of Adelaide, Australia (T.H.N., J.D.H.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6883-0703","authenticated-orcid":true,"given":"John D.","family":"Horowitz","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Basil Hetzel Institute, Queen Elizabeth Hospital, University of Adelaide, Australia (T.H.N., J.D.H.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yoshio","family":"Kobayashi","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan (Y.K., K.K.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ken","family":"Kato","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan (Y.K., K.K.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0741-2633","authenticated-orcid":true,"given":"Benjamin","family":"Meder","sequence":"additional","affiliation":[{"name":"Institute for Cardiomyopathies and Department of Cardiology, University Hospital Heidelberg, Germany (B.M.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Annalisa","family":"Pasquini","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Sciences, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy (A.P.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4708-5120","authenticated-orcid":true,"given":"Nicola","family":"Galea","sequence":"additional","affiliation":[{"name":"Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Italy (N.G.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-1457-061X","authenticated-orcid":true,"given":"Elisa","family":"Fedele","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6062-5286","authenticated-orcid":true,"given":"Leonardo","family":"Cal\u00f2","sequence":"additional","affiliation":[{"name":"Department of Motor, Human and Health Sciences, Foro Italico University of Rome Rome, Italy (L.C.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3725-8884","authenticated-orcid":true,"given":"Sebastian","family":"Kozerke","sequence":"additional","affiliation":[{"name":"Institute for Biomedical Engineering, University and ETH Zurich, Switzerland (A.G., S.K., R.M.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5972-0596","authenticated-orcid":true,"given":"Frank","family":"Ruschitzka","sequence":"additional","affiliation":[{"name":"Department of Cardiology, University Hospital Zurich, University of Zurich, Switzerland (A.G., V.L.C., V.S., R.S., F.R., R.M., J.R.G.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9482-411X","authenticated-orcid":true,"given":"Filippo","family":"Crea","sequence":"additional","affiliation":[{"name":"Catholic University of the Sacred Heart, Rome, Italy (F.C.)."},{"name":"Ospedale Isola Tiberina \u2013 Gemelli Isola, Universit\u00e0 Cattolica del Sacro Cuore, Rome, Italy (F.C.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5259-538X","authenticated-orcid":true,"given":"Thomas F.","family":"L\u00fcscher","sequence":"additional","affiliation":[{"name":"Center for Molecular Cardiology, University of Z\u00fcrich, Schlieren, Switzerland (T.F.L., J.R.G., C.T.)."},{"name":"Heart Division, Royal Brompton &amp; Harefield Hospitals GSTT, Cardiovascular Academic Group, King\u2019s College and Imperial College London, United Kingdom (T.F.L.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3383-4998","authenticated-orcid":true,"given":"Robert","family":"Manka","sequence":"additional","affiliation":[{"name":"Department of Cardiology, University Hospital Zurich, University of Zurich, Switzerland (A.G., V.L.C., V.S., R.S., F.R., R.M., J.R.G.)."},{"name":"Institute for Biomedical Engineering, University and ETH Zurich, Switzerland (A.G., S.K., R.M.)."},{"name":"Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Switzerland (A.G., M.K., R.M.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jelena R.","family":"Ghadri","sequence":"additional","affiliation":[{"name":"Department of Cardiology, University Hospital Zurich, University of Zurich, Switzerland (A.G., V.L.C., V.S., R.S., F.R., R.M., J.R.G.)."},{"name":"Internal Medicine B, University Medicine Greifswald, Germany (D.D.V., J.R.G., C.T.)."},{"name":"Center for Molecular Cardiology, University of Z\u00fcrich, Schlieren, Switzerland (T.F.L., J.R.G., C.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0287-4193","authenticated-orcid":true,"given":"Christian","family":"Templin","sequence":"additional","affiliation":[{"name":"Internal Medicine B, University Medicine Greifswald, Germany (D.D.V., J.R.G., C.T.)."},{"name":"DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald, Germany (D.D.V., C.T.)."},{"name":"Center for Molecular Cardiology, University of Z\u00fcrich, Schlieren, Switzerland (T.F.L., J.R.G., C.T.)."},{"name":"Swiss CardioVascularClinic, Private Hospital Bethanien, Zurich, Switzerland (C.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leonarda","family":"Galiuto","sequence":"additional","affiliation":[{"name":"Department of Medical and Cardiovascular Sciences, Sapienza University of Rome; Policlinico Umberto I University Hospital, Italy (L.G.)."}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"key":"e_1_3_3_2_2","unstructured":"Sato HTH Uchida T Dote K Ishihara M. Tako-tsubo-like left ventricular dysfunction due to multivessel coronary spasm. In: Kodama K Haze K Hori M eds. Clinical aspect of myocardial injury: from ischemia to heart failure. 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