{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T10:59:45Z","timestamp":1785149985340,"version":"3.55.0"},"reference-count":94,"publisher":"MDPI AG","issue":"15","license":[{"start":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T00:00:00Z","timestamp":1784851200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Spontaneous coronary artery dissection (SCAD) and Takotsubo syndrome (TTS) are two conditions presenting as acute coronary syndromes that predominantly affect women and are frequently triggered by emotional or physical stress. While traditionally considered distinct entities, emerging evidence suggests that these conditions may coexist more frequently than previously recognized, sharing common pathophysiological mechanisms centered on catecholamine-mediated pathways, vascular vulnerability, and hormonal influences. Their overlapping presentations create significant diagnostic challenges that may lead to misdiagnosis and suboptimal management. This narrative review examines the pathophysiological convergence between SCAD and TTS, addresses the diagnostic complexity arising when these entities coexist, and proposes a novel stepwise diagnostic algorithm integrating clinical risk stratification, coronary angiography, intracoronary imaging, and cardiac magnetic resonance imaging. The review also provides scenario-dependent management guidance and outlines priorities for future research.<\/jats:p>","DOI":"10.3390\/jcm15155810","type":"journal-article","created":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T09:47:41Z","timestamp":1785145661000},"page":"5810","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Spontaneous Coronary Artery Dissection and Takotsubo Syndrome: Converging Mechanisms, Diagnostic Pitfalls, and a Unified Clinical Algorithm"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0141-0127","authenticated-orcid":false,"given":"Michele","family":"Golino","sequence":"first","affiliation":[{"name":"Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-1990-2770","authenticated-orcid":false,"given":"Khalid","family":"Shakfeh","sequence":"additional","affiliation":[{"name":"Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ashley A.","family":"Stiglich","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, University of Florida College of Medicine, Jacksonville, FL 32209, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2182-6250","authenticated-orcid":false,"given":"Cristina","family":"Font","sequence":"additional","affiliation":[{"name":"Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fabiana","family":"Rollini","sequence":"additional","affiliation":[{"name":"Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1685-6690","authenticated-orcid":false,"given":"Madeline K.","family":"Mahowald","sequence":"additional","affiliation":[{"name":"Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gladys","family":"Velarde","sequence":"additional","affiliation":[{"name":"Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Demilade","family":"Adedinsewo","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL 32224, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesco","family":"Franchi","sequence":"additional","affiliation":[{"name":"Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ali","family":"Zgheib","sequence":"additional","affiliation":[{"name":"Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Georges","family":"El Khoury","sequence":"additional","affiliation":[{"name":"Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jose","family":"Rivas Rios","sequence":"additional","affiliation":[{"name":"Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pasquale","family":"Mollo","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Fabrizio Spaziani Hospital, 03100 Frosinone, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonio","family":"Abbate","sequence":"additional","affiliation":[{"name":"Berne Cardiovascular Research Center, Division of Cardiology, University of Virginia, Charlottesville, VA 22908, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6374-1821","authenticated-orcid":false,"given":"Mihail","family":"Celeski","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Fabrizio Spaziani Hospital, 03100 Frosinone, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-1835-6128","authenticated-orcid":false,"given":"Michele","family":"Marchetta","sequence":"additional","affiliation":[{"name":"Berne Cardiovascular Research Center, Division of Cardiology, University of Virginia, Charlottesville, VA 22908, USA"},{"name":"Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,24]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e523","DOI":"10.1161\/CIR.0000000000000564","article-title":"Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association","volume":"137","author":"Hayes","year":"2018","journal-title":"Circulation"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1016\/j.jacc.2016.05.034","article-title":"Contemporary Review on Spontaneous Coronary Artery Dissection","volume":"68","author":"Saw","year":"2016","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"961","DOI":"10.1016\/j.jacc.2020.05.084","article-title":"Spontaneous Coronary Artery Dissection: JACC State-of-the-Art Review","volume":"76","author":"Hayes","year":"2020","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"645","DOI":"10.1161\/CIRCINTERVENTIONS.114.001760","article-title":"Spontaneous Coronary Artery Dissection: Association with Predisposing Arteriopathies and Precipitating Stressors and Cardiovascular Outcomes","volume":"7","author":"Saw","year":"2014","journal-title":"Circ. Cardiovasc. Interv."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"929","DOI":"10.1056\/NEJMoa1406761","article-title":"Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy","volume":"373","author":"Templin","year":"2015","journal-title":"N. Engl. J. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"2032","DOI":"10.1093\/eurheartj\/ehy076","article-title":"International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology","volume":"39","author":"Ghadri","year":"2018","journal-title":"Eur. Heart J."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e028511","DOI":"10.1161\/JAHA.122.028511","article-title":"Trigger-Associated Clinical Implications and Outcomes in Takotsubo Syndrome: Results From the Multicenter GEIST Registry","volume":"12","author":"Santoro","year":"2023","journal-title":"J. Am. Heart Assoc."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Eltabbakh, A., Khudair, A., Khudair, A., and Fredericks, S. (2024). Spontaneous Coronary Artery Dissection and Fibromuscular Dysplasia: Insights into Recent Developments. Front. Cardiovasc. Med., 11.","DOI":"10.3389\/fcvm.2024.1409278"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"654.e11","DOI":"10.1016\/j.amjmed.2015.01.016","article-title":"Comorbidities Frequency in Takotsubo Syndrome: An International Collaborative Systematic Review Including 1109 Patients","volume":"128","author":"Pelliccia","year":"2015","journal-title":"Am. J. Med."},{"key":"ref_10","first-page":"485","article-title":"Spontaneous Coronary Artery Dissection and Its Association with Takotsubo Syndrome: Novel Insights from a Tertiary Center Registry","volume":"95","author":"Duran","year":"2020","journal-title":"Catheter. Cardiovasc. Interv."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e013581","DOI":"10.1161\/JAHA.119.013581","article-title":"Spontaneous Coronary Artery Dissection in Patients with a Provisional Diagnosis of Takotsubo Syndrome","volume":"8","author":"Hausvater","year":"2019","journal-title":"J. Am. Heart Assoc."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"717","DOI":"10.1016\/j.carrev.2018.02.002","article-title":"Spontaneous Coronary Artery Dissection and Takotsubo Syndrome: An Often Overlooked Association; Review","volume":"19","year":"2018","journal-title":"Cardiovasc. Revasc. Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"2231","DOI":"10.1016\/j.jacc.2018.08.1038","article-title":"Executive Group on behalf of the Joint European Society of Cardiology (ESC)\/American College of Cardiology (ACC)\/American Heart Association (AHA)\/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth Universal Definition of Myocardial Infarction (2018)","volume":"72","author":"Thygesen","year":"2018","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_14","first-page":"e891","article-title":"Contemporary Diagnosis and Management of Patients with Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease: A Scientific Statement From the American Heart Association","volume":"139","author":"Jneid","year":"2019","journal-title":"Circulation"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1016\/j.tcm.2025.07.007","article-title":"Gender and Sex-Related Differences in Type 2 Myocardial Infarction: The Undervalued Side of a Neglected Disease","volume":"36","author":"Angeli","year":"2026","journal-title":"Trends Cardiovasc. Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1388","DOI":"10.1016\/j.jacc.2021.10.050","article-title":"Sex as a Biological Variable in Cardiovascular Diseases: JACC Focus Seminar 1\/7","volume":"79","author":"Clayton","year":"2022","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"950","DOI":"10.1210\/en.2016-1930","article-title":"Steroid Hormones Are Key Modulators of Tissue Mechanical Function via Regulation of Collagen and Elastic Fibers","volume":"158","author":"Nallasamy","year":"2017","journal-title":"Endocrinology"},{"key":"ref_18","first-page":"106","article-title":"Local Release of Catecholamines from the Hearts of Patients with Tako-Tsubo-like Left Ventricular Dysfunction","volume":"72","author":"Kume","year":"2008","journal-title":"Circ. J. Off. J. Jpn. Circ. Soc."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"539","DOI":"10.1056\/NEJMoa043046","article-title":"Neurohumoral Features of Myocardial Stunning Due to Sudden Emotional Stress","volume":"352","author":"Wittstein","year":"2005","journal-title":"N. Engl. J. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1038\/ncpcardio1066","article-title":"Stress (Takotsubo) Cardiomyopathy--a Novel Pathophysiological Hypothesis to Explain Catecholamine-Induced Acute Myocardial Stunning","volume":"5","author":"Lyon","year":"2008","journal-title":"Nat. Clin. Pract. Cardiovasc. Med."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"697","DOI":"10.1161\/CIRCULATIONAHA.112.111591","article-title":"High Levels of Circulating Epinephrine Trigger Apical Cardiodepression in a \u03922-Adrenergic Receptor\/Gi-Dependent Manner: A New Model of Takotsubo Cardiomyopathy","volume":"126","author":"Paur","year":"2012","journal-title":"Circulation"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1002","DOI":"10.1161\/CIRCULATIONAHA.121.055854","article-title":"Takotsubo Syndrome: Pathophysiology, Emerging Concepts, and Clinical Implications","volume":"145","author":"Singh","year":"2022","journal-title":"Circulation"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"902","DOI":"10.1016\/j.jacc.2020.10.060","article-title":"Pathophysiology of Takotsubo Syndrome: JACC State-of-the-Art Review","volume":"77","author":"Lyon","year":"2021","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"192","DOI":"10.1093\/cvr\/27.2.192","article-title":"Increased Responsiveness of Left Ventricular Apical Myocardium to Adrenergic Stimuli","volume":"27","author":"Mori","year":"1993","journal-title":"Cardiovasc. Res."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1955","DOI":"10.1016\/j.jacc.2018.07.072","article-title":"Stress Cardiomyopathy Diagnosis and Treatment: JACC State-of-the-Art Review","volume":"72","author":"Ma","year":"2018","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1038\/s41569-023-00946-3","article-title":"The Role of the NLRP3 Inflammasome and Pyroptosis in Cardiovascular Diseases","volume":"21","author":"Toldo","year":"2024","journal-title":"Nat. Rev. Cardiol."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Kovacevic, M., Jarakovic, M., Milovancev, A., Cankovic, M., Petrovic, M., Bjelobrk, M., Ilic, A., Srdanovic, I., Tadic, S., and Dabovic, D. (2023). Contemporary Review on Spontaneous Coronary Artery Dissection: Insights into the Angiographic Finding and Differential Diagnosis. Front. Cardiovasc. Med., 10.","DOI":"10.3389\/fcvm.2023.1278453"},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Stanojevic, D., Apostolovic, S., Kostic, T., Mitov, V., Kutlesic-Kurtovic, D., Kovacevic, M., Stanojevic, J., Milutinovic, S., and Beleslin, B. (2023). A Review of the Risk and Precipitating Factors for Spontaneous Coronary Artery Dissection. Front. Cardiovasc. Med., 10.","DOI":"10.3389\/fcvm.2023.1273301"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"3353","DOI":"10.1093\/eurheartj\/ehy080","article-title":"European Society of Cardiology, Acute Cardiovascular Care Association, SCAD Study Group: A Position Paper on Spontaneous Coronary Artery Dissection","volume":"39","author":"Adlam","year":"2018","journal-title":"Eur. Heart J."},{"key":"ref_30","first-page":"3313","article-title":"Clinical and Biochemical Profiles Suggest Fibromuscular Dysplasia Is a Systemic Disease with Altered TGF-\u03b2 Expression and Connective Tissue Features","volume":"28","author":"Ganesh","year":"2014","journal-title":"FASEB J. Off. Publ. Fed. Am. Soc. Exp. Biol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1672","DOI":"10.1016\/j.amjcard.2015.03.011","article-title":"Prevalence of Extracoronary Vascular Abnormalities and Fibromuscular Dysplasia in Patients with Spontaneous Coronary Artery Dissection","volume":"115","author":"Prasad","year":"2015","journal-title":"Am. J. Cardiol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"3182","DOI":"10.1161\/CIRCULATIONAHA.112.091223","article-title":"The United States Registry for Fibromuscular Dysplasia: Results in the First 447 Patients","volume":"125","author":"Olin","year":"2012","journal-title":"Circulation"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"951","DOI":"10.1161\/HYPERTENSIONAHA.118.11647","article-title":"Arterial Tortuosity","volume":"73","author":"Loeys","year":"2019","journal-title":"Hypertension"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Yosofi, B., de Waard, G., van de Hoef, T.P., Maas, A.H.E.M., Khan, H., Dawson, D., El Farissi, M., Eerdekens, R., Zimmermann, F., and Nijveldt, R. (2026). Role of Coronary Microvascular Dysfunction in Takotsubo Syndrome. Heart, heartjnl-2025-326929.","DOI":"10.1136\/heartjnl-2025-326929"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"117332","DOI":"10.1016\/j.atherosclerosis.2023.117332","article-title":"Comprehensive Invasive Evaluation of Coronary Microcirculation in Patients with Takotsubo Syndrome","volume":"385","author":"Belmonte","year":"2023","journal-title":"Atherosclerosis"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1016\/j.hrtlng.2024.06.007","article-title":"Coronary Microvascular Dysfunction in Patients with Takotsubo Syndrome","volume":"68","author":"Shetrit","year":"2024","journal-title":"Heart Lung J. Crit. Care"},{"key":"ref_37","first-page":"1629","article-title":"Coronary Microvascular Dysfunction in Takotsubo Syndrome: An Analysis Using Angiography-Derived Index of Microcirculatory Resistance","volume":"113","author":"Schweiger","year":"2024","journal-title":"Clin. Res. Cardiol. Off. J. Ger. Card. Soc."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"2244","DOI":"10.1093\/eurheartj\/ehad274","article-title":"Takotsubo Syndrome Is a Coronary Microvascular Disease: Experimental Evidence","volume":"44","author":"Dong","year":"2023","journal-title":"Eur. Heart J."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1002\/ejhf.2400","article-title":"Pathophysiology of Takotsubo Syndrome\u2014A Joint Scientific Statement from the Heart Failure Association Takotsubo Syndrome Study Group and Myocardial Function Working Group of the European Society of Cardiology\u2014Part 1: Overview and the Central Role for Catecholamines and Sympathetic Nervous System","volume":"24","author":"Omerovic","year":"2022","journal-title":"Eur. J. Heart Fail."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1016\/j.amjcard.2016.09.055","article-title":"Tortuosity, Recurrent Segments, and Bridging of the Epicardial Coronary Arteries in Patients with the Takotsubo Syndrome","volume":"119","author":"Arcari","year":"2017","journal-title":"Am. J. Cardiol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"174","DOI":"10.3892\/ijmm.2025.5615","article-title":"Takotsubo Syndrome: Unraveling the Mystery behind Its Triggers (Review)","volume":"56","author":"Fan","year":"2025","journal-title":"Int. J. Mol. Med."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"113315","DOI":"10.1016\/j.jbiomech.2026.113315","article-title":"Pregnancy Hormones Reversibly Dampen Single Cell Vascular Smooth Muscle Traction Force and F-Actin Alignment","volume":"202","author":"Nielsen","year":"2026","journal-title":"J. Biomech."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"426","DOI":"10.1016\/j.jacc.2017.05.055","article-title":"Spontaneous Coronary Artery Dissection Associated with Pregnancy","volume":"70","author":"Tweet","year":"2017","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"S117","DOI":"10.1097\/00005344-200312001-00024","article-title":"Estrogen Attenuates the Emotional Stress-Induced Cardiac Responses in the Animal Model of Tako-Tsubo (Ampulla) Cardiomyopathy","volume":"42","author":"Ueyama","year":"2003","journal-title":"J. Cardiovasc. Pharmacol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1016\/j.ijcard.2015.02.113","article-title":"Estrogen Resisted Stress-Induced Cardiomyopathy through Increasing the Activity of \u03b22AR-G\u03b1s Signal Pathway in Female Rats","volume":"187","author":"Cao","year":"2015","journal-title":"Int. J. Cardiol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"340","DOI":"10.1002\/clc.21986","article-title":"Clinical Characteristics, Sex Hormones, and Long-Term Follow-up in Swiss Postmenopausal Women Presenting with Takotsubo Cardiomyopathy","volume":"35","author":"Brenner","year":"2012","journal-title":"Clin. Cardiol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1016\/j.ijcard.2017.10.047","article-title":"Comprehensive Assessment of Sex Hormones in Takotsubo Syndrome","volume":"250","author":"Stiermaier","year":"2018","journal-title":"Int. J. Cardiol."},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Frank, N., Herrmann, M.J., Lauer, M., and F\u00f6rster, C.Y. (2024). Exploratory Review of the Takotsubo Syndrome and the Possible Role of the Psychosocial Stress Response and Inflammaging. Biomolecules, 14.","DOI":"10.3390\/biom14020167"},{"key":"ref_49","first-page":"1215","article-title":"Spontaneous Coronary Artery Dissection and Takotsubo Syndrome: The Chicken or the Egg Causality Dilemma","volume":"89","author":"Themudo","year":"2017","journal-title":"Catheter. Cardiovasc. Interv. Off. J. Soc. Card. Angiogr. Interv."},{"key":"ref_50","doi-asserted-by":"crossref","unstructured":"Celeski, M., Nusca, A., De Luca, V.M., Antonelli, G., Cammalleri, V., Melfi, R., Mangiacapra, F., Ricottini, E., Gallo, P., and Cocco, N. (2024). Takotsubo Syndrome and Coronary Artery Disease: Which Came First-The Chicken or the Egg?. J. Cardiovasc. Dev. Dis., 11.","DOI":"10.3390\/jcdd11020039"},{"key":"ref_51","doi-asserted-by":"crossref","unstructured":"Mathew, D., Wang, W., and Kunadian, V. (2026). Coronary Microvascular Dysfunction in Menopausal Women. Heart, heartjnl-2026-328124.","DOI":"10.1136\/heartjnl-2026-328124"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"2047","DOI":"10.1093\/eurheartj\/ehy077","article-title":"International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management","volume":"39","author":"Ghadri","year":"2018","journal-title":"Eur. Heart J."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"1036","DOI":"10.1002\/ejhf.683","article-title":"A Novel Clinical Score (InterTAK Diagnostic Score) to Differentiate Takotsubo Syndrome from Acute Coronary Syndrome: Results from the International Takotsubo Registry","volume":"19","author":"Ghadri","year":"2017","journal-title":"Eur. J. Heart Fail."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1089\/jwh.2021.0054","article-title":"Predictive Performance of the International Takotsubo Registry Score in the Diagnosis of Takotsubo Syndrome Among Women with Non-ST Segment Elevation Myocardial Infarction","volume":"31","author":"Ali","year":"2022","journal-title":"J. Womens Health"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"1630","DOI":"10.1016\/j.amjcard.2018.07.042","article-title":"Differences in Initial Electrocardiographic Findings of Apical Takotsubo Syndrome According to the Time from Symptom Onset","volume":"122","author":"Isogai","year":"2018","journal-title":"Am. J. Cardiol."},{"key":"ref_56","doi-asserted-by":"crossref","unstructured":"Balta, A., Ceasovschih, A., \u0218orodoc, V., Dimitriadis, K., G\u00fczel, S., Lionte, C., St\u0103tescu, C., Sasc\u0103u, R.A., Mantzouranis, E., and Sakalidis, A. (2022). Broad Electrocardiogram Syndromes Spectrum: From Common Emergencies to Particular Electrical Heart Disorders. J. Pers. Med., 12.","DOI":"10.3390\/jpm12111754"},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"e40","DOI":"10.1016\/j.ijcard.2008.03.070","article-title":"Left Ventricular Wall Motion Abnormality and Myocardial Dysfunction in Stress Cardiomyopathy: New Pathophysiological Aspects Suggested by Echocardiography","volume":"135","author":"Dandel","year":"2009","journal-title":"Int. J. Cardiol."},{"key":"ref_58","doi-asserted-by":"crossref","unstructured":"Dandel, M., and Hetzer, R. (2018). Deleterious Effects of Catecholamine Administration in Acute Heart Failure Caused by Unrecognized Takotsubo Cardiomyopathy. BMC Cardiovasc. Disord., 18.","DOI":"10.1186\/s12872-018-0882-5"},{"key":"ref_59","first-page":"1543","article-title":"Striking Observations during Emergency Catecholamine Treatment of Cardiac Syncope in a Patient with Initially Unrecognized Takotsubo Cardiomyopathy","volume":"73","author":"Dandel","year":"2009","journal-title":"Circ. J. Off. J. Jpn. Circ. Soc."},{"key":"ref_60","doi-asserted-by":"crossref","unstructured":"Ansari, U., El-Battrawy, I., Fastner, C., Behnes, M., Sattler, K., Huseynov, A., Baumann, S., T\u00fcl\u00fcmen, E., Borggrefe, M., and Akin, I. (2018). Clinical Outcomes Associated with Catecholamine Use in Patients Diagnosed with Takotsubo Cardiomyopathy. BMC Cardiovasc. Disord., 18.","DOI":"10.1186\/s12872-018-0784-6"},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"509","DOI":"10.1097\/MCA.0000000000000984","article-title":"Spontaneous Coronary Artery Dissection and Takotsubo Syndrome: Comparison of Baseline Clinical and Angiographic Characteristics and in-Hospital Outcomes","volume":"32","author":"Salamanca","year":"2021","journal-title":"Coron. Artery Dis."},{"key":"ref_62","doi-asserted-by":"crossref","unstructured":"Dagrenat, C., Von Hunolstein, J.J., Matsushita, K., Thebaud, L., Greciano, S., Tuzin, N., Meyer, N., Trinh, A., Jesel, L., and Ohlmann, P. (2020). Value of Cardiac Biomarkers in the Early Diagnosis of Takotsubo Syndrome. J. Clin. Med., 9.","DOI":"10.3390\/jcm9092985"},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"1433","DOI":"10.1016\/j.chest.2021.04.072","article-title":"Incidence and Clinical Impact of Right Ventricular Involvement (Biventricular Ballooning) in Takotsubo Syndrome: Results From the GEIST Registry","volume":"160","author":"Santoro","year":"2021","journal-title":"Chest"},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"1581","DOI":"10.1161\/CIRCULATIONAHA.118.037975","article-title":"Myocardial and Systemic Inflammation in Acute Stress-Induced (Takotsubo) Cardiomyopathy","volume":"139","author":"Scally","year":"2019","journal-title":"Circulation"},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"153848","DOI":"10.1016\/j.jelectrocard.2024.153848","article-title":"Prevalence and Severity of QT Prolongation and Other ECG Abnormalities in Takotsubo Syndrome","volume":"88","author":"Margulescu","year":"2025","journal-title":"J. Electrocardiol."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"328","DOI":"10.1016\/j.ijcard.2011.09.077","article-title":"Takotsubo Cardiomyopathy Has a Unique Cardiac Biomarker Profile: NT-proBNP\/Myoglobin and NT-proBNP\/Troponin T Ratios for the Differential Diagnosis of Acute Coronary Syndromes and Stress Induced Cardiomyopathy","volume":"154","author":"Schoch","year":"2012","journal-title":"Int. J. Cardiol."},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1016\/j.cardfail.2013.12.004","article-title":"Diagnostic Utility of Cardiac Biomarkers in Discriminating Takotsubo Cardiomyopathy from Acute Myocardial Infarction","volume":"20","author":"Randhawa","year":"2014","journal-title":"J. Card. Fail."},{"key":"ref_68","first-page":"37","article-title":"Spontaneous Coronary Artery Dissection-A Review","volume":"5","author":"Yip","year":"2015","journal-title":"Cardiovasc. Diagn. Ther."},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"2566","DOI":"10.1093\/eurheartj\/ehz332","article-title":"Clinical Use of Intracoronary Imaging. Part 2: Acute Coronary Syndromes, Ambiguous Coronary Angiography Findings, and Guiding Interventional Decision-Making: An Expert Consensus Document of the European Association of Percutaneous Cardiovascular Interventions","volume":"40","author":"Johnson","year":"2019","journal-title":"Eur. Heart J."},{"key":"ref_70","doi-asserted-by":"crossref","unstructured":"Liang, K., Nakou, E., Del Buono, M.G., Montone, R.A., D\u2019Amario, D., and Bucciarelli-Ducci, C. (2021). The Role of Cardiac Magnetic Resonance in Myocardial Infarction and Non-Obstructive Coronary Arteries. Front. Cardiovasc. Med., 8.","DOI":"10.3389\/fcvm.2021.821067"},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"e2634546","DOI":"10.2214\/AJR.26.34546","article-title":"Late Gadolinium Enhancement on Cardiac MRI in Patients with Takotsubo Syndrome: Insights From the Multicenter EVOLUTION Registry","volume":"226","author":"Cau","year":"2026","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_72","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1016\/j.amjcard.2026.04.057","article-title":"CMR Findings Across Disease Phases in Takotsubo Syndrome: Insights From the Multicenter EVOLUTION Registry","volume":"271","author":"Cau","year":"2026","journal-title":"Am. J. Cardiol."},{"key":"ref_73","doi-asserted-by":"crossref","first-page":"624","DOI":"10.1161\/CIRCULATIONAHA.120.052008","article-title":"Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction with Nonobstructive Coronary Arteries in Women","volume":"143","author":"Reynolds","year":"2021","journal-title":"Circulation"},{"key":"ref_74","first-page":"55","article-title":"2023 ESC Guidelines for the Management of Acute Coronary Syndromes","volume":"13","author":"Byrne","year":"2024","journal-title":"Eur. Heart J. Acute Cardiovasc. Care"},{"key":"ref_75","doi-asserted-by":"crossref","unstructured":"D\u2019Amato, A., Mariani, M.V., Prosperi, S., Colombo, L., Prisco, A.D., Lavalle, C., Mancone, M., Vizza, C.D., and Severino, P. (2024). Spontaneous Coronary Artery Dissection in Clinical Practice: Pathophysiology and Therapeutic Approaches. Medicina, 60.","DOI":"10.3390\/medicina60020217"},{"key":"ref_76","doi-asserted-by":"crossref","unstructured":"Meier, C., Eisenbl\u00e4tter, M., and Gielen, S. (2024). Myocardial Late Gadolinium Enhancement (LGE) in Cardiac Magnetic Resonance Imaging (CMR)\u2014An Important Risk Marker for Cardiac Disease. J. Cardiovasc. Dev. Dis., 11.","DOI":"10.3390\/jcdd11020040"},{"key":"ref_77","doi-asserted-by":"crossref","first-page":"585","DOI":"10.4330\/wjc.v6.i7.585","article-title":"Distribution of Late Gadolinium Enhancement in Various Types of Cardiomyopathies: Significance in Differential Diagnosis, Clinical Features and Prognosis","volume":"6","author":"Satoh","year":"2014","journal-title":"World J. Cardiol."},{"key":"ref_78","doi-asserted-by":"crossref","first-page":"e771","DOI":"10.1161\/CIR.0000000000001328","article-title":"2025 ACC\/AHA\/ACEP\/NAEMSP\/SCAI Guideline for the Management of Patients with Acute Coronary Syndromes: A Report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines","volume":"151","author":"Rao","year":"2025","journal-title":"Circulation"},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1177\/1358863X231155305","article-title":"Management of Spontaneous Coronary Artery Dissection: Trends over Time","volume":"28","author":"Feldbaum","year":"2023","journal-title":"Vasc. Med."},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"345","DOI":"10.31083\/j.rcm2509345","article-title":"Advances in the Management of Spontaneous Coronary Artery Dissection (SCAD): A Comprehensive Review","volume":"25","author":"Morena","year":"2024","journal-title":"Rev. Cardiovasc. Med."},{"key":"ref_81","doi-asserted-by":"crossref","first-page":"6686230","DOI":"10.1155\/2021\/6686230","article-title":"Outcomes of Percutaneous Coronary Intervention in Patients with Spontaneous Coronary Artery Dissection","volume":"2021","author":"Hassan","year":"2021","journal-title":"J. Interv. Cardiol."},{"key":"ref_82","first-page":"153","article-title":"In-Hospital and Long-Term Clinical Outcomes of Spontaneous Coronary Artery Dissection (SCAD): A Meta-Analysis of Conservative versus Revascularization Approaches","volume":"76","author":"Pitliya","year":"2024","journal-title":"Egypt. Heart J. EHJ Off. Bull. Egypt. Soc. Cardiol."},{"key":"ref_83","doi-asserted-by":"crossref","unstructured":"Petrovi\u0107, M., Miljkovi\u0107, T., Ili\u0107, A., Kova\u010devi\u0107, M., \u010cankovi\u0107, M., Dabovi\u0107, D., Stoj\u0161i\u0107 Milosavljevi\u0107, A., \u010cemerli\u0107 Maksimovi\u0107, S., Jarakovi\u0107, M., and Andri\u0107, D. (2024). Management and Outcomes of Spontaneous Coronary Artery Dissection: A Systematic Review of the Literature. Front. Cardiovasc. Med., 11.","DOI":"10.3389\/fcvm.2024.1276521"},{"key":"ref_84","doi-asserted-by":"crossref","first-page":"515","DOI":"10.1016\/j.recesp.2021.08.002","article-title":"Rationale and Design of the BA-SCAD (Beta-Blockers and Antiplatelet Agents in Patients with Spontaneous Coronary Artery Dissection) Randomized Clinical Trial","volume":"75","author":"Alfonso","year":"2022","journal-title":"Rev. Esp. Cardiol."},{"key":"ref_85","doi-asserted-by":"crossref","first-page":"1148","DOI":"10.1016\/j.jacc.2017.06.053","article-title":"Spontaneous Coronary Artery Dissection: Clinical Outcomes and Risk of Recurrence","volume":"70","author":"Saw","year":"2017","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_86","doi-asserted-by":"crossref","unstructured":"McKenzie, A., and Bargout, R. (2025). Takotsubo Syndrome in 2025: Evolving Concepts in Pathophysiology, Diagnosis, and Long-Term Management. J. Clin. Med., 15.","DOI":"10.3390\/jcm15010197"},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"964","DOI":"10.1038\/s41588-023-01410-1","article-title":"Genome-Wide Association Meta-Analysis of Spontaneous Coronary Artery Dissection Identifies Risk Variants and Genes Related to Artery Integrity and Tissue-Mediated Coagulation","volume":"55","author":"Adlam","year":"2023","journal-title":"Nat. Genet."},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"4432","DOI":"10.1038\/s41467-020-17558-x","article-title":"Chromosome 1q21.2 and Additional Loci Influence Risk of Spontaneous Coronary Artery Dissection and Myocardial Infarction","volume":"11","author":"Saw","year":"2020","journal-title":"Nat. Commun."},{"key":"ref_89","first-page":"101498","article-title":"Guidance Directed Care of Spontaneous Coronary Artery Dissection: A Healthcare System-Based Experience","volume":"54","author":"Christenson","year":"2024","journal-title":"Int. J. Cardiol. Heart Vasc."},{"key":"ref_90","doi-asserted-by":"crossref","first-page":"2660","DOI":"10.1093\/eurheartj\/ehaf837","article-title":"Transgender Persons Receiving Gender-Affirming Hormone Therapy: Risk of Acute Cardiovascular Events in a Dutch Cohort Study","volume":"47","author":"Thijs","year":"2026","journal-title":"Eur. Heart J."},{"key":"ref_91","doi-asserted-by":"crossref","first-page":"1266","DOI":"10.1161\/HYPERTENSIONAHA.119.13080","article-title":"Gender-Affirming Hormone Therapy, Vascular Health and Cardiovascular Disease in Transgender Adults","volume":"74","author":"Connelly","year":"2019","journal-title":"Hypertension"},{"key":"ref_92","doi-asserted-by":"crossref","first-page":"e136","DOI":"10.1161\/CIR.0000000000001003","article-title":"Assessing and Addressing Cardiovascular Health in People Who Are Transgender and Gender Diverse: A Scientific Statement From the American Heart Association","volume":"144","author":"Streed","year":"2021","journal-title":"Circulation"},{"key":"ref_93","doi-asserted-by":"crossref","first-page":"108996","DOI":"10.1016\/j.pharmthera.2026.108996","article-title":"Therapeutic Management of Inflammatory Heart Diseases","volume":"280","author":"Bonaventura","year":"2026","journal-title":"Pharmacol. Ther."},{"key":"ref_94","doi-asserted-by":"crossref","first-page":"e14110","DOI":"10.1111\/eci.14110","article-title":"Pathogenic Pathways and Therapeutic Targets of Inflammation in Heart Diseases: A Focus on Interleukin-1","volume":"54","author":"Bonaventura","year":"2024","journal-title":"Eur. J. Clin. Investig."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/15\/5810\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T10:05:45Z","timestamp":1785146745000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/15\/5810"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,24]]},"references-count":94,"journal-issue":{"issue":"15","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["jcm15155810"],"URL":"https:\/\/doi.org\/10.3390\/jcm15155810","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,24]]}}}