The elusive link between sex hormone levels and takotsubo syndrome

The higher incidence of cardiovascular disease in men than in women of similar age and the menopause-associated increase in heart diseases in women have led to the belief that gender-related differences in sex hormones might affect the development and evolution of several cardiovascular conditions [1], including coronary artery disease, valvular heart disease, and cardiomyopathies. The well-recognized finding that the overwhelming majority of patients with TTS are postmenopausal women, with a similar prevalence across ethnic groups, has been adding fuel to the concept that female sex hormones have an important pathophysiologic role [2]. Indeed, experimental work has clearly demonstrated that estrogens exert various cardioprotective effects including inhibition of excessive sympatho-adrenal and renin– angiotensin system activations as well as of antioxidant effects [3], thus suggesting that an estrogen deficiency, typical of the postmenopausal state, may be a predisposing factor of TTS. More than 3 decades after the original description of the condition, however, no clinical study has documented any association between sex hormone levels and TTS and the hormonal status of patients with TTS remains poorly characterized [4]. Only Brenner et al., in 2012, assessed estradiol, progesterone, luteinizing hormone, and follicle-stimulating hormone in 17 women with TTS, 16 age-matched women with acute myocardial infarction and 15 women with normal coronary arteries. These investigators found that the estradiol concentration at hospital admission was significantly higher in TTS patients than in the control groups, although this increase was transient and disappeared at follow-up