Fuzzy boundaries between physical and emotional triggers in Takotsubo cardiomyopathy: a scoping review

Takotsubo Syndrome (TTS), often referred to as stress cardiomyopathy, is a transient cardiac condition that mimics myocardial infarction in the absence obstructive coronary disease. TTS is typically triggered by stressful or traumatic events, which are often categorized as either emotional/psychosocial or physical; nevertheless, emerging evidence suggests that this stark classification may be limiting. This scoping review aims to explore the interplay and potential overlap between emotional and physical triggering factors in TTS through an analysis of clinical case reports published between 2010 and February 2025. We searched through different databases (PsycInfo, Pubmed, Scopus and Web of Science) for clinical case report of TTS patients with clearly identified triggering factors and whose diagnosis was consistent with 2010 Mayo Clinic criteria; we removed duplicates and screened the remaining articles by reading their titles and abstracts, leading to 266 cases assessed for eligibility. After that, we thoroughly read each of them, resulting in 219 cases included in the final scoping review. Our findings reveal that the majority of TTS cases described female patients and that most of TTS episodes were elicited by physical stressors such as surgeries, infections, or substance use, while the most common psychosocial triggers were potentially traumatic experiences. However, many physical triggering factors were accompanied by strong emotional components, such as perioperative anxiety, psychopathologies or traumatic experiences, even though the authors addressed concurrent emotional factors only in 24.4% of case reports describing physical triggers, suggesting a gap in clinical recognition. Conversely, events classified as emotional (e.g., grief or work-related stress) are known to elicit intense physiological responses involving the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis. Consequently, the boundaries between these two categories could be seen as fuzzy. Our review also confirms that TTS predominantly affects women, particularly postmenopausal, likely due to hormonal changes in estrogen levels and heightened vulnerability to psychosocial stress. In conclusion, the distinction between physical and emotional triggers in TTS may not be as clear-cut as traditionally assumed.