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Am J Med Case Rep. 2019;7(9):203-209. doi: 10.12691/ajmcr-7-9-6. Epub 2019 Jul 19.

Defining Features of Patients who Develop Takotsubo Cardiomyopathy during Myasthenic Crisis: A Systematic Review of Case Studies.

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Division of Cardiovascular Diseases and Department of Internal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, U.S.A.
Saba University School of Medicine, 27 Jackson Road, Devens, MA 01434, U.S.A.
Department of Internal Medicine, NYC + HHC Jacobi Medical Center, 1400 Pelham Pkwy S, The Bronx, NY 10461, U.S.A.
Department of Internal Medicine, Wyckoff Heights Medical Center, 374 Stockholm St, Brooklyn, NY 1123, U.S.A.
Trinity School of Medicine, 925 Woodstock Road, Roswell, GA 30075, U.S.A.
Department of Internal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, U.S.A.



Myasthenic crisis can induce Takotsubo cardiomyopathy leading to transient systolic and diastolic left ventricular dysfunction and wall-motion abnormalities, including the characteristic apical ballooning. We aimed to define the clinical features of this disease entity.


A systematic review was conducted to examine the characteristics of Takotsubo cardiomyopathy presenting in myasthenia gravis patients. Case reports were accessed by searching MEDLINE/PubMed, Google Scholar, CINAHL, and Web of Science databases. 523 articles were identified and 14 were selected for review.


Takotsubo cardiomyopathy presenting in myasthenia gravis' patients tends to affect women between the ages of 40 to 77. History of atrial fibrillation or hypertension was found in a minority of cases. Generalized weakness, fatigue, dysphagia and respiratory distress were common at presentation. Vital signs demonstrated normal blood pressure without tachycardia or bradycardia. Elevated values of troponins, creatine kinase (CK), and CK-MB isoenzymes were recorded. ST-segment elevation followed by T-wave inversion were predominantly found on electrocardiograms. Apical abnormalities in the form of ballooning, hypokinesia, or sparing and reduced left ventricular ejection fraction (≤45%) were observed using transthoracic echocardiogram or left ventriculography. Coronary angiography demonstrated no obstructive lesions. Ventilatory support, cholinesterase inhibitors and glucocorticoids resulted in the recovery or improvement of the left ventricular ejection fraction and hemodynamic stability. Only a minority of patients died of refractory heart failure. Treatment with inotropes and/or vasopressors led to poorer outcomes, including death or intractable heart failure.


The management of Takotsubo cardiomyopathy developing in myasthenia gravis patients should focus on addressing the myasthenic crisis, while proving supportive care in and intensive care setting.


myasthenic crisis; takotsubo cardiomyopathy

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