Could “preclinical takotsubo syndrome” be the cause of spontaneous coronary artery dissection?

It is increasingly apparent that takotsubo syndrome (TTS) and spontaneous coronary artery dissection (SCAD) are associated. While the pathophysiology of TTS and SCAD are still debated, there should not be much doubt that SCAD could trigger TTS, as the latter often emerges in the context of a great variety of physical and emotional stresses, and thus SCAD should not be excluded as a TTS precipitant. In regards to TTS precipitating SCAD, it has been proposed that the anatomic junction of vigorously contracting base of the heart and the abutting akinetic/dyskinetic mid-ventricular/apical myocardium, could form a "hinge pivoting point”, exerting a disrupting mechanical influence on the coronary vessels crossing these 2 planes, precipitating tearing of the coronary vessel wall, formation of an intramural hematoma, with resultant SCAD in susceptible individuals. This review also provides a detailed list of recommendations for exploring the plausible association of TTS and SCAD, irrespective of their temporal sequence of occurrence.