Letter Regarding Article, "Biventricular Takotsubo Cardiomyopathy Associated with Epilepsy".

I read the report by Koo et al.1) published in the December 2015 issue of the Journal, about the 83-year-old woman with history of post-hemorrhagic stroke epilepsy, and status epilepticus-triggered Takotsubo syndrome (TTS), involving both the right and left ventricles. I have some comments and questions for the kind consideration of the authors: 1) The electrocardiogram (ECG) of their patient showed ST-segment elevations, Qwaves in leads V1–3, and low amplitude QRS complexes (LAQRS) in the limb leads, in accordance with a new insight recently published.2) Since such LAQRS are transient, I wonder whether prior or subsequent ECGs showed larger QRS complexes in the limb leads. Also, were the Q-waves transient? And, did the patient develop T-wave inversions and QTc prolongation during her 10 days of hospitalization? 2) I fully concur with the authors' views about the link between epilepsy and TTS, and its connotations about possible mechanistic association with the syndrome of the sudden unexpected death in epilepsy.1) 3) One wonders how we should act to protect our patients with recurrent seizures from TTS. Do such patients suffer atypical episodes of TTS,3) which do not reach a severity level requiring hospitalization? Do ECGs in patients with T-wave inversions, in the aftermath of such recurrent seizures, signify that such patients after all suffer mild forms of TTS? Indeed this author has proposed use by the patients or care-givers of "smart phone technology"-based frequent transmission of their ECGs4) to their physicians for evaluation? Such a strategy may be feasible for evaluation of patients following seizures, in their ambulatory environment, since serial echocardiograms cannot be realistically be recorded.