The Heart-Brain Syndrome in clinical practice: A comprehensive approach from cardiac imaging for differential diagnosis
DOI:
https://doi.org/10.37615/retic.v9n1a2Keywords:
stroke heart syndrome, takotsubo, stroke, neurocardiology, echocardiography, cardiac magnetic resonanceAbstract
Introduction: Stroke heart syndrome (SHS) is a frequent and clinically relevant condition characterized by myocardial injury, arrhythmias, or acute ventricular dysfunction secondary to severe neurological damage. Troponin elevation, present in a high percentage of patients, poses the dilemma of distinguishing between neurogenic stress cardiomyopathy and a true acute coronary syndrome (ACS) that may either cause or result from the cerebral event. Objective: To provide clinical cardiologists and cardiac imaging specialists with a practical, evidence based framework in which noninvasive imaging techniques play a central role for the differential diagnosis and management of SHS. Development: An integrative pathophysiological update is presented, ranging from classical neurohumoral mechanisms to recent findings on inflammation and genetic susceptibility. Based on this foundation, the different clinical phenotypes of SHS are delineated and a sequential diagnostic approach is detailed. Bedside-applicable algorithms are provided to guide the selection and interpretation of each imaging modality: transthoracic and transesophageal echocardiography, cardiac magnetic resonance, and computed tomography. Conclusion: The structured application of these algorithms allows optimization of diagnostic accuracy, refinement of risk stratification, and support for personalized therapeutic management in this particularly challenging patient population.
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References
Zhao B, Li T, Fan Z, et al. Heart-brain connections: Phenotypic and genetic insights from magnetic resonance images. Science. 2023;380(6648):eabn6598. doi: 10.1126/science.abn6598. DOI: https://doi.org/10.1126/science.abn6598
Scheitz JF, Nolte CH, Doehner W, Hachinski V, Endres M. Stroke-heart syndrome: clinical presentation and underlying mechanisms. Lancet Neurol. 2018;17(12):1109-1120. doi: 10.1016/S1474-4422(18)30336-3. DOI: https://doi.org/10.1016/S1474-4422(18)30336-3
Scheitz JF, Sposato LA, Schulz-Menger J, Nolte CH, Backs J, Endres M. Stroke-Heart Syndrome: Recent Advances and Challenges. J Am Heart Assoc. 2022;11(17):e026528. doi: 10.1161/JAHA.122.026528. DOI: https://doi.org/10.1161/JAHA.122.026528
Wang M, Peng Y. Advances in brain-heart syndrome: Attention to cardiac complications after ischemic stroke. Front Mol Neurosci. 2022;15:1053478. doi: 10.3389/fnmol.2022.1053478. DOI: https://doi.org/10.3389/fnmol.2022.1053478
Rosso M, Ramaswamy S, Kvantaliani N, et al. Stroke-Heart Syndrome: Does Sex Matter? J Am Heart Assoc. 2023;12(21):e029799. doi: 10.1161/JAHA.123.029799. DOI: https://doi.org/10.1161/JAHA.123.029799
Tang H, Xing X, Han Y, et al. A Retrospective Study of Brain-Heart Syndrome in Patients with Acute Cerebrovascular Diseases. Risk Manag Healthc Policy. 2024;17:2161-2168. doi: 10.2147/RMHP.S467205. DOI: https://doi.org/10.2147/RMHP.S467205
Fan X, Cao J, Li M, et al. Stroke Related Brain-Heart Crosstalk: Pathophysiology, Clinical Implications, and Underlying Mechanisms. Adv Sci. 2024;11(14):2307698. doi: 10.1002/advs.202307698. DOI: https://doi.org/10.1002/advs.202307698
Zou L, Han R. Inflammatory Response and Immune Regulation in Brain-Heart Interaction after Stroke. Cardiovasc Ther. 2022;2022:2406122. doi: 10.1155/2022/2406122. DOI: https://doi.org/10.1155/2022/2406122
Vornholz L, Nienhaus F, Gliem M, et al. Acute Heart Failure After Reperfused Ischemic Stroke: Association With Systemic and Cardiac Inflammatory Responses. Front Physiol. 2021;12:782760. doi: 10.3389/fphys.2021.782760. DOI: https://doi.org/10.3389/fphys.2021.782760
Hu JR, Abdullah A, Nanna MG, Soufer R. The Brain-Heart Axis: Neuroinflammatory Interactions in Cardiovascular Disease. Curr Cardiol Rep. 2023;25(12):1745-1758. doi: 10.1007/s11886-023-01990-8. DOI: https://doi.org/10.1007/s11886-023-01990-8
Brazdil V, Kala P, Hudec M, et al. The role of central autonomic nervous system dysfunction in Takotsubo syndrome: a systematic review. Clin Auton Res. 2022;32(1):9-17. doi: 10.1007/s10286-021-00844-z. DOI: https://doi.org/10.1007/s10286-021-00844-z
Suzuki H, Yasuda S, Shimokawa H. Brain-heart connection in Takotsubo syndrome before onset. Eur Heart J. 2021;42(19):1909-1911. doi: 10.1093/eurheartj/ehab026.
Markousis-Mavrogenis G, Pepe A, Bacopoulou F, et al. Combined Brain-Heart Imaging in Takotsubo Syndrome: Towards a Holistic Patient Assessment. J Clin Med. 2024;13(10):2991. doi: 10.3390/jcm13102991. DOI: https://doi.org/10.3390/jcm13102991
Lesch H, Kruska M, Marx A, et al. The phenomenon of dynamic change of cardiac troponin levels in patients with spontaneous intracerebral hemorrhage increases in-hospital mortality independent of macrovascular coronary artery disease. J Neurol Sci. 2025;476:123633. doi: 10.1016/j.jns.2025.123633. DOI: https://doi.org/10.1016/j.jns.2025.123633
Suzuki H, Yasuda S, Shimokawa H. Brain-heart connection in Takotsubo syndrome. Eur Heart J. 2021;42(19):1909-1911. doi: 10.1093/eurheartj/ehab026. DOI: https://doi.org/10.1093/eurheartj/ehab026
Zheng J, Ma Y, Guo X, Wu J. Immunological characterization of stroke-heart syndrome and identification of inflammatory therapeutic targets. Front Immunol. 2023;14:1227104. doi: 10.3389/fimmu.2023.1227104. DOI: https://doi.org/10.3389/fimmu.2023.1227104
Sethi Y, Murli H, Kaiwan O, et al. Broken Heart Syndrome: Evolving Molecular Mechanisms and Principles of Management. J Clin Med. 2022;12(1):125. doi: 10.3390/jcm12010125. DOI: https://doi.org/10.3390/jcm12010125
Liang Y, Wang G, Fan S, et al. Brain-to-heart cholinergic synapse-calcium signaling mediates ischemic stroke-induced atrial fibrillation. Theranostics. 2024;14(17):6625-6649. doi: 10.7150/thno.99065. DOI: https://doi.org/10.7150/thno.99065
Myrmel GMS, Waje-Andreassen U, Pirinen J, et al. Multimodality Cardiac Imaging in Ischemic Stroke: Insights into the Heart-Brain Interaction. Cardiology. 2025;150(5):525-539. doi: 10.1159/000543170. DOI: https://doi.org/10.1159/000543170
Cau R, Porcu M, Suri JS, et al. Heart-Brain axis: is microvascular dysfunction the link between stroke and Takotsubo syndrome? Int J Cardiovasc Imaging. 2025;41(10):1895-1906. doi: 10.1007/s10554-025-03477-9. DOI: https://doi.org/10.1007/s10554-025-03477-9
Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015;16(3):233-270. doi: 10.1093/ehjci/jev014. DOI: https://doi.org/10.1093/ehjci/jev014
Voigt JU, Pedrizzetti G, Lysyansky P, et al. Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging. Eur Heart J Cardiovasc Imaging. 2015;16(1):1-11. doi: 10.1093/ehjci/jeu184. DOI: https://doi.org/10.1093/ehjci/jeu184
Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29(4):277-314. doi: 10.1016/j.echo.2016.01.011. DOI: https://doi.org/10.1016/j.echo.2016.01.011
Kerro A, Woods T, Chang JJ. Neurogenic stunned myocardium in subarachnoid hemorrhage. J Crit Care. 2017;38:27-34. doi: 10.1016/j.jcrc.2016.10.010. DOI: https://doi.org/10.1016/j.jcrc.2016.10.010
Ghadri JR, Wittstein IS, Prasad A, et al. International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology. Eur Heart J. 2018;39(22):2032-2046. doi: 10.1093/eurheartj/ehy076. DOI: https://doi.org/10.1093/eurheartj/ehy076
Templin C, Ghadri JR, Diekmann J, et al. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N Engl J Med. 2015;373(10):929-938. doi: 10.1056/NEJMoa1406761. DOI: https://doi.org/10.1056/NEJMoa1406761
Eitel I, von Knobelsdorff-Brenkenhoff F, Bernhardt P, et al. Clinical characteristics and cardiovascular magnetic resonance findings in stress (takotsubo) cardiomyopathy. JAMA. 2011;306(3):277-286. doi: 10.1001/jama.2011.992. DOI: https://doi.org/10.1001/jama.2011.992
Saric M, Armour AC, Arnaout MS, et al. Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism. J Am Soc Echocardiogr. 2016;29(1):1-42. doi: 10.1016/j.echo.2015.09.011. DOI: https://doi.org/10.1016/j.echo.2015.09.011
Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021;52(7):e364-e467. doi: 10.1161/STR.0000000000000375. DOI: https://doi.org/10.1161/STR.0000000000000375
Friedrich MG, Sechtem U, Schulz-Menger J, et al. Cardiovascular magnetic resonance in myocarditis: a JACC White Paper. J Am Coll Cardiol. 2009;53(17):1475-1487. doi: 10.1016/j.jacc.2009.02.007. DOI: https://doi.org/10.1016/j.jacc.2009.02.007
Ferreira VM, Schulz-Menger J, Holmvang G, et al. Cardiovascular Magnetic Resonance in Nonischemic Myocardial Inflammation: Expert Recommendations. J Am Coll Cardiol. 2018;72(24):3158-3176. doi: 10.1016/j.jacc.2018.09.072.
Ferreira VM, Schulz-Menger J, Holmvang G, et al. Cardiovascular Magnetic Resonance in Nonischemic Myocardial Inflammation: Expert Recommendations. J Am Coll Cardiol. 2018;72(24):3158-3176. doi: 10.1016/j.jacc.2018.09.072. DOI: https://doi.org/10.1016/j.jacc.2018.09.072
Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2021;42(5):373-498. doi: 10.1093/eurheartj/ehaa612. DOI: https://doi.org/10.1093/eurheartj/ehaa798
Rubiera M, Aires A, Antonenko K, et al. European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin. Eur Stroke J. 2022;7(3):VI. doi: 10.1177/23969873221099478. DOI: https://doi.org/10.1177/23969873221099478
Mas JL, Derumeaux G, Guillon B, et al. Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke. N Engl J Med. 2017;377(11):1011-1021. doi: 10.1056/NEJMoa1705915.
Søndergaard L, Kasner SE, Rhodes JF, et al. Patent Foramen Ovale Closure or Antiplatelet Therapy for Cryptogenic Stroke. N Engl J Med. 2017;377(11):1033-1042. doi: 10.1056/NEJMoa1707404.
Habib G, Lancellotti P, Antunes MJ, et al. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J. 2023;44(39):3948-4042. doi: 10.1093/eurheartj/ehad193. DOI: https://doi.org/10.1093/eurheartj/ehad193
Tamis-Holland JE, Jneid H, Reynolds HR, et al. Contemporary Diagnosis and Management of Patients With Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease: A Scientific Statement From the American Heart Association. Circulation. 2019;139(18):e891-e908. doi: 10.1161/CIR.0000000000000670. DOI: https://doi.org/10.1161/CIR.0000000000000670
Juncà G, Teis A, Kasa G, et al. Timing of cardiac magnetic resonance and diagnostic yield in patients with myocardial infarction with nonobstructive coronary arteries. Rev Esp Cardiol (Engl Ed). 2024;77(7):515-523. doi: 10.1016/j.rec.2023.11.013. DOI: https://doi.org/10.1016/j.rec.2023.11.013
Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020;41(3):407-477. doi: 10.1093/eurheartj/ehz425.
Romero J, Husain SA, Kelesidis I, et al. Detection of left atrial appendage thrombus by cardiac computed tomography in patients with atrial fibrillation: a meta-analysis. Circ Cardiovasc Imaging. 2013;6(2):185-194. doi: 10.1161/CIRCIMAGING.112.000153. DOI: https://doi.org/10.1161/CIRCIMAGING.112.000153
Yu S, He W, Wang R, et al. Cardiac Computed Tomography Versus Transesophageal Echocardiography for the Detection of Left Atrial Appendage Thrombus: A Systemic Review and Meta-Analysis. J Am Heart Assoc. 2021;10(23):e022505. doi: 10.1161/JAHA.121.022505. DOI: https://doi.org/10.1161/JAHA.121.022505
Spagnolo P, Giglio M, Di Marco D, et al. Diagnosis of left atrial appendage thrombus in patients with atrial fibrillation: delayed contrast-enhanced cardiac CT. Eur Radiol. 2021;31(3):1236-1244. doi: 10.1007/s00330-020-07172-2. DOI: https://doi.org/10.1007/s00330-020-07172-2
Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. Circulation. 2021;144(22):e368-e454. doi: 10.1161/CIR.0000000000001029. DOI: https://doi.org/10.1161/CIR.0000000000001029
Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020;41(3):407-477. doi: 10.1093/eurheartj/ehz425. DOI: https://doi.org/10.1093/eurheartj/ehz425
Gladstone DJ, Spring M, Dorian P, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med. 2014;370(26):2467-2477. doi: 10.1056/NEJMoa1311376. DOI: https://doi.org/10.1056/NEJMoa1311376
Sanna T, Diener HC, Passman RS, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. 2014;370(26):2478-2486. doi: 10.1056/NEJMoa1313600. DOI: https://doi.org/10.1056/NEJMoa1313600
Saver JL, Carroll JD, Thaler DE, et al. Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke. N Engl J Med. 2017;377(11):1022-1032. doi: 10.1056/NEJMoa1610057. DOI: https://doi.org/10.1056/NEJMoa1610057
Mas JL, Derumeaux G, Guillon B, et al. Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke. N Engl J Med. 2017;377(11):1011-1021. doi: 10.1056/NEJMoa1705915. DOI: https://doi.org/10.1056/NEJMoa1705915
Søndergaard L, Kasner SE, Rhodes JF, et al. Patent Foramen Ovale Closure or Antiplatelet Therapy for Cryptogenic Stroke. N Engl J Med. 2017;377(11):1033-1042. doi: 10.1056/NEJMoa1707404. DOI: https://doi.org/10.1056/NEJMoa1707404
Markousis-Mavrogenis G, Sfikakis PP, Mavrogeni SI, Tektonidou MG. Combined brain/heart magnetic resonance imaging in antiphospholipid syndrome-two sides of the same coin. Clin Rheumatol. 2021;40(7):2559-2568. doi: 10.1007/s10067-020-05498-2. DOI: https://doi.org/10.1007/s10067-020-05498-2
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Copyright (c) 2026 José Alberto Sánchez-Guerra, Pedro María Azcárate Agüero, Miguel Ángel García Fernández
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