Objective Alterations in cortisol awakening and stress responses (CAR, CSR) are sensitive markers for the basal activity and responsiveness of the hypothalamus–pituitary–adrenal axis (HPAA) in psychopathological conditions. We investigated whether patients with takotsubo cardiomyopathy (TTC) differ in these markers when compared with non-ST-segment elevation myocardial infarction (NSTEMI) patients and healthy controls.

Methods 19 female TTC patients were compared with 20 female NSTEMI patients and with 20 healthy women, matched by age and index event date. Salivary sampling indicated cortisol release, questionnaires assessed personality, life events, chronic stress and psychiatric symptoms.

Results The groups did not differ relevantly in their basal HPAA activity, psychiatric or personality profiles. Despite increased heart rates in response to stress (median difference (MD_diff)=3.5, p=0.002) and higher nervousness scores (MD_diff=−3.0, p=0.024), TTC patients revealed a blunted CSR with a medium effect compared to the controls (MD_diff=−3.2 nmol/L, p=0.022, r=0.36); even when controlled for prestress cortisol differences (p=0.044, r=0.33). In comparison with NSTEMI patients, no significant differences in CSR (MD_diff=−1.9 nmol/L, p=0.127, r=0.25) or nervousness (MD_diff=2.0, p=0.107) can be observed. Stressful life events, for example, traumatic experiences, occurred more often in TTC (42%) than in NSTEMI patients and controls (both 10%, p=0.031).

Conclusions In this small exploratory trial, a trend for a blunted CSR and high incidences of stressful life events were observed in TTC patients. If these results can be confirmed in larger studies, chronic stress and the inhibitory influence of cortisol on catecholamine release might be significant for the pathogenesis of TTC.