Author's reply.

We appreciate the interest expressed by Dr. Kapoor in our published report of TTC after initiation of therapy for pulmonary arterial hypertension.[1] The importance of stress-induced cardiomyopathies, as an entity, should not be underestimated. The end result of a TTC can be devastating and fatal, especially if the clinical context is in an already clinically tenuous patient.[2]

The process of treatment initiation, medical, and/or surgical, can promote enormous emotional anxieties, irrespective of the underlying disease process.[3] The entity itself, TTC, demonstrates the power of perception and its interaction with physiologic functioning. In addition, TTC reminds us of the importance of open communication as a physician. As seen in our case, despite what we perceived as open dialogue, the initiation of prostacyclin therapy led to this reaction. As Dr. Kapoor has detailed, there are a variety of clinical scenarios previously described, both life-threatening and relatively less severe, that have the potential to promote a TTC. Detailed discussion and time for processing therapeutic decisions is critical to alleviate patient concerns, although it is unclear if this will indeed alter this response. Unfortunately, it also remains unclear who will develop this type of response, and if it is preventable. We hope that our case brings about a greater awareness and earlier recognition and will perhaps promote an international registry to learn more about the entity.