Clinical profile and in-hospital outcome of Caucasian patients with takotsubo syndrome and right ventricular involvement

Takotsubo cardiomyopathy in India and its electrocardiography (ECG) comparison to myocardial infarction

BACKGROUND

Owing to the limited research on Takotsubo Cardiomyopathy (TCM) in Asia, we aim to evaluate in detail the clinical profiles, lab parameters, investigations, and major adverse cardiovascular events (MACE) seen in patients with TCM in the Indian subcontinent. Additionally, we have compared the electrocardiographic findings of patients with TCM to those of patients with myocardial infarction (MI).

RESULTS

The average age of the patients affected was found to be 60 ± 11 years. Women (87.5%) and patients with hypertension (40%) were found to be at an increased risk of developing the syndrome. The most common presenting symptom was dyspnea (48%) following a trigger most commonly emotional (45%). ST elevation and significant T wave inversions were observed in 40% of patients with TCM. Echocardiography revealed a low left ventricular ejection fraction of 43 ± 9%. Coronary angiography was normal in 60%, the rest had mild/subcritical stenoses. The 6-month MACE was 20% and the mortality rate was 7.5%. Follow-up echocardiography of patients with TCM showed improvement in EF in 75% patients.

CONCLUSIONS

TCM was majorly seen in postmenopausal women following an emotional trigger, but a variety of other triggers were noted. T-wave inversions in TCM follow a diffuse pattern in contrast to specific leads seen in MI. Normal or subcritical stenosis in coronaries at presentation, along with a low EF which improves on follow up provide greater evidence for the diagnosis of TCM.

A Case of Reverse McConnell's Sign Associated With Acute Respiratory Distress Syndrome and Septic Shock

We present a case of reverse McConnell's sign, a rare echocardiographic finding of right ventricular apical hypokinesis and basal hyperkinesis, in a patient with acute respiratory distress syndrome and septic shock. Although multiple etiologies were hypothesized, providers attributed this cardiomyopathy to increased right heart afterload from hypoxic pulmonary vasoconstriction. Cardiac function normalized as the patient's respiratory failure and sepsis resolved. This study highlights the value of early echocardiography to help guide management in critical illness. In our case, this finding helped initiate diuresis and establish a baseline for monitoring cardiac function as this patient's critical illness resolved. Literature has most commonly associated reverse McConnell's sign with massive pulmonary embolism and, more rarely, takotsubo cardiomyopathy. Given the absence of PE, takotsubo, or other identifiable cause, this case suggests that reverse McConnell's sign may more generally indicate acutely increased right ventricular afterload rather than a specific diagnosis. When reverse McConnell's sign is detected, treatment should focus on reversible causes of elevated right heart pressure (e.g., volume overload, PE) and increased pulmonary resistance.

Arterial hypertension in patients with takotsubo syndrome: prevalence, long-term outcome, and secondary preventive strategies: a report from the Takotsubo Italian Network register

AIMS

The aim of this study was to investigate the long-term outcome of takotsubo syndrome (TTS) patients with and without hypertension (HT) and to evaluate the effectiveness of treatment with beta-blockers (BBs) and/or renin-angiotensin-aldosterone system inhibitors (RAASi).

METHODS AND RESULTS

The study population includes a register-based, multicentre cohort of consecutive patients with TTS, divided into two groups according to the history of HT. Further stratification was performed for BB/RAASi prescription at discharge. The primary outcome was the composite of all-cause death and TTS recurrence at the longest available follow-up. The propensity score weighting technique was used to account for potential confounding. In the overall population (903 patients, mean age 70 ± 11 years), HT was reported in 66% of cases. At a median 2-year follow-up, there was no difference in the risk of the primary composite outcome between patients with and without HT. The adjusted Cox regression analysis showed a significantly lower risk for the primary outcome [adjusted hazard ratio (aHR): 0.69; 95% confidence interval (CI): 0.49-0.99] in patients who received BB vs. those who did not. Renin-angiotensin-aldosterone system inhibitors treatment was not associated with the primary study outcome. The lower risk for the primary outcome with BB treatment was confirmed in patients with HT (aHR: 0.37; 95% CI: 0.24-0.56) but not in patients without (aHR: 1.83; 95% CI: 0.92-3.64; Pinteraction < 0.001).

CONCLUSION

In this TTS study, HT did not affect the long-term risk of adverse events but increased the probability of benefit from BB treatment after discharge. Owing to the favourable outcome impact of BB prescription in TTS patients with HT, a tailored pharmacological therapy should be considered in this cohort.

Takotsubo Syndrome in Black Americans: Insights From the National Inpatient Sample

BACKGROUND

Data on race-related differences in the clinical outcomes of Takotsubo syndrome are limited, particularly for Black patients. This study aimed to assess whether race and sex may have an additional impact on the inpatient mortality of patients with Takotsubo syndrome.

METHODS

A total of 4,628 patients from the United States' National Inpatient Sample from 2012 to 2016 were identified; propensity score analysis revealed a similar propensity score between Black patients (n = 2,314) and White patients (n = 2,314), which was used to balance observed covariates. Sex and age distributions were identical between the 2 groups. The groups were also similar in baseline characteristics, including cardiovascular risk factors. White patients were compared with Black patients on in-hospital outcomes and inpatient mortality. A logistic regression analysis was conducted to measure the difference in mortality based on race and sex.

RESULTS

Compared with White patients, Black patients had a higher percentage of in-hospital complications, including cerebrovascular accidents (4.9% vs 2.5%, P ≤ .01), acute kidney injury (25% vs 19%, P ≤ .01); longer lengths of stay (8 vs 7 days, P ≤ .01); and higher inpatient mortality (6.1% vs 4.5%, P < .01). When analysis was conducted with race and sex combined, inpatient mortality was higher among Black men than among White women (odds ratio, 2.7 [95% CI, 1.80-3.95]; P ≤ .01).

CONCLUSION

This study showed that Black patients with Takotsubo syndrome have higher in-hospital complications and inpatient mortality rates. When race and sex were combined, inpatient mortality was significantly higher among Black men than among either White men and women or Black women.

Age-sex effect on in-hospital complications and mortality in patients with Takotsubo syndrome. Insights from the National Inpatient Sample

Age and sex differences in Takotsubo syndrome (TTS) are still a matter of debate. The present study aimed to evaluate the difference in cardiovascular (CV) risk factors, CV disease, in-hospital complications, and death within different sex-age groups. Using the National Inpatient Sample database between 2012 and 2016, 32,474 patients older than 18 years of age hospitalized with the primary diagnosis of TTS were identified. A total of 32,474 patients were enrolled; 27,611 (85.04%) were female. CV risk factors were higher in females, while CV diseases and in-hospital complications were significantly higher in males. The mortality in males was twice as high as that of female patients (9.83% versus 4.58%, p<0.01), and in the logistic regression model after adjustment for confounders, the odds ratio (OR) was 1.79, the confidence interval was 1.60-2.02, and p<0.01. After dividing the group based on age, in-hospital complications were inversely related to age in both sexes, and the length of in-hospital stay was double in the youngest group compared to the oldest one. Mortality increased progressively with age in both groups but was constantly higher in males for each age group. Multiple logistic regression analysis for mortality was performed for the two sexes separately and for the three age groups, considering the youngest one as the reference group. In females, the OR was 1.59 and 2.88, respectively, for groups 2 and 3; for males, the OR was 1.92 and 3.15, all of them statistically significant (p<0.01). In-hospital complications were more common in younger patients with TTS, particularly in males. Mortality was positively correlated with age for both sexes, but mortality was higher in males compared to females in all age groups.

Smidt Heart Institute Takotsubo Registry - Study design and baseline characteristics

Background

Takotsubo syndrome (TTS) is an acute form of transient systolic heart failure that occurs predominantly among women and in association with emotional or physical stressors. The Smidt Heart Institute Takotsubo Registry aims to establish a database through an online patient-advocate registry for deep phenotyping of this syndrome.

Methods

The Takotsubo Registry is a retrospective and prospective observational registry of individuals with a prior history of TTS. Participants are sourced through physician referrals, medical records review, peer- and self-referrals using social media. Research Electronic Data Capture (REDCap) and Mitra® microsamplers are used to collect questionnaire data and blood samples to facilitate completely remote study enrollment and participation for most participants.

Results

From January 2019 to May 2021, 125 participants (99% female, mean age: 61.5 ± 9.9 years) enrolled in the registry across 25 US states and 3 international countries, with reported first TTS event a median of 2 years prior to enrollment. Psychosocial characteristics determined by standardized questionnaires at baseline include relatively high anxiety trait (44%), moderate to severe depression severity (19%), moderate to high severity of posttraumatic stress disorder symptoms (58%) and a history of childhood trauma/abuse (50%).

Conclusions

The Smidt Heart Institute Takotsubo Registry will contribute to advancing the management of TTS by deep phenotyping to understand its pathophysiology, and identify treatment targets in a participant base for future clinical trials.

Epidemiology, Pathogenesis, and Clinical Course of Takotsubo Syndrome

Takotsubo syndrome is an acute reversible heart failure syndrome, most frequently seen in postmenopausal women and precipitated generally by significant emotional stress or physical illness. A sudden sympathetic activation seems to play a key role in the pathophysiology, but growing evidence is emerging about the role of inflammation in the subacute and chronic phases. An incidence of life-threatening complications occurring in the acute phase and at long-term follow-up has been demonstrated, comparable with the acute coronary syndrome. Multimodality imaging could be useful to stratify in-hospital and long-term prognosis. The efficacy of specific medical treatments in long-term follow-up should be investigated.

Dynamic Left Intraventricular Obstruction Phenotype in Takotsubo Syndrome

Takotsubo syndrome (TTS) is characterized by acute, generally transient left ventricular (LV) dysfunction. Although TTS has been long regarded as a benign condition, recent evidence showed that rate of acute complications and in-hospital mortality is comparable to that of patients with acute coronary syndrome. In particular, the prevalence of cardiogenic shock ranges between 6% and 20%. In this setting, detection of mechanisms leading to cardiogenic shock can be challenging. Besides a severely impaired systolic function, onset of LV outflow tract obstruction (LVOTO) together with mitral regurgitation related to systolic anterior motion of mitral valve leaflets can lead to hemodynamic instability. Early identification of LVOTO with echocardiography is crucial and has important implications on selection of the appropriate therapy. Application of short-acting b1-selective betablockers and prudent administration of fluids might help to resolve LVOTO. Conversely, inotrope agents may increase basal hypercontractility and worsen the intraventricular pressure gradient. To date, outcomes and management of patients with TTS complicated by LVOTO as yet has not been comprehensively investigated.

Takotsubo Syndrome-Is There a Need for CMR?

PURPOSE OF REVIEW

Takotsubo syndrome (TTS) is a transient but severe myocardial dysfunction that has been known for decades and is still to be fully understood regarding its clinical presentations and pathophysiological mechanisms. Cardiac magnetic resonance (CMR) imaging plays a key role in the comprehensive analysis of patients with TTS in acute and follow-up examinations. In this review, we focus on the major advantages and latest evolutions of CMR in diagnosis and prognostication of TTS and discuss future perspectives and needs in the field of research and cardiovascular imaging in TTS.

RECENT FINDINGS

Specific CMR criteria for TTS diagnosis at the time of acute presentation are established. In addition to identifying the typical regional wall motion abnormalities, CMR allows for precise quantification of right ventricular and left ventricular (LV) function, the assessment of additional abnormalities/complications (e.g. pericardial and/or pleural effusion, LV thrombi), and most importantly myocardial tissue characterization (myocardial oedema, inflammation, necrosis/fibrosis). CMR enables a comprehensive assessment of the entire spectrum of functional and structural changes that occur in patients with TTS and may have also a prognostic impact. CMR can distinguish between TTS and other important differential diagnoses (myocarditis, myocardial infarction) with direct consequences on medical therapy.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase.

Prognostic implications of pre-existing medical comorbidity in Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC) is associated with significant short-term morbidity and mortality. Several risk factors for poor outcomes have been identified; however, the prognostic implications of pre-existing comorbidity in TC are poorly delineated. We sought to assess the association of aggregate pre-existing comorbidity with short-term outcomes in TC. We performed a retrospective observational study of adult subjects diagnosed with TC at two academic tertiary care hospitals between 2005 and 2018. Overall burden of medical comorbidity was estimated using the Charlson comorbidity index (CCI). Multivariable logistic regression was used to test for independent association of CCI with 30-day mortality and severe shock at index presentation. Multivariable poisson regression was performed to assess the association of CCI with duration of hospitalization. Five-hundred and thirty-eight subjects were diagnosed with TC during the study period. The median CCI score of all subjects was 2 (IQR 1-4). Among subjects with physical triggers of TC, the median CCI score was 2 (IQR 1-4) compared to a median CCI score of 1 (IQR 0-1) in subjects with non-physical triggers of TC (P < 0.001). Seventy-six (14%) subjects died within 30 days of index diagnosis and 185 (34%) subjects experienced severe shock. The median duration of hospitalization was 7 days (IQR 3-14 days). In multivariable logistic regression, CCI was not associated with 30-day mortality or severe shock. In multivariable Poisson regression, CCI (IRR 1.17, 95% CI 1.16-1.18, P < 0.001) was associated with duration of hospitalization. Increased burden of pre-existing medical comorbidity was not independently associated with 30-day mortality or severe shock at index presentation, but was associated with increased duration of hospitalization after diagnosis of TC.

Impact of body temperature at admission on inhospital outcomes in patients with takotsubo syndrome: insights from the Tokyo Cardiovascular Care Unit Network Registry

Background:

Takotsubo syndrome occasionally occurs in patients with fever due to underlying diseases. However, the impact of body temperature on inhospital prognosis of patients with takotsubo syndrome remains unknown.

Methods:

Using the patient cohort in the Tokyo Cardiovascular Care Unit Network Registry from 2013 to 2015, we identified 421 eligible patients whose data on body temperature at admission were available and classified them into three groups: high body temperature group (≥37.5°C; n=27), normal body temperature group (36.0–37.4°C; n=319), and low body temperature group (≤35.9°C; n=75). We compared the patient characteristics and inhospital outcomes among the three groups.

Results:

On admission, the high body temperature group showed a higher proportion of men and preceding physical triggers, higher heart and respiratory rates, and higher C-reactive protein level than the other groups. Inhospital all-cause mortality was significantly higher in the high body temperature group than in the normal or low body temperature group (18.5% vs. 2.2% vs. 4.0%, respectively, P&lt;0.001). Both cardiac mortality (11.1% vs. 1.3% vs. 1.3%, P=0.001) and non-cardiac mortality (7.4% vs. 0.9% vs. 2.7%, P=0.031) were also significantly higher in the high body temperature group. Multivariable logistic regression analysis showed that high body temperature (reference: normal body temperature) was significantly associated with higher inhospital mortality (adjusted odds ratio 4.22; 95% confidence interval 1.15–15.51; P=0.030).

Conclusions:

Our findings suggest that high body temperature at admission is a strong predictor of inhospital mortality in patients with takotsubo syndrome. Febrile takotsubo syndrome patients may need to be managed with recognition of life-threatening conditions from the time of diagnosis, no matter what the causes of fever are.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase.

Neutrophil/lymphocyte ratio predicts in-hospital complications in Takotsubo syndrome. Results from a prospective multi-center registry

Background

Several hematological indices including subtypes of leukocytes populations have been associated with cardiovascular outcome. Takotsubo syndrome (TTS) is a form of acute heart failure syndrome featured by several in‐hospital complications (IHCs).

Hypothesis

Hematological indices at admission may predict IHCs in TTS patients.

Methods

One hundred and sixty consecutive patients with TTS were enrolled in a multicenter prospective registry. Clinical data, admission hemogram, and IHCs were recorded.

Results

Incidence of IHCs was 37%, including pulmonary edema 9%, cardiogenic shock 9%, need of invasive ventilation 10%, death 8%, stroke 2.5%, and left ventricular thrombi 6%.

Patients with IHCs were older, more frequently male, with physical stressor‐induced TTS, lower left ventricular ejection fraction at admission. Neutrophil/lymphocyte ratio (NLr) (12 ± 12 vs 7 ± 8, P = .002) and white blood cells/mean platelet volume ratio (1.2 ± 0.5 vs 1.0 ± 0.5, P = .03) at admission were significantly higher in patients with IHCs.

NLr values were predictor of IHCs (Odds ratios [OR] 1.07, 95% CI 1.03‐1.11, P < .01). When stratified according to NLr into tertiles, the rate of IHCs was from first to third tertile was, respectively, 22%, 31%, and 58%. NLr values in the higher tertile were independent predictors of IHCs even at multivariate analysis (OR 3.7, 95% CI 1.5‐9.4, P < .01).

NLr values higher than 5 were able to predict IHCs with a sensitivity of 82% and specificity of 58%; negative predictive power was 84% (area under the ROC curve 0.73).

Conclusions

NLr is an independent predictor of IHCs in patients admitted with TTS. Admission hemogram may represent a potential tool for prediction of IHCs in TTS.

Assessment of the German and Italian Stress Cardiomyopathy Score for Risk Stratification for In-hospital Complications in Patients With Takotsubo Syndrome

Importance

Takotsubo syndrome (TTS) is an acute, reversible heart failure syndrome featured by significant rates of in-hospital complications. There is a lack of data for risk stratification during hospitalization.

Objective

To derive a simple clinical score for risk prediction of in-hospital complications among patients with TTS.

Design, Setting, and Participants

In this prognostic study, 1007 consecutive patients were enrolled in the German and Italian Stress Cardiomyopathy (GEIST) registry from July 1, 2007, through December 31, 2017, and identified as the derivation cohort; 946 patients were enrolled in the Spanish Registry for Takotsubo Cardiomyopathy (RETAKO) as the external score validation. An admission risk score was developed using a stepwise multivariable regression analysis from 2 registries. Data analysis was performed from March 1, 2018, through July 31, 2018.

Main Outcomes and Measures

In-hospital complications were defined as death, pulmonary edema, need for invasive ventilation, and cardiogenic shock. Four variables were identified as independent predictors of in-hospital complications and were used for the score: male sex, history of neurologic disorder, right ventricular involvement, and left ventricular ejection fraction (LVEF).

Results

Of the 1007 patients enrolled in the GEIST registry, 107 (10.6%) were male, with mean (SD) age of 69.8 (11.4) years. Overall rate of in-hospital complications was 23.3% (235 of 1007) (death, 4.0%; pulmonary edema, 5.8%; invasive ventilation, 6.4%; and cardiogenic shock, 9.1%). The GEIST prognosis score was derived by providing 20 points each for male sex and history of neurologic disorders and 30 points for right ventricular involvement and then subtracting the value in percent of LVEF (decimal values between 0.15 and 0.70). Score accuracy on area under the receiver operating characteristic curve analysis was 0.71, with a negative predictive power of 87% with scores less than 20. External validation in the RETAKO population (124 [13.1%] male; mean [SD] age, 69.5 [14.9] years) revealed an area under the curve of 0.73 (P = .46 vs GEIST derivation cohort). Stratification into 3 risk groups (<20, 20-40, and >40 points) classified 316 patients (40.9%) as having low risk; 342 (44.3%) as having intermediate risk, and 114 (14.8%) as having high risk of complications. The observed in-hospital complication rates were 12.7% for low-risk patients, 23.4% for intermediate-risk patients, and 58.8% for high-risk patients (P < .001 for trend). After 2.6 years of follow-up, patients with in-hospital complications had significantly higher rates of mortality than those without complications (40% vs 10%, P = .01).

Conclusions and Relevance

The GEIST prognostic score may be useful in early risk stratification for TTS. High-risk patients with TTS may require an intensive care unit stay, and low-risk patients with TTS could be discharged within a few days. In-hospital complications in patients with TTS may be associated with increased risk of long-term mortality.

Impact of right ventricular impairment on morbidity and mortality in takotsubo syndrome-a meta-analysis of observational trials

The impact of right ventricular impairment (RVI) on the morbidity and mortality of patients with Takotsubo syndrome (TTS) is well-debated. We conducted a meta-analysis to evaluate the mortality and morbidity risk associated with RVI compared with those without RVI in patients with TTS. A comprehensive search was performed in PubMed and Embase from inception to April 19, 2019. Our primary outcome of interest was in-hospital and long-term mortality. Other outcomes of interest were acute heart failure, left ventricular systolic function, tricuspid and mitral regurgitation, and length of hospital stay (LOS). We are reporting our outcomes as a cumulative odds ratio (OR). After an initial search, 10 studies with 1210 subjects were included in the quantitative analysis. Mean follow-up was 31 months. The odds of in-hospital and long-term mortality in TTS patients with and without RVI were not significantly different (p = 0.13 and 0.40). In TTS patients without RVI, the odds of acute heart failure, and mitral and tricuspid regurgitation were significantly lower at an OR of 0.26 (p < 0.0001), 0.40 (p = 0.0001), and 0.52 (p = 0.02) respectively. TTS patients with RVI had significantly lower mean LVEF (34% vs 41%, p = 0.03) and numerically higher mean LOS (9.5 days vs 7.6 days, p = 0.52) compared with those without RVI. The presence of RVI represents a severe form of TTS disease spectrum, characterized by severely reduced LVEF, higher incidence of MR and presence of TR. Although there was a trend toward increased in-hospital and long-term mortality, RVI in TTS does not portend worse survival.

Imaging-Specific Cardiomyopathies: A Practical Guide

Heart failure is a clinical syndrome with a broad spectrum of presentations. Cardiovascular imaging techniques such as echocardiography, cardiovascular magnetic resonance, computed tomography, and nuclear imaging play a crucial role in diagnosis, guiding management, and providing prognostic information. Each of these imaging modalities has their own respective strengths and weaknesses. Cardiac imaging can help differentiate between ischemic and nonischemic cardiomyopathies. Additionally, imaging techniques can display disease-specific findings, aiding in diagnosis of nonischemic cardiomyopathies and can provide a means to monitor response to therapy. The choice of imaging modality in the workup of cardiomyopathy should be based on the specific clinical question and the knowledge of the strengths and limitations of each imaging modality.

Long-term outcome in patients with Takotsubo syndrome presenting with severely reduced left ventricular ejection fraction

AIM

To evaluate the long-term outcome of patients with Takotsubo syndrome (TTS) and severely reduced left ventricular ejection fraction (LVEF ≤ 35%) at presentation.

METHODS AND RESULTS

The study population included 326 patients (mean age 69.5 ± 10.7 years, 28 male) with TTS enrolled in the Takotsubo Italian Network, divided into two groups according to LVEF (≤ 35%, n = 131; > 35%, n = 195), as assessed by transthoracic echocardiography at hospital admission. In-hospital events were recorded in both groups. At long-term follow-up (median 26.5 months, interquartile range 18-33), composite major adverse cardiac events (MACE: cardiac death, acute myocardial infarction, heart failure, and TTS recurrence) and rehospitalization were investigated. Compared to patients with LVEF > 35%, patients with LVEF ≤ 35% were older (71.2 ± 10.8 vs. 68.4 ± 10.6 years; P = 0.026) and experienced more frequently cardiogenic shock (16% vs. 4.6%; P < 0.001), acute heart failure (28.2% vs. 12.8%; P = 0.001), and intra-aortic balloon pump support (11.5% vs. 2.6%; P = 0.001) in the acute phase. At long-term follow-up, higher rates of composite MACE (25.2% vs. 10.8%; P = 0.001) and rehospitalization for cardiac causes (26% vs. 13.3%; P = 0.004) were observed in these patients. LVEF ≤ 35% at admission [hazard ratio (HR) 2.184, 95% confidence interval (CI) 1.231-3.872; P = 0.008] and age (HR 1.041, 95% CI 1.011-1.073; P = 0.006) were independent predictors of MACE. Patients with LVEF ≤ 35% also had a significant lower freedom from composite MACE during long-term follow-up (χ² = 11.551, P = 0.001).

CONCLUSION

Left ventricular ejection fraction ≤ 35% at presentation is a key parameter to identify TTS patients at higher risk not only in the acute phase but also at long-term follow-up.

Takotsubo cardiomyopathy: queries of the current era

: Takotsubo cardiomyopathy (TTS), also known as left ventricular apical ballooning syndrome, is an acute, usually reversible heart failure syndrome that most often affects postmenopausal women experiencing an emotionally stressful event. It is characterized by sudden left ventricular dysfunction and wall motion abnormalities involving the apical and mid segments. TTS has been increasingly recognized in recent years, and more and more information about the pathophysiology, diagnosis, and treatment of these patients has been reported. However, much is still unknown. TTS has a wide variety of clinical subtypes and has been described in several clinical contexts. Moreover, TTS simulates ST-segment elevation myocardial infarction and acute myocarditis, and it can be difficult to obtain a certain diagnosis. As a result, clinical decisions are challenging, and many patients currently receive an inappropriate management strategy. The aim of this review is to critically analyze the evidence about this disease reported in the literature, with particular focus on the pathophysiological processes, the diagnostic elements that can help the clinician differentiate it from other diseases, and the best management of these patients.

Thoracic Epidural Blockade for Ventricular Tachycardia Storm in Patient with Takotsubo Cardiomyopathy

Introduction

Takotsubo cardiomyopathy is acute nonischemic myocardial dysfunction of the left and/or right ventricle which usually recovers completely within several days to weeks. We report a case where thoracic epidural analgesia was used to manage sympathetic storm in Takotsubo cardiomyopathy.

Case description

A 58-year-old diabetic female who was being treated for urinary tract infection and diabetic ketoacidosis for the past 2 days sustained an episode of pulseless ventricular tachycardia which was treated as per ACLS protocol. Troponin levels were raised, and 2D echocardiography was showing "Takotsubo cardiomyopathy" with typical apical ballooning of the left ventricle at the time of admission, and she was mechanically ventilated and receiving vasopressors. She continued to get episodes of ill-sustained ventricular tachycardia. In spite of conventional management, episodes of ill-sustained ventricular tachycardia continued, and hence, sympathetic blockade with thoracic epidural catheter was administered to control the ventricular tachycardia storm.

Conclusion

Sympathetic blockade to treat ventricular tachycardia is a promising approach which needs to be validated with more evidence.

How to cite this article

Ashwini J, Durgesh M, Girish D. Thoracic Epidural Blockade for Ventricular Tachycardia Storm in Patient with Takotsubo Cardiomyopathy. IJCCM 2019;23(11):529-532.

Right ventricular strain assessment by cardiovascular magnetic resonance myocardial feature tracking allows optimized risk stratification in Takotsubo syndrome

Background

A substantial number of patients with Takotsubo syndrome (TTS) exhibit right ventricular (RV) dysfunction which has been associated with adverse outcome. The aim of this study was to assess the clinical and prognostic value of RV myocardial strain in TTS using cardiovascular magnetic resonance myocardial feature tracking (CMR-FT).

Methods

CMR-FT was performed in a core laboratory to determine RV longitudinal strain in 134 TTS patients undergoing CMR in median 2 days after admission to 2 experienced centers. For comparison, RV involvement was evaluated by sole visual assessment concerning RV contraction abnormalities. Both approaches were analyzed regarding their long-term prognostic value.

Results

The peak global RV longitudinal strain was in median -19%. Segmental analyses located contraction abnormalities primarily in the apical parts of the right ventricle. Sole visual assessment identified 38 patients (28%) with RV involvement. These patients showed a numerically higher long-term mortality without reaching statistical significance (17.1% versus 10.5%; hazard ratio 1.38 [95% confidence interval 0.49–3.88]; p = 0.31). The optimal RV strain cutoff value for risk prediction was -17.24%. Stratification according to this threshold categorized 41% of TTS patients (n = 55) in the high-risk group which demonstrated a significantly increased long-term mortality compared to patients with preserved global RV strain (20.0% versus 7.0%; hazard ratio 2.98 [95% confidence interval 1.02–8.73]; p = 0.03).

Conclusions

The assessment of RV myocardial strain using CMR-FT enables an accurate evaluation of RV involvement in TTS and represents a promising approach for optimized risk stratification.

Ventricular arrhythmias in patients with Takotsubo syndrome

Takotsubo syndrome (TTS) is a unique nonischemic cardiac disease characterized by acute myocardial dysfunction of the left and/or right ventricle. Patients are predominantly postmenopausal women and usually present with symptoms indistinguishable from acute coronary syndrome. Although the exact pathomechanisms of TTS remain elusive, increasing evidence suggests that sympathetic overdrive and catecholamine excess might play a central role. Despite the complete recovery of ventricular dysfunction within several days to weeks, patients with TTS exhibit considerable short- and long-term mortality rates and ventricular arrhythmias have been identified as key contributor to morbidity and mortality. This article summarizes the prevalence, underlying mechanisms, therapeutic strategies, and prognostic implications of ventricular arrhythmias in TTS. Furthermore, the need for implantable cardioverter-defibrillators is discussed in view of the transient character of the disease.

Novel Understanding of Takotsubo Syndrome

Takotsubo cardiomyopathy is described as a transient reversible cardiomyopathy which typically occurs in older women after emotional or physical stress. This cardiomyopathy is also recognized as a "syndrome" because it develops in conjunction with various diseases. Since the clinical presentation of takotsubo syndrome (TTS) is similar to acute coronary syndrome (ACS), TTS should be distinguished from ischemic heart disease. Although the pathophysiology of TTS has not well been established, a number of its specific features have been suggested. The predictor of mortality in TTS is still unknown. In this review article, we describe a series of treatment decisions in TTS.

Role of echocardiography for takotsubo cardiomyopathy: clinical and prognostic implications

Takotsubo cardiomyopathy (TTC) is newly-described secondary cardiomyopathy characterized by transient left ventricular (LV) dysfunction, which is increasingly recognized in the field of cardiology. TTC occurs in approximately 2% of the patients with acute coronary syndrome. Its onset is rare; however, its specific features play a crucial role in diagnosing the chest pain in clinical practice. TTC has generally favorable outcome with rapid recovery of LV function; however, an increasing evidence suggests that it should be regarded as a more serious acute cardiac disorder with a variety of complications. Owing to its widespread availability, even in emergency settings, transthoracic echocardiography plays a key role in the diagnostic assessment of TTC and contributes to an increased number of disease detection and incidence reports in contemporary clinical practice. This review focuses on the role of echocardiography in understanding the clinical prognostic implications in patients with TTC.

Prolonged circulatory support with an Impella assist device in the management of cardiogenic shock associated with takotsubo syndrome, severe sepsis and acute respiratory distress syndrome

Severe sepsis has been known to trigger for takotsubo syndrome which is associated with profound physical or emotional stress. Severe sepsis is also associated with sepsis-induced cardiomyopathy, a reversible myocardial depression. We report a case in which a patient with takotsubo syndrome, cardiogenic shock, severe sepsis, and adult respiratory distress syndrome was managed with an Impella Cardiac Power circulatory support device for 108 h (4.5 days) because of sustained hemodynamic compromise. To the best of our knowledge, this represents the longest reported use of the Impella Cardiac Power device for the management of cardiogenic shock in a patient with takotsubo syndrome and severe sepsis. This report also highlights the importance of considering a ventricular assist device in the management of takotsubo syndrome cardiogenic shock with severe sepsis which is unresponsive to maximal medical therapy.

Persistent Long-Term Structural, Functional, and Metabolic Changes After Stress-Induced (Takotsubo) Cardiomyopathy

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Background:

Takotsubo cardiomyopathy is an increasingly recognized acute heart failure syndrome precipitated by intense emotional stress. Although there is an apparent rapid and spontaneous recovery of left ventricular ejection fraction, the long-term clinical and functional consequences of takotsubo cardiomyopathy are ill-defined.

Methods:

In an observational case-control study, we recruited 37 patients with prior (>12-month) takotsubo cardiomyopathy, and 37 age-, sex-, and comorbidity-matched control subjects. Patients completed the Minnesota Living with Heart Failure Questionnaire. All participants underwent detailed clinical phenotypic characterization, including serum biomarker analysis, cardiopulmonary exercise testing, echocardiography, and cardiac magnetic resonance including cardiac ³¹P-spectroscopy.

Results:

Participants were predominantly middle-age (64±11 years) women (97%). Although takotsubo cardiomyopathy occurred 20 (range 13–39) months before the study, the majority (88%) of patients had persisting symptoms compatible with heart failure (median of 13 [range 0–76] in the Minnesota Living with Heart Failure Questionnaire) and cardiac limitation on exercise testing (reduced peak oxygen consumption, 24±1.3 versus 31±1.3 mL/kg/min, P<0.001; increased VE/Vco₂ slope, 31±1 versus 26±1, P=0.002). Despite normal left ventricular ejection fraction and serum biomarkers, patients with prior takotsubo cardiomyopathy had impaired cardiac deformation indices (reduced apical circumferential strain, −16±1.0 versus −23±1.5%, P<0.001; global longitudinal strain, −17±1 versus −20±1%, P=0.006), increased native T1 mapping values (1264±10 versus 1184±10 ms, P<0.001), and impaired cardiac energetic status (phosphocreatine/γ-adenosine triphosphate ratio, 1.3±0.1 versus 1.9±0.1, P<0.001).

Conclusions:

In contrast to previous perceptions, takotsubo cardiomyopathy has long-lasting clinical consequences, including demonstrable symptomatic and functional impairment associated with persistent subclinical cardiac dysfunction. Taken together our findings demonstrate that after takotsubo cardiomyopathy, patients develop a persistent, long-term heart failure phenotype.

Clinical Trial Registration:

URL: https://clinicaltrials.gov. Unique identifier: NCT02989454.

Impact and management of left ventricular function on the prognosis of Takotsubo syndrome

BACKGROUND

Early research has proposed that patients with Takotsubo syndrome (TTS) could have a higher mortality rate than the general population. Our study was conducted to determine the short- and long-term outcome of TTS patients associated with a significantly compromised left ventricular function on hospital admission.

MATERIALS AND METHODS

Our institutional database constituted a collective of 112 patients diagnosed with TTS between 2003 and 2015. The patients were classified into two groups based on the left ventricular ejection fraction (LVEF), with those presenting with a LVEF > 35% on admission categorized into one group (n = 65, 58%) and those presenting with LVEF ≤ 35% (n=47, 42%) categorized into another group. The endpoint was the all-cause of mortality over a mean follow-up of 1529 ± 1121 days.

RESULTS

Preliminary results indicated that patients with an EF ≤ 35% had a significantly greater risk of developing life-threatening arrhythmias, and were much more likely to suffer from cardiogenic shock. Patients often required varying forms of mechanical respiratory support. The in-hospital mortality, 30-day mortality, 1-year mortality and ongoing long-term mortality was significantly higher in TTS patients with an EF ≤ 35%. In a multivariate Cox regression analysis, an EF ≤ 35% (HR 3·3, 95% CI: 1·2-9·2, P < 0·05) was identified as a strong independent predictor of the primary endpoint.

CONCLUSIONS

In-hospital events as well as short- and long-term mortality rates among TTS patients diagnosed with a significantly reduced LVEF on admission were significantly higher. There is an urgent need for randomized trials, which could help define uniform clinical management strategies for high risk TTS patients.

Renal dysfunction indicative of outcomes in hospitalized patients with takotsubo syndrome

Background:

Left ventricular dysfunction as part of takotsubo syndrome is reversible, and the long-term prognosis appears favorable. However, life-threatening complications are not uncommon during the acute phase, and it remains unclear whether renal dysfunction is a factor in complications suffered by hospitalized patients with takotsubo syndrome. The present study was conducted to investigate the implications of renal dysfunction in this setting.

Methods:

Data from 61 consecutive patients (male, 21; female, 40) diagnosed with takotsubo syndrome at our hospital between years 2010 and 2016 were evaluated retrospectively. In-hospital complications by definition were all-cause deaths and severe pump failure (Killip class ≥III).

Results:

Overall, 30 patients (49%) developed renal dysfunction. In the 32 patients (52%) who suffered in-hospital complications (mortality, 10; severe pump failure, 22), estimated glomerular filtration rate (eGFR) was significantly lower by comparison (51.3±29.8 vs. 69.5±29.0; p=0.019). Low eGFR (<30 ml/min per 1.73m2) proved independently predictive of in-hospital complications (hazard ratio =2.84, 95% confidence interval: 1.20–6.69) in multivariate Cox hazard analysis, also showing a significant association with peak event rate of Kaplan–Meier curve (log-rank test, p=0.0073). Similarly, patients with chronic kidney disease were at significantly greater risk of in-hospital complications (hazard ratio=2.49, 95% confidence interval: 1.01–5.98), relative to non-compromised counterparts (eGFR >60 ml/min per 1.73m2).

Conclusion:

Renal dysfunction is a simple but useful means of predicting complications in hospitalized patients with takotsubo syndrome, especially those with chronic kidney disease.