Trigger-Associated Clinical Implications and Outcomes in Takotsubo Syndrome: Results From the Multicenter GEIST Registry

Triggering type and long-term survival following ST segment elevation-myocardial infarction treated with primary percutaneous coronary intervention

BACKGROUND

Physical and emotional stress are recognized triggers of acute coronary syndromes, including ST segment elevation-myocardial infarction (STEMI). We have previously shown that identifiable triggers precede symptoms in over one-third of STEMI patients and inversely correlate with the extent of coronary artery disease (CAD). This study aims to investigate the association between trigger type (physical vs. emotional) and long-term mortality in STEMI patients treated with primary percutaneous coronary intervention (PCI).

METHODS

This retrospective, single-center observational study included all patients admitted with an STEMI diagnosis from January 2008 to December 2013. Physical and emotional triggers were identified retrospectively from patient records. Mortality data were obtained from the Israeli Ministry of Health.

RESULTS

Of 1345 consecutive STEMI patients treated with primary PCI, mortality data were available for 1267 patients (median age: 61 years). A trigger preceding symptoms onset was identified in 36.5% of patients, with 85% experiencing physical stress and 15% emotional stress. Triggered STEMI patients tended to be younger with fewer comorbidities and lower incidence of multiple vessel CAD compared with nontriggered patients. Notably, emotionally triggered STEMI patients exhibited improved long-term survival compared with those without emotional triggers or with physical triggers. Emotional triggering was identified as an independent predictor of enhanced long-term survival post-PCI compared with physical triggering.

CONCLUSION

Patients with emotionally triggered STEMI showed less extensive CAD and improved long-term survival following PCI compared with those with physically triggered STEMI. These findings highlight the importance of considering both the presence and type of trigger in the management of STEMI patients and their long-term prognosis.

Vasoactive-Inotropic Score in Takotsubo syndrome induced cardiogenic shock

OBJECTIVE

To determine the prognostic value of the Vasoactive-Inotropic Score (VIS) in patients with Takotsubo syndrome (TTS) complicated by cardiogenic shock (CS).

DESIGN

Retrospective cohort analysis.

SETTING

Multicenter registry (RETAKO) of patients diagnosed with TTS between 2003 and 2022.

PATIENTS OR PARTICIPANTS

A total of 1591 patients with TTS, of which 412 (26%) developed CS.

INTERVENTIONS

Patients were managed according to clinical criteria, with VIS calculated based on the maximum doses of inotropic and vasoactive drugs administered within the first 24 h of CS diagnosis.

MAIN VARIABLES OF INTEREST

30-day and 1-year mortality rates, VIS tertile classifications.

RESULTS

Of the patients who developed CS, 208 received inotropic support. Patients in the highest VIS tertile had significantly higher 30-day (HR 8.80, 95% CI 1.96-39.48; p = 0.005) and 1-year (HR 4.55, 95% CI 1.11-18.63; p < 0.035) mortality compared to the lowest tertile. High VIS was also linked to increased complications, including acute kidney injury, major bleeding, and the need for mechanical circulatory support. In-hospital mortality rates were 4% for the low tertile, 14% for the middle tertile, and 47% for the high tertile (p < 0.001).

CONCLUSIONS

VIS is associated with worse short- and long-term outcomes in TTS complicated by CS. Further research is needed to explore potential causal pathways, if any, and to optimize therapeutic strategies for these patients.

Happy heart syndrome - The impact of different triggers on the characteristics of takotsubo syndrome

Takotsubo syndrome (TTS) is a condition of acute ventricular dysfunction mainly in aging women that is frequently precipitated by episodes of physical or emotional stress. The association with negative emotional triggers such as fear, grief, or interpersonal conflicts was observed soon after the first description of TTS three decades ago and led to the popular term "broken heart syndrome". However, more recent research shows that TTS can also be provoked by pleasant emotions in some patients, referred to as "happy heart syndrome". This review will discuss the role of stressful triggers in patients with TTS and their impact on the course of the disease with a particular focus on characteristic features of happy heart syndrome.

Long-term outcomes and worse clinical course in Takotsubo syndrome patients with amyotrophic lateral sclerosis

AIMS

Takotsubo syndrome (TTS) is usually triggered by either physical/psychological stressors or comorbidities, neurological among others. The prevalence of amyotrophic lateral sclerosis (ALS) among TTS and whether it has a worse clinical course is not known. We aim to describe ALS prevalence and its impact on clinical presentation, clinical course, and long-term mortality.

METHODS

We retrospectively screened the overall TTS population admitted and followed up at our institution between 2007 and 2020. Clinical, electrocardiographic, and echocardiographic data were collected. Kaplan-Meier method was applied for time-to-event analysis to assess the outcome of interest of all-cause death.

RESULTS

Eighty-five patients with TTS were included in our study. Overall, the mean age was 70 ± 12 years, 86% were females. Six patients (7% prevalence) were affected by ALS. At admission, patients with ALS were more likely to present left ventricular systolic dysfunction (P = 0.007). The clinical course of ALS patients was more likely complicated by cardiogenic shock (P = 0.003) which required catecholamines infusion (P = 0.001) and mechanical ventilation (P = 0.009). Despite similar in-hospital mortality rates, ALS patients exhibited significantly elevated all-cause mortality during a median 6-year follow-up (hazard ratio, 19.189, 95% confidence interval 5.639-65.296, log-rank test P < 0.001) with significantly shorter hospitalization to death time (P = 0.039).

CONCLUSIONS

Our findings highlight a notable prevalence of ALS among TTS patients, with worse clinical presentation and in-hospital course in ALS-affected individuals. While in-hospital mortality rates were comparable, highlighting the reversible nature of TTS in both groups, long-term follow-up revealed significantly heightened all-cause mortality in ALS patients, emphasizing the impact of ALS on patient prognosis.

Refractory cardiogenic shock in hypertrophic cardiomyopathy complicated by apical ballooning: A case report

Hypertrophic cardiomyopathy can be accompanied by dynamic obstruction in the left ventricular outflow tract and acute apical ballooning, which are among the very rare causes of cardiogenic shock. This condition requires a specific treatment approach that in many ways differs from the treatment of other causes of cardiogenic shock. We present a case and our treatment strategy (including extracorporeal life support) for refractory cardiogenic shock in a patient with previously undiagnosed hypertrophic cardiomyopathy.

Emotional Stress in Cardiac and Vascular Diseases

INTRODUCTION/OBJECTIVE

Emotional, mental, or psychological distress, defined as increased symptoms of depression, anxiety, and/or stress, is common in patients with chronic diseases, such as cardiovascular (CV) disease (CVD).

METHODS

Literature was reviewed regarding data from studies and meta-analyses examining the impact of emotional stress on the occurrence and outcome of several CVDs (coronary disease, heart failure, hypertension, arrhythmias, stroke). These influences' pathophysiology and clinical spectrum are detailed, tabulated, and pictorially illustrated.

RESULTS

This type of stress is a newly recognized risk and prognosticator for CVD including coronary artery disease, heart failure, hypertension, cardiac arrhythmias, and stroke, independently of conventional risk factors. It can impact CV outcomes, and also affect health care utilization, with more patient visits to health care facilities. The biological systems activated by mental stress comprise the sympathetic nervous system (SNS), the renin-angiotensin system (RAS), and the hypothalamic- pituitary-adrenal (HPA) axis, while several other biological processes are disrupted, such as endothelial function, inflammatory responses, oxidative stress, mitochondrial function and the function of the amygdala which is the central nervous system processing center of emotions and emotional reactions.

CONCLUSION

Emotional stress that aggravates symptoms of depression, anxiety, and/or perceived mental stress is common in patients with chronic diseases, such as CVD. It is a newly recognized risk and prognosticator for several CVDs. It can influence CV outcomes, and also affect health care utilization. The biological systems activated by mental stress comprise the SNS, the RAS, and the HPA axis, while several other biological processes are disrupted.

Cardiogenic Shock Complicating Takotsubo Syndrome: Sex-Related Differences

BACKGROUND

Sex-related differences in Takotsubo syndrome have been described, but no information is available in patients who develop cardiogenic shock.

METHODS AND RESULTS

Of 412 patients with Takotsubo syndrome with cardiogenic shock, 71 (17.2%) were men. Male patients were older (71.1±12.2 versus 65.3±17.1 years, P<0.001), more frequently smokers (47 [66.2%] versus 66 [19.4%], P<0.01), with higher prevalence of neoplasms (6 [8.5%] versus 8 [2.3%], P=0.01), lower left ventricular ejection fraction (31% versus 37%, P<0.001), more frequent invasive mechanical ventilation (30 [42.3%] versus 90 [26.4%], P=<0.01), higher rate of infections (43 [60.6%] versus 148 [43.4%], P=<0.01), and longer in-hospital stay (19±20 days versus 13±15 days, P=0.02). A total of 55 patients (13.3%) died during hospital admission, and 90 patients (21.8%) died at the end of the 5-year follow-up. Male sex was not significantly associated with the in-hospital (odds ratio, 1.31 [95% CI, 0.64-2.68]) or 5-year mortality rate (hazard ratio, 1.66 [95% CI, 0.93-2.94]). In the matched cohort, no significant differences in the short- and long-term mortality rate were found either.

CONCLUSIONS

Cardiogenic shock due to Takotsubo syndrome has high short- and long-term mortality rates that are similar in men and women.

Takotsubo Cardiomyopathy: Patients Characteristics, Mortality, and Clinical Significance of Left Ventricular Outflow Tract Gradient, Retrospective Study

Background

Takotsubo cardiomyopathy (TC) is a reversible left ventricular systolic dysfunction with apical ballooning. Left ventricular outflow tract (LVOT) obstruction may develop in these cases due to hyperdynamic state of the left ventricle. Limited data are available on the prevalence of LVOT gradient in TC and its association with patient outcomes and mortality.

Methods

Data were collected retrospectively for patients diagnosed with TC in a single tertiary center, demographic information, blood analysis results, and imaging finding including ejection fraction, and LVOT gradient was obtained from medical records. Additionally, medical treatment and outcome during hospitalization were extracted. Follow-up was conducted through cardiology clinic or phone contact.

Result

A total of 59 patients diagnosed with TC were reviewed during hospitalization, and 40 patients were followed up after discharge by phone contact and cardiology clinic. Most patients were female (91.5%), and nonsignificant coronary artery disease was present in 16.9% of patients. Approximately two-third of the patients had a reduced ejection fraction on admission, and only two patients (5.4%) continued to have reduced ejection fraction on echocardiography follow-up within a period of 2-14 days. LVOT gradient was present in 17 patients (28.5%); patients with preserved ejection fraction had a higher probability of having an LVOT gradient. However, there was no association between LVOT gradient and shock or mortality. Four patients (6.7%) experienced 30-day mortality, while all-cause mortality was reported in eight patients (13.5%) over the follow-up period (mean (±SD) 20.8 months ± 16.2).

Conclusion

LVOT obstruction may occur in TC patients; it has no correlation with shock or mortality. However, determining whether there is a gradient is important for deciding on specific treatment approach.

Long-Term Functional Limitations on Cardiopulmonary Exercise Testing in Emotion-Triggered Takotsubo Syndrome

Background: In patients with prior Takotsubo syndrome (TTS), long-lasting functional cardiac limitations were described as compared with normal subjects. Emotion-triggered Takotsubo syndrome (E-TTS) has more favorable outcomes than TTS preceded by a physical trigger or by no identifiable factors. The aim of the present study was to assess long-term cardiac functional limitations in a cohort of asymptomatic E-TTS patients. Methods: We enrolled n = 40 asymptomatic patients with a diagnosis of E-TTS. Cardiopulmonary exercise tests (CPET) were performed at 30 (12-40) months median follow-up from the acute event. A cohort of n = 40 individuals matched for age, sex, body mass index and comorbidities served as control. Results: Despite recovery of left ventricular ejection fraction, patients with prior E-TTS had lower peak VO2 and percentage of predicted peak VO2 (17.8 ± 3.6 vs. 22.1 ± 6.5; p < 0.001 and 75.2 ± 14.1% vs. 100.6 ± 17.1%, p < 0.001), VO2 at anaerobic threshold (AT) (11.5 [10.1-12.9] vs. 14.4 [12.5-18.7]; p < 0.001), peak O2 pulse (9.8 ± 2.5 vs. 12.9 ± 3.5; p < 0.001) and higher VE/VCO2 slope (30.5 ± 3.7 vs. 27.3 ± 3.5; p < 0.001) compared with matched controls. We found no statistically significant differences in heart rate reserve (HRR), respiratory equivalent ratio (RER), mean blood pressure and peak PetCO2 between patients and controls. Conclusions: Despite its favorable outcome, patients with E-TTS in our population were found to have subclinical long-term functional cardiac limitations as compared with a control cohort.

A contemporary update on cancer and takotsubo syndrome

Takotsubo syndrome (TTS) is characterized by a transient left ventricular systolic dysfunction, burdened by significant acute and long-term mortality and morbidity. The prognosis of TTS, especially in the long-term, is influenced by both non-cardiovascular (non-CV) and CV comorbidities, among which cancer is one of the most common. The presence of a malignancy is proven to be associated with higher mortality in TTS. Moreover, a number of anticancer treatments has been reported to possibly cause TTS as a form of cardiotoxicity, even though clearcut associations are lacking. The aim of this narrative review is to sum up contemporary knowledge on the association of cancer and TTS, addressing unmet needs and practical implications. The importance of a close collaboration between cardiologists and oncologists is herein highlighted, both to allow an adequate management of the acute TTS phase, and to actively and safely return to the oncologic management once the acute setting is resolved.

Smoking influence in Takotsubo syndrome: insights from an international cohort

AIMS

To assess the influence of tobacco on acute and long-term outcomes in Takotsubo syndrome (TTS).

METHODS

Patients with TTS from the international multicenter German Italian Spanish Takotsubo registry (GEIST) were analyzed. Comparisons between groups were performed within the overall cohort, and an adjusted analysis with 1:1 propensity score matching was conducted.

RESULTS

Out of 3,152 patients with TTS, 534 (17%) were current smokers. Smoker TTS patients were younger (63 ± 11 vs. 72 ± 11 years, p < 0.001), less frequently women (78% vs. 90%, p < 0.001), and had a lower prevalence of hypertension (59% vs. 69%, p < 0.01) and diabetes mellitus (16% vs. 20%, p = 0.04), but had a higher prevalence of pulmonary (21% vs. 15%, p < 0.01) and/or psychiatric diseases (17% vs. 12%, p < 0.01). On multivariable analysis, age less than 65 years [OR 3.85, 95% CI (2.86-5)], male gender [OR 2.52, 95% CI (1.75-3.64)], history of pulmonary disease [OR 2.56, 95% CI (1.81-3.61)], coronary artery disease [OR 2.35, 95% CI (1.60-3.46)], and non-apical ballooning form [OR 1.47, 95% CI (1.02-2.13)] were associated with smoking status. Propensity score matching (PSM) 1:1 yielded 329 patients from each group. Smokers had a similar rate of in-hospital complications but longer in-hospital stays (10 vs. 9 days, p = 0.01). During long-term follow-up, there were no differences in mortality rates between smokers and non-smokers (5.6% vs. 6.9% yearly in the overall, p = 0.02, and 6.6%, vs. 7.2% yearly in the matched cohort, p = 0.97).

CONCLUSIONS

Our findings suggest that smoking may influence the clinical presentation and course of TTS with longer in-hospital stays, but does not independently impact mortality.