Prognostic factors of Takotsubo cardiomyopathy: a systematic review

Clinical characteristics and outcomes of Takotsubo syndrome in patients with chronic obstructive pulmonary disease

BACKGROUND

takotsubo syndrome (TTS) is an acute heart failure syndrome characterized by a relevant comorbid background, including chronic obstructive pulmonary disease (COPD). However, TTS patients with COPD are still not well characterized.

AIM

to describe the clinical characteristics and outcomes of patients with TTS and COPD.

METHODS

n = 440 TTS patients were dichotomized according to the presence of COPD. Endpoint of the study were in-hospital complications (composite of death, major arrhythmias, cardiogenic shock and acute pulmonary edema), TTS recurrence and long-term mortality at follow-up.

RESULTS

mean age of the population was 72±11, 10 % males. COPD prevalence was 16 % (n = 69). On subgroup analysis, patients with COPD were more likely smokers (41 % vs 13 %, p < 0.001), with higher rates of dyspnea and physical triggers at presentation (52 % vs 18 %, p < 0.001 and 52 % vs 32 %, p = 0.001 respectively) and lower left ventricular ejection fraction (36 % vs 39 %, p = 0.035) In-hospital complications were more common in patients with COPD (26 % vs 13 %, p = 0.006), driven by higher rates of acute pulmonary edema (19 % vs 6 %, p < 0.001) and cardiogenic shock (10 % vs 4 %, p = 0.023). At multivariable logistic regression analysis, COPD was independently associated with in-hospital complications occurrence (Odds Ratio 2.10, 95 % CI 1.09-4.05; p = 0.027). At univariable Cox regression analysis COPD was associated with TTS recurrence (Hazard Ratio (HR 9.82, 95 % CI 3.2-30.12; p < 0.001)), at multivariable Cox regression analysis with long-term mortality (HR 2.97, 95 % CI 1.44-6.12; p = 0.003).

CONCLUSION

COPD marks a vulnerable TTS phenotype including higher risk of in-hospital complications, long-term recurrence and mortality.

Temperature and repeated catecholamine surges modulate regional wall motion abnormalities in a rodent takotsubo syndrome model

Transient regional wall motion abnormalities (RWMA) after stress are a hallmark of experimental and clinical Takotsubo Syndrome (TS). The mechanisms driving RWMA remain incompletely understood. This study investigates these mechanisms in a small-animal model of TS, validating the model's complication profile, recovery dynamics, and recurrence, while assessing the predictive value of echocardiography. Male, 7-9-week-old rats underwent TS induction via isoprenaline infusion. The effects of body temperature and repeated catecholaminergic surges on RWMA were assessed using high-resolution speckle-tracking echocardiography. Complications were evaluated through ECG, autopsy, and blood gas analysis. The TS phenotype showed reduced longitudinal strain with RWMA characterized by apical end-systolic akinesia/dyskinesia, a contracting base, and a narrow transition zone, resulting in apical ballooning. RWMA originated from the apex and recovered in the opposite direction. Hyperthermia increased RWMA incidence, while hypothermia attenuated RWMA (p = 0.008). A repeated catecholamine surge exacerbated RWMA in the acute phase (p = 0.042) but not during recovery (p = 0.308), with reduced RWMA susceptibility after recovery (RR 0.45, 95%CI; 0.27-0.76). Systolic function at initial echocardiography predicted worse outcomes (odds ratio 0.73; 95%CI 0.57-0.85), and RWMA extent correlated with recovery time (Rho = 0.772). TS rats developed complications similar to patients, including heart failure, arrhythmias, and thrombus formation. This study validates the small-animal TS model by replicating patient findings, and emphasizing the importance of controlling body temperature and limiting adrenergic drug use in managing TS. RWMA analysis offers promise as a diagnostic and prognostic tool in TS, and the delayed adaptive response presents a potential pathway for therapeutic intervention.

Association between the Tpeak-Tend interval on admission and coronary microvascular dysfunction in Takotsubo syndrome

AIMS

The Tpeak-Tend interval on electrocardiogram may be a predictor of worse outcomes in Takotsubo syndrome (TTS), but the mechanisms have not been fully determined. This study aimed to investigate the relationships between the corrected Tpeak-Tend (cTp-e) interval and coronary microvascular-dysfunction (CMD) assessed by the angiography-derived index of microvascular resistance (Angio-IMR) and the in-hospital prognosis in patients with TTS.

METHODS AND RESULTS

We retrospectively evaluated 111 consecutive patients admitted for TTS who underwent coronary angiography at Kindai University Hospital from October 2009 to July 2023. The Tpeak-Tend interval was defined as the time interval between the peak and the end of the T wave in electrocardiogram lead V5 on admission. Angio-IMR was assessed from aortic pressure, quantitative flow ratio (QFR), vessel length and hyperemic velocity using the formula described in validation studies. QFR, vessel length and hyperemic velocity was derived from coronary angiography and QAngio XA 3D software package. The degree of CMD was assessed by the maximum Angio-IMR value in each of the three coronary arteries. The primary endpoint was the relationship between the grade of a prolonged cTp-e interval on admission and Angio-IMR. The secondary endpoint was the relationship between the grade of a prolonged cTp-e interval on admission and in-hospital adverse cardiovascular events (composite of acute heart failure, cardiogenic shock, life-threatening arrhythmia, thrombotic events, stroke and all-cause death). The median age was 77.5 [71.0-83.0] years, and most patients were women (82.0%). The median cTp-e interval was 114.5 [91.2-147.0] ms. The patients were categorized according to the tertiles of the cTp-e interval (T1: 52.4-96.9 ms; T2: 100.1-129.1 ms; T3: 131.7-309.8 ms). There was a stepwise increment in the values of maximum Angio-IMR in each of the three coronary arteries in tertiles of the cTp-e interval (T1 vs. T2 vs. T3: 16.1 [14.7-19.3] vs. 21.8 [16.0-31.1] vs. 29.0 [27.2-31.9], P < 0.001). In-hospital adverse cardiovascular events occurred in 53 of 111 patients (47.7%). There was a stepwise increment in the incidence of in-hospital adverse cardiovascular events in tertiles of the cTp-e interval (T1 vs. T2 vs. T3: 27.1% vs. 54.1% vs. 62.2%, P = 0.007). The multivariable analysis showed that prolonged cTp-e interval (OR: 1.30; 95% CI: 1.12-1.56; P < 0.001) was independent predictors of in-hospital adverse cardiovascular events.

CONCLUSIONS

The Tpeak-Tend interval on admission reflected CMD and predicts in-hospital adverse cardiovascular events in patients with TTS.

A dynamic variant of Takotsubo cardiomyopathy mimicking apical hypertrophic cardiomyopathy: a case report

Background

Takotsubo cardiomyopathy usually presents with acute reversible left ventricular apical hypokinesia and apical ballooning with basal hyperdynamic function. We describe an underreported case of Takotsubo cardiomyopathy (TCM), misinterpreted as apical hypertrophic cardiomyopathy (HCM) due to transient apical oedema in the recovery phase of the condition.

Case summary

A 74-year-old Caucasian woman, presented to the emergency department complaining of retrosternal chest pain following, emotional stress. Her electrocardiogram (ECG) demonstrated poor R-wave progression in the right precordial leads raising the possibility of an anterior non-ST elevation myocardial infarction. High sensitivity troponin was elevated at 2232 ng/L, echocardiography demonstrating apical ballooning and left ventricular ejection fraction of 45%. Computed tomography coronary angiography revealed unobstructive coronary arteries. Cardiac magnetic resonance imaging (cMRI) demonstrated morphological features consistent with apical HCM. However, subsequent cMRI examination, illustrated resolution of the hypertrophic segments, with T1 parametric mapping and extracellular volume (ECV) favouring TCM over apical HCM.

Discussion

Following emotional stress, takotsubo cardiomyopathy is understood caused by various mechanisms: catecholamine surge, inflammation, or transient ischaemia event leading to dysregulated cellular mechanisms. This results in myocardial oedema and increased wall stiffness leading to non-type 1 coronary plaque event-related regional wall motion abnormalities.In this instance, the initial two cMRI studies reported morphological features consistent with apical HCM, however, a subsequent examination demonstrated resolution of these features. The key to delineating these distinct pathologies lies in myocardial T1 times that exceeded what is normally observed in HCM, the absence of late gadolinium enhancement and ECV values which favour takotsubo cardiomyopathy.

Reverse takotsubo induced cardiogenic shock in the peripartum period: A case report and literature review

Reverse takotsubo cardiomyopathy is a rare variant of a rare disease characterized by basal ballooning and dysfunction of the left ventricle. While it can render patients profoundly unwell and reliant on intensivist care, it is a transient phenomenon, with the worst symptoms subsiding after 2-3 days. At term, a young woman spontaneously entered labor prior to a planned repeat cesarean section. After experiencing physical and psychological distress during labor and a vacuum extraction, she developed cardiogenic shock from reverse takotsubo cardiomyopathy, quickly diagnosed with transthoracic echocardiogram. She required 2 days of intensive care support and made an excellent recovery. This very rare condition should be considered in systemically unwell women in the peripartum as it can be quickly diagnosed, providing patients with the best appropriate care.

Prognostic value of CHA2DS2-VASc score for in-hospital outcomes in patients with Takotsubo syndrome

BACKGROUND

There is uncertainty about the use of the CHA2DS2-VASc score to predict clinical events in patients with Takotsubo syndrome (TTS). This study aimed to assess the short-term prognostic role of CHA2DS2-VASc score in this population.

METHODS

All admissions with a primary diagnosis of TTS were included using data from the National Inpatient Sample database during 2016-2019. The primary outcome was in-hospital mortality and secondary outcomes included ischemic stroke, intracardiac thrombus, cardiogenic shock, requirement for mechanical circulatory support, and renal replacement therapy. Patients were divided into 3 groups according to the CHA2DS2-VASc score. (0-3, 4-6, and >6). Logistic regression was used to estimate odds ratios (OR) with 95 % confidence intervals (CI).

RESULTS

A total 32,595 weighted hospitalizations were included (median age was 67 [58-76] years; 90 % female). The median CHA2DS2-VASc score value was 4 (2-5). In the adjusted models, in-hospital mortality was significantly higher in the CHA2DS2-VASc 4-6 (OR 1.86, 95 % CI 1.09-3.16, p = 0.022) and CHA2DS2-VASc >6 (OR 3.35, 95 % CI 1.60-7.04, p = 0.001) groups compared to the CHA2DS2-VASc 0-3 group. Likewise, the CHA2DS2-VASc >6 group had significantly higher odds of ischemic stroke (OR 2.92, 95 % CI 1.22-6.96, p = 0.016), intracardiac thrombus (OR 3.56, 95 % CI 1.36-9.30, p = 0.010), cardiogenic shock (OR 1.73, 95 % CI 1.05-2.86, =0.033), and renal replacement therapy (OR 2.87, 95 % CI 1.04-7.92, p = 0.042).

CONCLUSIONS

Our results suggest that the CHA2DS2-VASc score is relatively useful for predicting in-hospital mortality and a range of clinical events in hospitalized patients with TTS.

Takotsubo syndrome linked to paroxysmal sympathetic hyperactivity as a postoperative complication after brain tumor removal: a case report and literature review

Paroxysmal sympathetic hyperactivity (PSH) is a relatively common syndrome typically observed following traumatic brain injury (TBI). It manifests through a combination of non-specific symptoms that collectively define its presentation. Linked to sympathetic hyperactivity, takotsubo syndrome is a cardiomyopathy marked by left ventricular dysfunction and may coincide with PSH. While various factors can lead to the simultaneous occurrence of these syndromes, a notably rare scenario involves their manifestation after brain tumor removal. The nonspecific nature of PSH symptoms and of the cardiac dysfunction in takotsubo syndrome pose challenges in accurately diagnosing these conditions in an intensive care unit (ICU) setting. They often overlap with more prevalent diagnoses like sepsis, pulmonary embolism, and acute heart failure. Thus, it is crucial for clinicians dealing with these patients to be aware that symptoms indicating sympathetic activity surge and left heart failure might prompt consideration of takotsubo syndrome and PSH. This study presents the case of an 8-year-old girl who developed takotsubo syndrome associated with sympathetic hyperactivity following the surgical removal of a bulbar tumor. To the best of our knowledge, this is the tenth case of PSH following brain tumor removal in a pediatric patient and the first reported case of occurrence of takotsubo linked to PSH after brain tumor removal. We offer a detailed account of the patient's clinical journey in the ICU, accompanied by a comprehensive review of relevant literature to identify similar cases. The significance of this case study lies in emphasizing the potential occurrence of takotsubo syndrome due to PSH and underscores the importance of early diagnosis and management due to their association with unfavorable clinical outcomes.

Importance of hospital and clinical factors for early mortality in Takotsubo syndrome: Insights from the Swedish Coronary Angiography and Angioplasty Registry

BACKGROUND

Takotsubo syndrome (TTS) is an acute heart failure syndrome with symptoms similar to acute myocardial infarction. TTS is often triggered by acute emotional or physical stress and is a significant cause of morbidity and mortality. Predictors of mortality in patients with TS are not well understood, and there is a need to identify high-risk patients and tailor treatment accordingly. This study aimed to assess the importance of various clinical factors in predicting 30-day mortality in TTS patients using a machine learning algorithm.

METHODS

We analyzed data from the nationwide Swedish Coronary Angiography and Angioplasty Registry (SCAAR) for all patients with TTS in Sweden between 2015 and 2022. Gradient boosting was used to assess the relative importance of variables in predicting 30-day mortality in TTS patients.

RESULTS

Of 3,180 patients hospitalized with TTS, 76.0% were women. The median age was 71.0 years (interquartile range 62-77). The crude all-cause mortality rate was 3.2% at 30 days. Machine learning algorithms by gradient boosting identified treating hospitals as the most important predictor of 30-day mortality. This factor was followed in significance by the clinical indication for angiography, creatinine level, Killip class, and age. Other less important factors included weight, height, and certain medical conditions such as hyperlipidemia and smoking status.

CONCLUSIONS

Using machine learning with gradient boosting, we analyzed all Swedish patients diagnosed with TTS over seven years and found that the treating hospital was the most significant predictor of 30-day mortality.

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.

Takotsubo Syndrome in Patients With COVID-19: A Systematic Review

Background

Respiratory conditions are major physical triggers of takotsubo syndrome (TTS) and portend worse outcomes. However, data on TTS in patients with coronavirus disease-2019 infection (COVID-19) are limited.

Methods

We searched PubMed, Embase, and Cochrane Library databases for case reports for the period 2019-2022 describing TTS in patients with COVID-19 pneumonia (TTS-COVID). We summarized the clinical data and outcomes and compared them to those in patients with TTS with an acute respiratory disease other than COVID-19 as a trigger (TTS-acute respiratory disease) and those with TTS with no respiratory disease (TTS-no respiratory disease).

Results

The mortality rate was higher in those with TTS-COVID (26.0%) than those with TTS-acute respiratory disease (5.7%) or TTS-no respiratory disease (4.2%; P < 0.001 for both). The proportion of men was higher in TTS-COVID (33.3%) than it was in TTS-no respiratory disease (9.1%; P < 0.001). The manifestations of TTS in COVID patients were atypical (dyspnea [70.3%] and cough [40.6%]); few had chest pain (23.4%). Cardiovascular risk factors were common in the TTS-COVID cohort, but fewer patients were on cardioprotective medications in this group than in the other 2 groups. Level of catecholamine use was higher in the TTS-COVID group (37.7%) than it was in the TTS-no respiratory disease (10.9%; P < 0.001) group. Apical ballooning (72.6%) was the most common TTS subtype, and basal segment type was seen in 11.0% of TTS-COVID patients.

Conclusions

COVID-19 patients who developed TTS had high mortality rates and unique features, compared with those in the TTS-acute respiratory disease group or the TTS-no respiratory disease group. Understanding the pathophysiology of TTS in COVID-19 may help prevent TTS and direct therapy in this setting.

Animal models of Takotsubo syndrome: bridging the gap to the human condition

Modelling human diseases serves as a crucial tool to unveil underlying mechanisms and pathophysiology. Takotsubo syndrome (TS), an acute form of heart failure resembling myocardial infarction, manifests with reversible regional wall motion abnormalities (RWMA) of the ventricles. Despite its mortality and clinical similarity to myocardial infarction, TS aetiology remains elusive, with stress and catecholamines playing central roles. This review delves into current animal models of TS, aiming to assess their ability to replicate key clinical traits and identifying limitations. An in-depth evaluation of published animal models reveals a variation in the definition of TS among studies. We notice a substantial prevalence of catecholamine-induced models, particularly in rodents. While these models shed light on TS, there remains potential for refinement. Translational success in TS research hinges on models that align with human TS features and exhibit the key features, including transient RWMA. Animal models should be comprehensively evaluated regarding the various systemic changes of the applied trigger(s) for a proper interpretation. This review acts as a guide for researchers, advocating for stringent TS model standards and enhancing translational validity.

Takotsubo syndrome: left atrial and ventricular myocardial strain impairment in the subacute and convalescent phases assessed by CMR

BACKGROUND

We investigated the differences in impairment of left ventricle (LV) and left atrium (LA) contractile dysfunction between subacute and convalescent takotsubo syndrome (TTS), using myocardial strain analysis by cardiac magnetic resonance (CMR) feature-tracking technique.

METHODS

We retrospectively selected 50 patients with TTS clinical-radiological diagnosis who underwent CMR within 30 days since symptoms onset: 19 studied during the early subacute phase (sTTS, ≤ 7 days) and 31 during the convalescence (cTTS, 8-30 days). We measured the following: LV global longitudinal, circumferential, and radial strain (lvGLS, lvGCS, lvGRS) and strain rate (SR) and LA reservoir (laS_r), conduit (laS_cd), and booster pump strain (laS_bp) and strain rate (laSR_r, laSR_cd, laSR_bp). Patients were compared with 30 age- and sex-matched controls.

RESULTS

All patients were women (mean age 63 years). TTS patients showed altered LV- and LA-strain features, compared to controls. sTTS was associated with increased laS_bp (12.7% versus 9.8%) and reduced lvEF (47.4% versus 54.8%), lvGLS (-12.2% versus 14.6%), and laS_cd (7.0% versus 9.5%) compared to cTTS (p ≤ 0.029). The interval between symptoms onset and CMR was correlated with laS_bp (r = -0.49) and lvGLS (r = 0.47) (p = 0.001 for both). At receiver operating characteristics analysis, laS_bp was the best discriminator between sTTS and cTTS (area under the curve [AUC] 0.815), followed by lvGLS (AUC 0.670).

CONCLUSIONS

LA dysfunction persists during the subacute and convalescence of TTS. laS_bp increases in subacute phase with progressive decrease during convalescence, representing a compensatory mechanism of LV dysfunction and thus a useful index of functional recovery.

RELEVANCE STATEMENT

Atrial strain has the potential to enhance the delineation of cardiac injury and functional impairment in TTS patients, assisting in the identification of individuals at higher risk and facilitating the implementation of more targeted and personalized medical therapies.

KEY POINTS

• In TTS, after ventricular recovery, atrial dysfunction persists assessable with CMR feature tracking. • Quantitative assessment of atrial strain discriminates atrial functions: reservoir, conduit, and booster pump. • Atrial booster pump changes after acute TTS, regardless of ventricular function. • Atrial strain may serve as a temporal marker in TTS.

Body Mass Index and Outcomes in Patients with Takotsubo Syndrome: A Nationwide Retrospective Cohort Study

BACKGROUND

Takotsubo syndrome (TTS) is a cardiac disorder that mimics acute coronary syndrome at presentation. While previous studies have demonstrated a relationship between body mass index (BMI) and outcomes in acute coronary syndrome, few have examined its relationship with TTS.

METHODS

Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified 14,551 patients admitted for TTS between 2010 and 2021. By applying multivariable regressions with restricted cubic splines, we examined the association between BMI and in-hospital mortality after adjusting for potential confounders.

RESULTS

Mean BMI was 21.1 kg/m2, classifying patients into severe underweight (<16.0 kg/m2, 7.1%), mild/moderate underweight (16.0-18.4 kg/m2, 18.3%), normal weight (18.5-22.9 kg/m2, 46.8%), overweight (23.0-27.4 kg/m2, 22.2%), and obese (≥27.5 kg/m2, 5.6%) groups. Patients with severe or mild/moderate underweight were older and had a higher prevalence of impaired physical activity, malignancy, chronic pulmonary disease, and pneumonia. In-hospital mortality was the highest (9.4%) in the severe underweight group, followed by the mild/moderate underweight group (5.4%), with the lowest being in the obese group (2.1%). Severe underweight (adjusted odds ratio = 2.05; 95% confidence interval [CI] = 1.54-2.73) and mild/moderate underweight (1.26; 95% CI = 1.01-1.57) were significantly associated with higher mortality compared with normal weight, while no significant association was noted with obesity. A nonlinear association between continuous BMI and mortality was observed, with mortality increasing when BMI decreased <20.0 kg/m2 but nearly plateauing in BMI >20.0 kg/m2.

CONCLUSIONS

The present nationwide analysis demonstrated a nonlinear association between BMI and in-hospital mortality of TTS. BMI is an easily available and clinically relevant marker for the risk stratification of TTS.

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.

Unveiling the Multifaceted Problems Associated with Dysrhythmia

Dysrhythmia is a term referring to the occurrence of spontaneous and repetitive changes in potentials with parameters deviating from those considered normal. The term refers to heart anomalies but has a broader meaning. Dysrhythmias may concern the heart, neurological system, digestive system, and sensory organs. Ion currents conducted through ion channels are a universal phenomenon. The occurrence of channel abnormalities will therefore result in disorders with clinical manifestations depending on the affected tissue, but phenomena from other tissues and organs may also manifest themselves. A similar problem concerns the implementation of pharmacotherapy, the mechanism of which is related to the impact on various ion currents. Treatment in this case may cause unfavorable effects on other tissues and organs. Drugs acting through the modulation of ion currents are characterized by relatively low tissue specificity. To assess a therapy's efficacy and safety, the risk of occurrences in other tissues with similar mechanisms of action must be considered. In the present review, the focus is shifted prominently onto a comparison of abnormal electrical activity within different tissues and organs. This review includes an overview of the types of dysrhythmias and the basic techniques of clinical examination of electrophysiological disorders. It also presents a concise overview of the available pharmacotherapy in particular diseases. In addition, the authors review the relevant ion channels and their research technique based on patch clumping.

Impact of hypoalbuminemia on in-hospital mortality in patients with takotsubo syndrome: A multicenter registry of the Tokyo Cardiovascular Care Unit Network

BACKGROUND

Hypoalbuminemia is common in critically ill patients and is associated with poor outcomes. However, the relationship between serum albumin levels and clinical outcomes in patients with takotsubo syndrome remains unclear. We examined the impact of hypoalbuminemia on in-hospital mortality in patients with takotsubo syndrome.

METHODS

Using the multicenter registry of the Tokyo Cardiovascular Care Unit Network between January 2017 and December 2020, we identified 631 eligible patients with takotsubo syndrome (median age, 78 years; male proportion, 22 %) and documented serum albumin levels at admission, which were used to allocate patients to hypoalbuminemia (serum albumin <3.5 g/dL) or normal albumin (serum albumin ≥3.5 g/dL) groups. Patient characteristics and in-hospital mortality were compared between the groups.

RESULTS

Hypoalbuminemia was detected in 200 (32 %) patients at admission. The hypoalbuminemia group was older and had a higher proportion of men and preceding physical triggers than the normal albumin group. In-hospital all-cause mortality was greater in the hypoalbuminemia group than in the normal albumin group (9.5 % vs. 1.9 %, p < 0.001). Both cardiac (3.0 % vs. 0.5 %, p = 0.015) and non-cardiac (6.5 % vs. 1.4 %, p = 0.002) mortality was greater in the hypoalbuminemia group. In multivariable logistic regression analysis, hypoalbuminemia was independently associated with increased in-hospital mortality, even after adjusting for confounders, including age, sex, and triggering events (odds ratio, 3.23; 95 % confidence interval, 1.31-7.95; p = 0.011).

CONCLUSIONS

In patients with takotsubo syndrome, hypoalbuminemia is a common comorbidity and is associated with a substantial risk of in-hospital death. Close monitoring and comprehensive critical care are required in these patients.

A study of takotsubo syndrome over 9 years at the Tokyo Cardiovascular Care Unit Network Registry

BACKGROUND

Takotsubo syndrome (TTS) is an acute cardiovascular disease with clinical manifestations similar to those of acute myocardial infarction (AMI), and TTS sometimes occurs just after catastrophes. Large-scale studies of TTS in Japan are scarce, so we examined data over 9 years from Tokyo metropolitan acute cardiovascular care hospital network registry.

METHODS

A total of 1626 patients were diagnosed with TTS between 2010 and 2018 at Tokyo Cardiovascular Care Unit Network facilities, and data from all these patients were analyzed. We investigated annual and monthly captured incidence of TTS, temporal trend of the captured incidence proportion of TTS versus AMI, the occurrence of TTS on the day of the great earthquake, and we elucidated the prognostic factors for in-hospital death.

RESULTS

The annual incidence proportion of TTS versus AMI increased from 2.3 % to 4.5 % (p < 0.001) over 9 years. The mean TTS patient age was 74.4 years: the peak incidence of TTS was at 80 to 84 years of age for both male and female; females accounted for 78.5 % of patients. The monthly variation of the incidence of TTS was found (p = 0.009). In 2011, a total of 137 cases of TTS occurred, with as many as 6 occurring on March 11, the day of the Great East Japan Earthquake. There was a definable trigger for TTS in 64 % (physical: 36 %; emotional: 27 %; others: 2 %). All-cause in-hospital mortality was 5.3 % and was higher in males than in females (10.3 % vs 3.9 %; p < 0.001). Non-cardiac causes accounted for 62 % of in-hospital mortality. Factors at presentation that were associated with in-hospital all-cause mortality were male sex, low body mass index, and a high C-reactive protein level.

CONCLUSIONS

This study elucidated the clinical features, in-hospital outcomes, and their attributed factors in patients with TTS in real-world clinical practice in Japan.

A year in heart failure: updates of clinical and preclinical findings

We witnessed major advances in the management of heart failure (HF) in 2022. Results of recent clinical and preclinical investigations aid preventive strategies, diagnostic efforts, and therapeutic interventions, and collectively, they hold promises for a more effective HF care for the near future. Accordingly, currently available information extends the 2021 European Society of Cardiology guidelines and provides a solid background for the introduction of improved clinical approaches in the number of HF-related cases. Elaboration on the relationships between epidemiological data and risk factors lead to better understanding of the pathophysiology of HF with reduced ejection fraction and HF with preserved ejection fraction. The clinical consequences of valvular dysfunctions are increasingly interpreted not only in their haemodynamic consequences but also in association with their pathogenetic factors and modern corrective treatment possibilities. The influence of coronavirus disease 2019 pandemic on the clinical care of HF appeared to be less intense in 2022 than before; hence, this period allowed to refine coronavirus disease 2019 management options for HF patients. Moreover, cardio-oncology emerges as a new subdiscipline providing significant improvements in clinical outcomes for oncology patients. Furthermore, the introduction of state-of-the-art molecular biologic methods, multi-omic approaches forecast improved phenotyping and precision medicine for HF. All above aspects are addressed in this article that highlights a selection of papers published in ESC Heart Failure in 2022.

Takotsubo syndrome after a minimally invasive tooth extraction in a patient without dental phobia: A case report

Takotsubo syndrome (TTS) is a rare, stress-induced acute cardiac disorder. Its precipitating factors include emotionally or physically stressful events and exogenous and endogenous adrenaline. In this report, we describe a case of atypical TTS in a 73-year-old woman who reported no dental fear and required acute cardiac care in an outpatient setting. She underwent routine extraction of an upper left premolar under local anesthesia. She reported heart palpitations after the injection, and the procedure was completed in 15 min. After presenting symptoms of sweating, pale skin, vomiting, low blood pressure, and ST-segment elevation, cardiologists ordered echocardiography, coronary angiography, and ventriculography. Upon receiving a TTS diagnosis, the patient was hospitalized and administered an intra-aortic balloon pump and beta-blocker. Her symptoms resolved, and she was discharged with no sequelae. We found no precipitating factors in the progression of TTS in this case, which suggests that TTS can develop in the absence of precipitating factors. All general dentists and oral surgeons should recognize the possible risk of TTS, even during minimally invasive dental procedures, such as routine extractions in patients without dental phobia.

Takotsubo Syndrome and Sudden Cardiac Death

Takotsubo syndrome (TTS), triggered by intense emotional or physical stress, occurring most commonly in post-menopausal women, presents as an ST-elevation myocardial infarction (MI). Cardiovascular complications occur in almost half the patients with TTS, and the inpatient mortality is comparable to MI (4-5%) owing to cardiogenic shock, myocardial rupture, or life-threatening arrhythmias. Thus, its prognosis is not as benign as previously thought, as it may cause mechanical complications (cardiac rupture) and potentially lethal arrhythmias and sudden cardiac death (SCD). Similar to MI, some patients may perish before reaching the hospital due to out-of-hospital cardiac arrest; this may lead to underestimation of the actual SCD risk. Furthermore, after discharge, some patients may develop late SCD and/or TTS recurrence that may result in SCD. There are risk factors for SCD in TTS patients, such as severe/persistent QT-interval prolongation inciting torsade-de-pointes, other ECG abnormalities (diffuse giant negative T-waves, widened QRS-complex), bradyarrhythmias, comorbidities, concurrent obstructive coronary artery disease or vasospasm, male gender, older age, severe left ventricular dysfunction, and use of sympathomimetic drugs. All these issues are herein reviewed, case reports/series and data from large cohort studies and meta-analyses are analyzed, risk factors are tabulated, and proarrhythmic effects and management strategies are discussed and pictorially illustrated.

Development and validation of a prognostic nomogram for Takotsubo syndrome patients in the intensive care units: a retrospective cohort study

Patients with Takotsubo syndrome (TTS) admitted to the intensive care unit (ICU) always confront a higher risk of in-hospital death than those hospitalized in the cardiology unit. The prognosis of the latter was analyzed by a large number of studies. However, there was no utility model to predict the risk of in-hospital death for patients with TTS in the ICU. This study aimed to establish a model predicting in-hospital death in patients with TTS admitted to ICU. We retrospectively included ICU patients with TTS from the MIMIC-IV database. The outcome of the nomogram was in-hospital death. Least Absolute Shrinkage Selection Operator (LASSO) analysis selected predictors preliminarily. The model was developed by multivariable logistic regression analysis. Calibration, decision curve analysis (DCA), and receiver operating characteristic (ROC) measured the performance of the nomogram on the accuracy, clinical utility, and discrimination, respectively. Eventually, 368 ICU patients with TTS were enrolled in this research. The in-hospital mortality was 13.04%. LASSO regression and multivariate logistic regression analysis verified risk factors significantly associated with in-hospital mortality. They were potassium, prothrombin time (PT), age, myocardial infarction, white cell count (WBC), hematocrit, anion gap, and sequential organ failure assessment (SOFA) score. This nomogram excellently discriminated against patients with a risk of in-hospital death. The area under curve (AUC) was 0.779 (95%CI: 0.732-0.826) in training set and 0.775 (95%CI: 0.711-0.839) in test set. The calibration plot and DCA showed good clinical benefits for this nomogram. We developed a nomogram that predicts the probability of in-hospital death for ICU patients with TTS. This nomogram was able to discriminate patients with a high risk of in-hospital death and performed clinical utility.

QT Prolongation and In-Hospital Ventricular Arrhythmic Complications in Patients With Apical Ballooning Takotsubo Syndrome

BACKGROUND

Takotsubo syndrome is associated with life threatening arrhythmias, and the apical ballooning pattern is characterized by a peculiar QT prolongation and particularly high-risk of arrhythmias.

OBJECTIVES

The aim of the study was to determine the association of QT interval on electrocardiogram for ventricular arrhythmic complications in patients with apical ballooning Takotsubo syndrome in a diverse population at a large urban hospital in the U.S.

METHODS

We reviewed 105 cases of apical ballooning Takotsubo syndrome in patients admitted between 2011 and 2017. Two cardiologists reviewed the electrocardiograms to measure QT interval, adjusted for rate using the Fridericia formula (QT_CF), and ventricular arrhythmic complications during the hospitalization. Data are reported as median and interquartile range or number and percentage.

RESULTS

Of the 105 patients, 86 (82%) were female, and 34 (32%) were self-reported Black or African American. The mean age was 65 years (range: 58-72 years). Left ventricular ejection fraction was 25% (range: 25%-35%). Heart rate was 101 beats/min (range: 83-121 beats/min). Ten (11%) patients experienced a ventricular arrhythmic complication and had significantly longer QT_CF (470 [range: 422-543] milliseconds) than did those without complications (417 [range: 383-456] milliseconds, P = 0.031). The area under the curve for QT_CF was 0.708 (95% CI: 0.536-0.880; P = 0.031). Twenty-eight (27%) patients had a QT_CF ≥460 milliseconds and significantly more arrhythmic complications (21% vs 5%, odds ratio 4.997 [95% CI: 1.288-19.237], P = 0.021). QT_CF was an independent predictor of ventricular arrhythmias: odds ratio 1.090 for each 10-millisecond increase in QT_CF (95% CI: 1.004-1.183; P = 0.040, corrected for sex).

CONCLUSIONS

In a diverse population of patients with apical ballooning Takotsubo syndrome admitted to a large urban hospital in the United States, QT_CF at admission ≥460 milliseconds identifies patients at high risk for in-hospital arrhythmic complications. Further studies are needed to determine strategies aimed at shortening QT interval to potentially prevent life-threatening arrhythmic events.

Reverse Takotsubo cardiomyopathy after orthotopic liver transplantation. A case report

Introduction

Takotsubo cardiomyopathy is a rare reversible type of heart failure, often precipitated by emotional stress; other risk factors include intracranial bleeding, ischemic stroke, sepsis, major surgery, pheochromocytoma. The clinical, electrical and blood sample analysis features resemble those of a myocardial infarction- however, they occur in the absence of angiographic coronary filling defects.

Case presentation

A 61-year-old male patient, 71 kg, 175 cm, underwent liver transplantation for Child-Pugh B cirrhosis secondary to mixed viral hepatitis (B and D). His medical records revealed mild mitral, aortic, and tricuspid insufficiencies and heart failure with preserved ejection fraction. An initially uneventful perioperative stage was succeeded by cardiogenic shock (cardiac index – 1.2 l/min/ sqm), which the patient developed 24 hours after the intervention. Elevated cardiac markers and ECG abnormalities showing ST-T changes in the V2-V5 leads were additionally noted. Transesophageal echocardiography (TEE) revealed an acute onset reduction in the left ventricular systolic function secondary to basal hypokinesia. No coronary obstruction was detected by percutaneous angiography. The above findings lead to the diagnosis of reverseTakotsubo cardiomyopathy. Further, the patient developed acute kidney injury and liver graft failure, succumbing within 48 hours after the surgical procedure.

Conclusions

We report a rare case of reverse Takotsubo cardiomyopathy in a male patient after orthotopic liver transplant.