"Ballooning" patterns in takotsubo cardiomyopathy reflect different clinical backgrounds and outcomes: a BOREAS-TCM study

Comparison of electrographic changes, clinical features and outcomes in different variants of Takotsubo syndrome

BACKGROUND

Dysfunction of the left ventricular (LV) apex (apical variant) is the most common form in Takotsubo syndrome (TS). Several less common non-apical variants have been described - mid-ventricular, basal and focal. We hypothesised that the clinical presentation, and electrocardiographic (ECG) findings may vary between apical and non-apical TS.

METHODS

We prospectively identified 194 consecutive patients with TS presenting to Middlemore Hospital, Auckland and obtained clinical, echocardiography, coronary angiography, and long-term follow-up data. ECGs at admission and Day 1 were compared.

RESULTS

Of 194 patients with TS, 168 (86.6%) had apical TS, and 26 (13.4%) non-apical TS (11 mid-ventricular TS, 5 basal TS, 10 focal TS). Apical TS patients had more significant LV systolic impairment (p = 0.001) and longer length of stay (p = 0.001). The extent of T-wave inversion (TWI) was similar for both groups on admission (p = 0.88). By Day 1 the extent of TWI was greater in apical TS group (median number of leads 5 vs. 1, p = 0.02). The change in QTc interval between admission and Day 1 was greater in apical TS group (29.7 ms vs. 2.77 ms, p < 0.001). Composite in-hospital complication rate was similar for both groups (13.7% vs. 15.4%, p = 0.77).

CONCLUSIONS

Compared with non-apical variants, apical TS patients develop more extensive TWI and greater QT prolongation on ECG, and more significant LV systolic impairment, but in-hospital complications were similar. Clinicians should be aware that there is a sub-group of TS patients who have non-apical regional wall motion abnormalities and who don't develop ECG changes typical of the more common apical variant.

Beta-blockers and renin-angiotensin system inhibitors for Takotsubo syndrome recurrence: a network meta-analysis

INTRODUCTION

Takotsubo syndrome (TTS) is an acute heart failure syndrome, featured by transient left ventricular systolic dysfunction. Recurrences of TTS are not infrequent and there is no standard preventive therapy. The aim of this study was to evaluate in a network meta-analysis if beta-blockers (BB) and ACE inhibitors/angiotensin receptor blockers (ACEi/ARBs), in combination or not, can effectively prevent TTS recurrences.

METHODS

We performed a systematic network meta-analysis, using MEDLINE/EMBASE and the Cochrane Central Register of Controlled Trials for clinical studies published between January 2010 and September 2022. We considered all those studies including patients receiving medical therapy with BB, ACEi/ARBs. The primary outcome was TTS recurrence.

RESULTS

We identified 6 clinical studies encompassing a total of 3407 patients with TTS. At 40±10 months follow-up, TTS recurrence was reported in 160 (4.7%) out of 3407 patients. Mean age was 69.8±2 years and 394 patients (11.5%) out of 3407 were male. There were no differences in terms of TTS recurrence when comparing ACEi/ARBs versus control (OR 0.83; 95% CI 0.47 to 1.47, p=0.52); BB versus control (OR 1.01; 95% CI 0.63 to 1.61, p=0.96) and ACEi/ARBs versus BB (OR 0.88; 95% CI 0.51 to 1.53, p=0.65).Combination of BB and ACEi/ARBs was also not effective in reducing the risk of recurrence versus control (OR 0.91; 95% CI 0.58 to 1.43, p=0.68) vs ACEi/ARBs (OR 0.79; 95% CI 0.46 to 1.34, p=0.38)) and vs BB (OR 0.77; 95% CI 0.49 to 1.21, p=0.26).

CONCLUSIONS

Our study did not find sufficient statistical evidence regarding combination therapy with BB and ACEi/ARBs in reduction of TTS recurrence.

Takotsubo Syndrome, Stressful Triggers, and Risk of Recurrence

The risk of recurrence in takotsubo syndrome (TTS) appears to be low, although previous studies have shown conflicting results and factors associated with recurrences are unclear. The aim of this study is to evaluate the incidence and predictors of TTS recurrences. Adult patients included in the Spanish Multicenter REgistry of TAKOtsubo syndrome (RETAKO) between January 2003 and September 2019 were identified. Patients were categorized based on recurrences during follow-up and a multivariate logistic regression model was used to identify factors associated with recurrences. A total of 1097 patients (mean age 71.0±11.9 years, 87% females) were included, repeated TTS events were documented in 44 patients (4.0%), including 13 patients with prior TTS and 31 patients with recurrent TTS during a median follow-up of 279 days. Two patients (0.02%) had two episodes of recurrence. Compared to patients who had no recurrence of TTS, those with recurrent TTS more frequently had no identifiable stressful trigger in the index admission (20 [64.5%] vs 352 [33.0%], p <0.001). Primary TTS, defined as TTS without physical trigger, was also more common in the recurrence group (93.5% vs 68.3%, p <0.001). The only factor independently associated with recurrences was the absence of an identifiable trigger (odds ratio 3.7 [95% confidence interval 1.8-7.8], p=0.001). In conclusion, our data indicate that for patients presenting with TTS, the rate of early recurrent TTS is approximately 4% per year. Among TTS patients, those who have no identifiable trigger events appear to have a higher rate of recurrence.

Favorable Effects of Impella on Takotsubo Syndrome Complicated with Cardiogenic Shock

Reportedly, approximately 9.9%-12.4% of patients with Takotsubo syndrome (TTS) are complicated with cardiogenic shock (CS) and its prognosis remains poor even with the support of conventional mechanical circulatory assist devices including intra-aortic balloon pumping and venoarterial extracorporeal membrane oxygenation. Impella, a novel percutaneous left ventricular assist device, provides strong circulatory support together with the unloading of the left ventricle, and it is theoretically a promising mechanical circulatory assist device for TTS. In this case study, we report four consecutive patients with TTS complicated with CS who were successfully resuscitated using the Impella support.

Prognostic factors of Takotsubo cardiomyopathy: a systematic review

Takotsubo cardiomyopathy (TCM), characterized by reversible ventricular dysfunction, has similar mortality to acute coronary syndrome. With the growing interest in the diagnosis of and interventions for TCM, many risk factors had been found to affect the prognosis of TCM patients, such as age, sex, and pre-existing diseases. Because of the incomplete understanding of the pathophysiologic mechanism in TCM, evidence-based medical therapy for this condition is lacking. Early intervention on risk factors may improve the outcomes of TCM. In this review, we sought to provide up-to-date evidence on risk factors and medical therapies that affect TCM outcome. We found that male sex, physical triggers, and certain comorbidities such as chronic kidney disease, malignant disease, higher body mass index, sepsis, chronic obstructive pulmonary disease, and anaemia were associated with poor TCM prognosis. In contrast, race, hyperlipidaemia, diabetes mellitus, and mood disorders were not clearly associated with TCM prognosis. We also reviewed the effect of medical therapies on TCM outcome, including angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, calcium channel blockers, and statins. The evidence that these medications confer a survival benefit on TCM patients is limited. Understanding these prognostic factors could help develop risk-stratification tools for TCM and establish effective prevention and interventions for this not-so-benign condition. Further multicentre clinical studies with large samples and meta-analyses of findings from previous studies are needed to address the inconsistent findings among the many potential risk factors for TCM.

Factors Associated with Recurrence in Takotsubo Syndrome: A Systematic Review

Fundamento:

A síndrome de Takotsubo (STT) é caracterizada por uma disfunção sistólica temporária do ventrículo esquerdo (VE) relacionada a um evento estressante. No entanto, os fatores associados à sua recorrência ainda não estão bem estabelecidos.

Objetivo:

Analisar os principais fatores associados à recorrência da STT.

Métodos:

Uma revisão sistemática foi realizada usando o modelo PRISMA. Foram incluídos estudos observacionais, publicados entre janeiro de 2008 e outubro de 2017, que apresentaram uma taxa de recorrência de pelo menos 3% e/ou 5 ou mais pacientes com recidiva e que preencheram pelo menos 80% dos critérios STROBE.

Resultados:

Seis artigos atenderam aos critérios para esta revisão sistemática. A taxa de recorrência variou de 1 a 3,5% ao ano (taxa de recorrência global 3,8%). Um estudo associou maior taxa de recorrência ao sexo feminino, quatro relataram o tempo entre o primeiro e o segundo episódio, um estudo associou o índice de massa corporal (IMC) e a hipercontratilidade da parede anterior média do VE a uma maior taxa de recorrência. Não foi determinada associação entre recorrência e alterações eletrocardiográficas. O uso de betabloqueadores não foi associado a taxas de recorrência.

Conclusões:

Sexo feminino, tempo desde o primeiro episódio da síndrome, baixo IMC e obstrução ventricular foram relatados como possíveis preditores de recorrência da STT.

Comparison of Contractility Patterns on Left Ventriculogram Versus Longitudinal Strain by Echocardiography in Patients With Takotsubo Cardiomyopathy

BACKGROUND

Takotsubo cardiomyopathy (TTC) is characterized by transient left ventricular (LV) dysfunction, electrocardiographic changes that can mimic acute myocardial infarction (MI), and release of myocardial enzymes in the absence of obstructive coronary artery disease (CAD). Conventionally, gross visual assessment of LV angiogram has been used to classify TTC. We aim to compare quantitative assessment of different regions of LV on angiogram and segmental strain on transthoracic echo to determine a better way to classify TTC rather than conventional qualitative visual assessment.

METHODS

We conducted a retrospective observational study of 20 patients diagnosed with TTC who had LV angiogram and transthoracic echocardiograms performed on presentation that were suitable for analysis. Twenty LV angiograms were analyzed using Rubo DICOM viewer software. Areas of different LV regions were measured in diastole and systole, and percentage changes in area of these regions were calculated. Percentage changes in area of less than 10% was considered "akinetic." On the other hand, using echocardiograms of these patients, LV regional longitudinal strain (LS) was derived from speckle-tracking analysis. These findings were compared to determine concordance between both modalities.

RESULTS

On quantitative analysis of 20 LV angiograms, the area of all the three LV regional (apex, mid ventricle, and base) shortening (>10%) was observed in 16 patients (80%) during systole as compared to diastole. However, only 4 out of 20 patients (20%) were noted to have apical region area change of <10% between diastole and systole. Analysis of LV regional LS patterns of 20 patients showed that 14 patients had abnormal values (> -18%) in all three LV regions: apex, mid ventricle, and base. The apical region was the most severely affected region (mean LS -13.9%), followed by the basal region (mean -14.7%) and the mid ventricular region (mean -15.1%). Comparing the results of both modalities showed that there was 35% (n = 7) concordance in the results noted for base and apical regions of the LV, whereas only 20% (n = 4) concordance was noted in mid ventricular region.

CONCLUSION

Contractility (shortening) on LV angiogram is present in a majority of patients in the three LV regions, but contractility assessed by LS is impaired in most of them. The concordance in both quantitative assessment modalities was low. LV angiogram may not be an accurate imaging modality to assess contractility patterns in Takotsubo patients, and echocardiographic LS analysis should be taken as the preferred imaging modality.

One Patient, Three Variants, Four Episodes of Takotsubo Cardiomyopathy

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TCM is an increasingly recognized clinical entity.

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Variants include apical, midventricular, basal, and focal.

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The authors present a unique case in which one patient developed three variants.

An Emerging Cardiovascular Disease: Takotsubo Syndrome

Takotsubo syndrome (TTS) is a recently identified cardiac disease, which is far from being completely known. The aims of this narrative review are to provide a better understanding of the pathophysiological features of TTS and to update clinical findings in order to improve the management of subjects affected by this syndrome (according to the most recent consensus papers issued by the international scientific societies). We based our search on the material obtained via PubMed up to April 2019. The terms used were "Takotsubo Syndrome and Takotsubo cardiomyopathy" in combination with "heart failure, pathophysiology, complications, diagnosis, and treatment." TTS is a reversible form of ventricular dysfunction usually characterized by akinesia of the apex in the absence of obstructive coronary artery disease. In its initial phase, TTS may be indistinguishable from AMI and is usually triggered by a sudden emotional/physical stressor which abruptly increases catecholamine levels. However, the mechanisms by which catecholamines or other unidentified molecules can cause myocardial dysfunction is unknown. In-hospital stay may be hampered by various life-threatening complications, while data on long-term survival remain scarce and unclear. Furthermore, TTS may sometimes recur. We believe that TTS is clearly a much more complex condition than previously thought. Much remains to be discovered about its pathophysiologic mechanisms, the role of the link between the heart and brain and that of triggering factors and gender, and the reasons why this syndrome displays different phenotypes and sometimes recurs. Undoubtedly, preliminary evidence from pathophysiological studies (mainly genetic studies) has shown promising advances. However, prospective randomized clinical trials are still needed in order to identify and to tailor the best medical treatments for TTS patients.

Left ventricular mechanics in the acute phase of Takotsubo cardiomyopathy: distinctive ballooning patterns translate into different diastolic properties

Although apical and midventricular Takotsubo cardiomyopathies (TTCs) share common triggers and pathophysiological features, little is known about the potential differences in left ventricular (LV) mechanistic properties between these TTC phenotypes. We sought to investigate whether LV systolic and/or diastolic function, as assessed invasively by left heart catheterization (LHC), differ according to ballooning patterns in the acute phase of TTC. One hundred and fourteen TTC patients were retrospectively identified between January 2009 and December 2015 at the University Hospital of Strasbourg, France. A comprehensive list of LV quantitative parameters was derived from LHC analysis for each patient. We examined 2 groups of patients according to ballooning patterns in the acute phase of TTC: patients with apical ballooning ("Apical group"; n = 76) and those with midventricular ballooning ("Midventricular group"; n = 38). LV minimal diastolic pressure (8.72 ± 6.72 vs. 5.02 ± 6.08 mmHg; p = 0.004), LV end diastolic pressure (23.11 ± 8.32 vs. 18.84 ± 8.06 mmHg; p = 0.01), and LV diastolic stiffness (LV stiffness 1: 0.29 ± 0.23 vs. 18.84 ± 8.06 mmHg/mL; p = 0.04-LV stiffness 2: 0.16 ± 0.08 vs. 0.12 ± 0.05 mmHg/mL; p = 0.005) were significantly higher in patients with apical TTC than in the midventricular group. Concomitantly, these findings were associated with significantly higher BNP levels in the apical group (923.91 ± 1164.53 vs. 418.71 ± 557.75 pg/mL; p = 0.004) than in the midventricular group. In the acute phase of stress cardiomyopathy, the classic apical form of TTC is associated with poorer diastolic function compared to the midventricular ballooning variant, as assessed through direct invasive hemodynamic measurements using LHC.

In-hospital Takotsubo syndrome versus in-hospital acute myocardial infarction among patients admitted for non-cardiac diseases: a nationwide inpatient database study

Takotsubo syndrome (TTS) and acute myocardial infarction (AMI) occasionally occur during hospitalization for non-cardiac diseases. However, no study has compared the clinical characteristics between in-hospital TTS and AMI. Using the Diagnosis Procedure Combination database in Japan between 2010 and 2014, we retrospectively identified eligible inpatients who were admitted for non-cardiac diseases and developed TTS (n = 230) or AMI (n = 611) as an early in-hospital complication diagnosed by coronary angiography within 7 days after admission. We examined factors associated with developing in-hospital TTS or AMI using multivariable logistic regression. We also compared 30-day and overall in-hospital mortality between patients with TTS and AMI using 1:1 propensity score matching. Despite similar age (72.7 ± 12.4 vs. 72.8 ± 10.4 years), patients with TTS were more often female (63.5 vs. 32.9%) and underweight (24.8 vs. 14.1%) and were more likely to have had impaired activities of daily living (ADL) and impaired consciousness than those with AMI. Multivariable logistic regression analysis showed that female sex [adjusted odds ratio: 4.16 (95% confidence interval: 2.73-6.34)], impaired ADL [2.33 (1.18-4.60)], chronic pulmonary disease [3.33 (1.49-7.44)], and pneumonia [3.00 (1.81-4.98)] were associated with developing TTS relative to AMI, while overweight status, aortic disease, cerebrovascular disease, peripheral arterial disease, and dyslipidemia were associated with developing AMI relative to TTS. Propensity score-matched analysis (189 pairs) showed that 30-day in-hospital mortality was not significantly different between patients with TTS and AMI (15.3 vs. 19.0%, p = 0.41), but overall in-hospital mortality was significantly lower in patients with TTS than in those with AMI (19.6 vs. 29.1%, p = 0.041). This study suggests that although in-hospital TTS and in-hospital AMI are similarly likely to occur in older patients, in-hospital TTS is more likely to occur in female patients with impaired ADL and/or respiratory disease and carries a similar 30-day mortality risk but a lower overall in-hospital mortality risk compared with in-hospital AMI. Our results indicate the importance of differentiating TTS from AMI in hospital settings.

Three Episodes of Takotsubo Cardiomyopathy with Variant Ballooning Patterns in 2 Elderly Women

Takotsubo cardiomyopathy can present with transient apical, midventricular, or basal left ventricular ballooning patterns. Reported recurrences of this cardiomyopathy are few. We present the cases of 2 elderly women who each had 3 episodes of takotsubo cardiomyopathy in various ballooning patterns. We explore the potential pathophysiologic mechanisms, and we discuss the best treatment approach for this disease, which carries a substantial risk of in-hospital complications.

Seasonal variation in patient characteristics and in-hospital outcomes of Takotsubo syndrome: a nationwide retrospective cohort study in Japan

Although there is reportedly seasonal variation in the occurrence of Takotsubo syndrome (TTS), it is unknown whether there is a relationship between season and patient characteristics, or whether season influences outcomes. Using the Diagnosis Procedure Combination database in Japan, we retrospectively identified 4306 patients (mean age 73.6 years) hospitalized with TTS between January 2011 and December 2013. We divided patients into four groups according to season of admission [n = 914, Spring (March-May); n = 1243, Summer (June-August); n = 1245, Autumn (September-November); n = 904, Winter (December-February)]. The outcomes were in-hospital mortality and cardiovascular complications. We compared patient backgrounds and outcomes across seasons and estimated the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for outcomes in logistic regression analyses adjusted for multiple propensity scores. Although there was no significant difference in age across seasons, the proportion of males differed significantly (from 18.5% in autumn to 23.9% in winter; p = 0.016). The incidence of psychiatric disease (from 4.9% in spring to 7.9% in summer; p = 0.025) and sepsis (from 0.8% in winter to 2.6% in summer; p = 0.019) also differed significantly with season. In-hospital mortality was not significantly influenced by season (p = 0.377): spring, 5.1%; summer, 6.0%; autumn, 4.6%; winter, 6.0%. However, in-hospital mortality ranged widely across months from 3.0% in September to 7.5% in April. The incidence of ventricular tachycardia/fibrillation was significantly different (p = 0.038): spring, 2.2% (reference); summer, 3.3% (aOR 1.46, 95% CI 0.84-2.51); autumn, 2.7% (aOR 1.27, 95% CI 0.72-2.22); winter, 4.4% (aOR 1.92, 95% CI 1.11-3.33). Although season did not appear to influence the in-hospital mortality of TTS, monthly variation may exist in the risk of death in patients with TTS. There were significant seasonal variations in the proportions of males, patients with psychiatric disease or sepsis, and the incidence of ventricular arrhythmias among patients with TTS.

The International Takotsubo Registry: Rationale, Design, Objectives, and First Results

Takotsubo syndrome (TTS) was first described in Japan in 1990. The clinical presentation is similar to that of acute coronary syndrome (ACS). Cardiac enzymes are commonly elevated. A global initiative was launched and the InterTAK Registry was established to provide a systematic database. The major goals of the International Takotsubo Registry (InterTAK Registry) are to provide a comprehensive clinical characterization on natural history, treatment, and outcomes. We linked a biorepository to identify biomarkers for the diagnosis and prognosis and to investigate the genetic basis as well as disease-related factors. We focus on the rationale, objectives, design, and first results of the InterTAK Registry.

Prognostic Usefulness of the Ballooning Pattern in Patients With Takotsubo Cardiomyopathy

The aim of the present analysis was to evaluate the prognostic impact of different ballooning patterns in patients with Takotsubo cardiomyopathy (TTC). A total of 285 consecutive patients with TTC were included. Clinical characteristics and short- and long-term outcomes were compared between patients with typical apical ballooning (n = 204) and patients with an atypical ballooning pattern including midventricular and basal ballooning (n = 81). Patients with typical apical ballooning were significantly older (73.3 ± 10.2 vs 68.4 ± 10.3 years; p <0.01) and had a higher prevalence of diabetes mellitus (25.5% vs 12.3%; p = 0.02). The initial left ventricular (LV) ejection fraction was significantly lower in case of apical ballooning (41.5 ± 10.4% vs 46.9 ± 10.9%; p <0.01) but recovered to normal values in both groups (58.4 ± 8.0 vs 59.7 ± 7.0; p = 0.25). Although 28-day mortality did not differ significantly (p = 0.10), typical apical ballooning was associated with an increased 6-month (13.4% vs 1.3%; hazard ratio [HR] 10.81, 95% confidence interval [CI] 1.47 to 79.66; p = 0.02) and long-term mortality rates (28.9% vs 14.5%; HR 2.24, 95% CI 1.17 to 4.71; p = 0.02). A landmark analysis which included only patients who survived the first 6 months after the initial event demonstrated similar mortality rates in patients with typical (17.9%) and atypical (13.3%) ballooning (HR 1.36, 95% CI 0.67 to 2.79; p = 0.40). In conclusion, in patients with TTC, typical apical ballooning is associated with more severe LV dysfunction at acute presentation and higher mortality rates within the first 6 months after the initial event. After complete recovery of LV function, prognosis is similar in patients with typical and atypical ballooning patterns.

Takotsubo Syndrome: Insights from Japan

We report the history and new insights of takotsubo syndrome based on the achievements that Japanese researchers have contributed and summarize the evidence originally presented from Japan. Takotsubo syndrome is a newly described heart failure characterized by transient left ventricular dysfunction. We should be aware of this entity as a syndrome, not actual cardiomyopathy. Japanese researchers focus on the experimental approaches for clinical diagnosis and treatment of takotsubo syndrome. As representatives from a country originally naming this syndrome takotsubo, a global registry for takotsubo syndrome including Japan should be established.

Prevalence and Clinical Features of Focal Takotsubo Cardiomyopathy

BACKGROUND

Because it is difficult to distinguish between focal takotsubo cardiomyopathy and aborted myocardial infarction, there is little information about the prevalence and clinical features of focal takotsubo cardiomyopathy.

METHODS AND RESULTS

Our cardiac catheterization databases were queried to identify patients with focal takotsubo cardiomyopathy and other types of takotsubo cardiomyopathy. We defined focal takotsubo cardiomyopathy as hypo-, a- or dyskinesis in both anterolateral and septal segments without obstructive coronary artery disease explaining the wall motion abnormality. A total of 10 patients were diagnosed with focal takotsubo cardiomyopathy. The control group comprised patients with takotsubo cardiomyopathy with apical, mid-ventricular, or basal ballooning. Clinical features and in-hospital outcomes were compared between patients with focal takotsubo cardiomyopathy and those with other types of takotsubo cardiomyopathy. Among the 144 patients with takotsubo cardiomyopathy, the apical, mid-ventricular, basal, and focal types occurred in 85 (59.0%), 49 (34.0%), 0 (0%), and 10 patients (6.9%), respectively. The left ventricular ejection fraction was significantly higher in the focal group compared with the apical and mid-ventricular group (56±13 vs. 45±13 vs. 46±12%, P=0.03). In-hospital outcome was not significantly different among the 3 groups.

CONCLUSIONS

Focal takotsubo cardiomyopathy is not rare. Biplane left ventriculography is useful for its diagnosis. (Circ J 2016; 80: 1824-1829).

Antiplatelet therapy in Takotsubo cardiomyopathy: does it improve cardiovascular outcomes during index event?

Plasma catecholamines may play an important role in Takotsubo cardiomyopathy (TCM) pathophysiology. Patients with disproportionately high catecholamine responses to stressful events are prone to worse clinical outcomes. Catecholamines stimulate platelet activation and, therefore, may determine the clinical presentation and outcomes of TCM. We conducted a retrospective, descriptive study TCM patients admitted between 2003 and 2013 to Einstein Medical Center, Philadelphia, PA, USA and Danbury Hospital, Danbury, CT, USA. A total of 206 patients met Modified Mayo TCM criteria. Using a multiple logistic model, we tested whether aspirin, dual antiplatelet therapy (DAPT) aspirin + clopidogrel, beta blocker, statin, or ACE inhibitor use were independent predictors of major adverse cardiovascular events (MACE) during the index hospitalization. MACE was defined as in-hospital heart failure, in-hospital death, stroke or respiratory failure requiring mechanical ventilation. Incidence of in-hospital heart failure was 26.7 %, in-hospital death was 7.3 %, stroke was 7.3 % and MACE was 42.3 %. In a multiple logistic regression model (adjusted for gender, race, age, physical stressor, hypertension, diabetes, hyperlipidemia, smoking history, body mass index, initial left ventricular ejection fraction, single antiplatelet therapy, DAPT, beta blocker, statin, and ACE inhibitor) aspirin and DAPT at the time of hospitalization were independent predictors of a lower incidence of MACE during the index hospitalization (aspirin: OR 0.4, 95 % CI (0.16-0.9), P = 0.04; DAPT: OR 0.23; 95 % CI (0.1-0.55); P < 0.01. Physical stressor itself was also found to be an independent predictor of worse MACE: OR 5.1; 95 % CI (2.4-11.5); P < 0.01. In our study, aspirin and DAPT were independent predictors of a lower incidence of MACE during hospitalization for TCM. Prospective clinical trials are needed to confirm the findings of this study.

Epidemiology and pathophysiology of Takotsubo syndrome

Takotsubo syndrome is an acute cardiac syndrome first described in 1990 and characterized by transient left ventricular dysfunction affecting more than one coronary artery territory, often in a circumferential apical, mid-ventricular, or basal distribution. Several pathophysiological explanations have been proposed for this syndrome and its intriguing appearance, and awareness is growing that these explanations might not be mutually exclusive. The reversible apical myocardial dysfunction observed might result from more than one pathophysiological phenomenon. The pathophysiology of Takotsubo syndrome is complex and integrates neuroendocrine physiology, potentially involving the cognitive centres of the brain, and including the hypothalamic-pituitary-adrenal axis. Cardiovascular responses are caused by the sudden sympathetic activation and surge in concentrations of circulating catecholamines. The multiple morphological changes seen in the myocardium match those seen after catecholamine-induced cardiotoxicity. The acute prognosis and recurrence rate are now known to be worse than initially thought, and much still needs to be learned about the epidemiology and the underlying pathophysiology of this fascinating condition in order to improve diagnostic and treatment pathways.

Usefulness of contrast computed tomography to detect left ventricular apical thrombus associated with takotsubo cardiomyopathy

Left ventricular (LV) apical thrombus can rarely occur during the early phase of takotsubo cardiomyopathy. We report such a case that was depicted clearly in contrast computed tomography (CT) but not in initial echocardiography. Because LV thrombus may lead to thromboembolic events, we should evaluate all patients with takotsubo cardiomyopathy for the presence of a LV thrombus. LV thrombus is generally recognized with echocardiography in the course of follow-up, but limited depiction of the LV apex with echocardiography can make evaluation of LV thrombus difficult. Contrast CT is useful to detect LV apical thrombus associated with takotsubo cardiomyopathy.