Clinical and echocardiographic course in tako­tsubo cardiomyopathy: Long­term follow­up from a multicenter study

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.

Update of Takotsubo cardiomyopathy: Present experience and outlook for the future

Takotsubo cardiomyopathy (TTS) has become a recognised clinical entity since the Japanese scientist Sato first described it in 1990. Despite an increasing number of confirmed cases, especially during the COVID-19 pandemic, its pathophysiology remains incompletely understood, and decision-making differs in the diagnosis and treatment. In addition, it is not evident whether a significant increase in TTS is due to better understanding among practitioners and widespread access to coronary angiography, or if it is a reflection of an actual increase in incidence. We analysed a series of international research studies from 1990 to 2021. Beyond epidemiology and clinical presentation, we evaluated and summarised fundamental knowledge about various predisposing factors, with particular attention to the iatrogenic impact of certain drugs, namely antidepressants, chemotherapy, and antiarrhythmics. Furthermore, we highlighted the main pathophysiological theories to date. In addition, based on published studies and clinical cases, we investigated the role of numerous diagnostic approaches in the differential diagnosis of TTS and identified predictors of TTS complications, such as cardiogenic shock, ventricular fibrillation, and left ventricular thrombi. Accordingly, we sought to propose a diagnostic algorithm and further treatment management of TTS under the presence of possible complications to help practitioners make more informed decisions, as the initial presentation continues to pose a challenge due to its close similarity to acute coronary syndrome with ST-elevation. In conclusion, this article examines Takotsubo cardiomyopathy from different perspectives and, along with future systematic reviews and meta-analyses, can be of particular interest to practising cardiologists and researchers in developing clinical guidelines.

Long-term outcome in patients with takotsubo syndrome : A single center study from Vienna

BACKGROUND

There is an increasing amount of evidence suggesting multiple fatal complications in takotsubo syndrome; however, findings on the long-term outcome are scarce and show inconsistent evidence.

METHODS

This is a single center study of long-term prognosis in takotsubo patients admitted to the Klinik Ottakring, Vienna, Austria, from September 2006 to August 2019. We investigated the clinical features, prognostic factors and outcome of patients with takotsubo syndrome. Furthermore, survivors and non-survivors and patients with a different cause of death were compared.

RESULTS

Overall, 147 patients were included in the study and 49 takotsubo patients (33.3%) died during the follow-up, with a median of 126 months. The most common cause of death was a non-cardiac cause (71.4% of all deaths), especially malignancies (26.5% of all deaths). Moreover, non-survivors were older and more often men with more comorbidities (chronic kidney disease, malignancy). Patients who died because of cardiovascular disease were older and more often women than patients who died due to non-cardiovascular cause. Adjusted analysis showed no feature of an independent predictor of cardiovascular mortality for takotsubo patients. Female gender (HR = 0.32, CI: 0.16-0.64, p < 0.001), cancer (HR = 2.35, CI: 1.15-4.8, p = 0.019) and chronic kidney disease (HR = 2.61, CI: 1.11-6.14, p = 0.028) showed to be independent predictors of non-cardiovascular mortality.

CONCLUSION

Long-term prognosis of takotsubo patients is not favorable, mainly due to noncardiac comorbidities. Hence, consequent outpatient care in regular intervals after a takotsubo event based on risk factor control and early detection of malignancies seems justified.

Left ventricular contraction patterns in Takotsubo Syndrome and their correlation with long-term clinical outcome

BACKGROUND

Takotsubo Syndrome (TTS) is diagnosed in 1-2% of all patients presenting with acute coronary syndrome. Next to the typical apical manifestation, other locations of left ventricular contraction abnormality are possible, but their relationship to patient characteristics, clinical correlates as well as long-term outcome are poorly understood.

METHODS & RESULTS

We retrospectively analyzed 126 patients presenting TTS. Cases were categorized according to left ventricular contraction abnormality patterns: typical apical pattern (71%, n = 89) vs. atypical patterns (29%, n = 37). Cases with typical TTS showed significantly higher levels of troponin I (3.12 ng/ml vs. 1.32 ng/ml, p = 0.013) and creatin kinase (CK) on admission (461 (±1207)U/l vs. 173 (±177) U/l, p = 0.03) as well as peak CK (973 (±2860)U/l vs. 301 (±328) U/l, p = 0.03) and more often ischemia related ECG changes (p = 0.02). Follow-up data was available for 85% of the patients. Median FU time was 4.4 years (IQR 1.4-7.7 years). All-cause mortality during follow-up was 39%, with no significant difference between patients with typical or atypical TTS (43% vs. 29%, p = 0.17). In multivariate logistic regression analysis, only anemia was predictive for long-term mortality (OR 3.93, 95%CI 1.02-2.08, p = 0.015). The majority of surviving patients (69%) reported good quality of life, even though only 56% reported being symptom-free.

CONCLUSION

Patients with TTS have poor long-term prognosis with an overall mortality of 39.1% within 4 years and nearly half of all patients report persisting symptoms. Even though the apical contraction pattern is associated with higher elevation of serum markers for myocardial damage, it was not associated with higher long-term mortality.

Reversible exercise-induced left ventricular dysfunction in symptomatic patients with previous Takotsubo syndrome: insights from stress echocardiography

AIMS

Takotsubo syndrome (TTS) is usually associated with rapid and spontaneous recovery of left ventricular (LV) function. However, a proportion of patients may have persistent symptoms. This study aimed to determine the haemodynamic and LV contractile responses to exercise in these patients.

METHODS AND RESULTS

Thirty symptomatic TTS patients referred for exercise echocardiography, a median of 15 months following the index TTS episode, were matched with 30 controls with normal exercise echocardiography. Beta-blockers were withheld prior to the test. LV volumes, ejection fraction (EF) and wall motion score index (WMSI), were measured at rest and stress. The TTS cohort were Caucasian women with mean age of 64.6 ± 7.4 years and similar coronary risk factor profile and EF to controls. Resting systolic blood pressure (SBP), LV end-diastolic volume, wall stress, and right ventricular fractional area change were higher in TTS patients compared with controls. Stress echo data showed similar exercise time, peak heart rate, and peak SBP in TTS patients vs. controls, but TTS patients had higher LV volumes, lower exercise LVEF (70 ± 10% vs. 78 ± 7%; P = 0.001), ΔLVEF (4 ± 8% vs. 12 ± 5%; P < 0.001), and WMSI (1.4 ± 0.4 vs. 1 ± 0; P < 0.001) compared with controls. Twenty TTS patients had clear exercise-induced wall motion abnormalities, mainly involving the apex or more globally, with a mean ΔLVEF of 1% compared with 12% in controls. Among the other 10 TTS patients, the ΔLVEF was 10%.

CONCLUSION

Symptomatic patients with previous TTS have a blunted contractile response to exercise. The therapeutic and prognostic implications of these findings need further investigation.

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.

Time Course of Functional Recovery in Takotsubo (Stress) Cardiomyopathy: A Serial Speckle Tracking Echocardiography and Electrocardiography Study

BACKGROUND

Although rapid recovery of cardiac contraction is a hallmark of Takotsubo cardiomyopathy (TTC), the time course of recovery is still ill-defined. We aimed to investigate the time course of left ventricular (LV) functional recovery using 2D speckle tracking echocardiography and electrocardiography (ECG).

METHODS

Thirty-two consecutive patients (65 ± 16 years, 26 women) with TTC were prospectively recruited. ECG and echocardiography were performed at baseline (No. 1), before discharge (No. 2), and at 1 week (No. 3) and 5 weeks (No. 4) after discharge. Echocardiographic images and ECGs were analyzed to measure ejection fraction (LVEF), global and regional longitudinal strain (GLS, RLS), and T wave inversion (TWI) scores.

RESULTS

At baseline, LVEF, GLS, and TWI score were 39 ± 8.8%, -11 ± 4.3%, and 1.8 ± 3.0, respectively. Both LVEF and GLS continued to improve from baseline at the No. 2, No. 3, and No. 4 timepoints (49 ± 9.3%, 56 ± 7.5%, 58 ± 6.8%, respectively, for LVEF and -15 ± 4.2%, -17 ± 3.9%, -19 ± 3.4%, respectively, for GLS). TWI score was decreased at the No. 3 ECG relative to baseline and then increased (No. 2: -2.5 ± 3.0, No. 3: -2.9 ± 5.2, No. 4: -0.3 ± 4.4). In the apical subgroup, the reverse base-to-apex gradient of RLS had disappeared by the No. 3 echocardiography.

CONCLUSIONS

Contractile function as assessed by LVEF and GLS recovered continuously in patients with TTC throughout the acute and subacute phases, with rapid recovery in the acute phase. Negative T wave progressed during the acute phase and recovered more slowly during the subacute phase.

The ECG in the differential diagnosis between takotsubo cardiomyopathy and acute coronary syndrome

INTRODUCTION

Takotsubo cardiomyopathy (TC) is an acquired cardiomyopathy affecting mostly postmenopausal women mimicking an acute coronary syndrome (ACS). TC clinical presentation involves chest pain, elevated cardiac enzymes, wall motion abnormalities and electrocardiographic changes, all of which share striking similarities to ACS. Areas covered: Differential diagnosis between TC and ACS can be complex since there are no reliable and widely-accepted electrocardiographic criteria and, at the moment, only coronary angiography can rule out one of the two diagnoses with good certainty. The present review will discuss the pros and cons of the ECG in TC, focusing on how the signal changes through the acute phase, the hospitalization, and after discharge. Specific information will be provided for each component of the ECG trace, and potential pitfalls will be highlighted, in order get to the core of this important unmet clinical issue. Expert commentary: There are at least several reasons why the ECG is still not considered a useful tool in differential diagnosis between TC and ACS. These include recent awareness of the syndrome, lack of evidence-based therapy, and, more importantly, a wide range of ECG features according to race, patient characteristics, wall motion abnormalities, triggers, and time from symptoms onset.