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Yang Z, Li Y, Huang M, Li X, Fan X, Yan C, Meng Z, Liao B, Hamdani N, El-Battrawy I, Yang X, Zhou X, Akin I. Small conductance calcium-activated potassium channel contributes to stress induced endothelial dysfunctions. Microvasc Res 2024; 155:104699. [PMID: 38901735 DOI: 10.1016/j.mvr.2024.104699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/26/2024] [Accepted: 06/02/2024] [Indexed: 06/22/2024]
Abstract
Patients with Takotsubo syndrome displayed endothelial dysfunction, but underlying mechanisms have not been fully clarified. This study aimed to explore molecular signalling responsible for catecholamine excess induced endothelial dysfunction. Human cardiac microvascular endothelial cells were challenged by epinephrine to mimic catecholamine excess. Patch clamp, FACS, ELISA, PCR, and immunostaining were employed for the study. Epinephrine (Epi) enhanced small conductance calcium-activated potassium channel current (ISK1-3) through activating α1 adrenoceptor. Phenylephrine enhanced edothelin-1 (ET-1) and reactive oxygen species (ROS) production, and the effects involved contribution of ISK1-3. H2O2 enhanced ISK1-3 and ET-1 production. Enhancing ISK1-3 caused a hyperpolarization, which increases ROS and ET-1 production. BAPTA partially reduced phenylephrine-induced enhancement of ET-1 and ROS, suggesting that α1 receptor activation can enhance ROS/ET-1 generation in both calcium-dependent and calcium-independent ways. The study demonstrates that high concentration catecholamine can activate SK1-3 channels through α1 receptor-ROS signalling and increase ET-1 production, facilitating vasoconstriction.
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Affiliation(s)
- Zhen Yang
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), Heidelberg University, 68167 Mannheim, Germany; Department of Ophthalmology, Affiliated Hospital of North Sichuan Medical College, 637000 Nanchong, Sichuan, China
| | - Yingrui Li
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), Heidelberg University, 68167 Mannheim, Germany
| | - Mengying Huang
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), Heidelberg University, 68167 Mannheim, Germany
| | - Xin Li
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), Heidelberg University, 68167 Mannheim, Germany
| | - Xuehui Fan
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), Heidelberg University, 68167 Mannheim, Germany
| | - Chen Yan
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), Heidelberg University, 68167 Mannheim, Germany
| | - Zenghui Meng
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), Heidelberg University, 68167 Mannheim, Germany
| | - Bin Liao
- Department of Cardiac Macrovascular Surgery, Affiliated Hospital of Southwest Medical University, 646000, Sichuan, China
| | - Nazha Hamdani
- Department of Molecular and Experimental Cardiology, Institut für Forschung und Lehre (IFL), Ruhr-University Bochum, Bochum, Germany
| | - Ibrahim El-Battrawy
- Department of Cardiology and Angiology, Ruhr University, Bochum, Germany; Institut für Forschung und Lehre (IFL), Department of Molecular and Experimental Cardiology, Ruhr-University Bochum, Bochum, Germany
| | - Xiaoli Yang
- Department of Ophthalmology, Affiliated Hospital of North Sichuan Medical College, 637000 Nanchong, Sichuan, China.
| | - Xiaobo Zhou
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), Heidelberg University, 68167 Mannheim, Germany; European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, and Centre for Cardiovascular Acute Medicine Mannheim (ZKAM), Medical Centre Mannheim, Heidelberg University, Germany; Key Laboratory of Medical Electrophysiology of Ministry of Education and Medical Electrophysiological Key Laboratory of Sichuan Province, Institute of Cardiovascular Research, Southwest Medical University, 646000, Sichuan, China.
| | - Ibrahim Akin
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), Heidelberg University, 68167 Mannheim, Germany; European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, and Centre for Cardiovascular Acute Medicine Mannheim (ZKAM), Medical Centre Mannheim, Heidelberg University, Germany
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2
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Falcão-Pires I, Ferreira AF, Trindade F, Bertrand L, Ciccarelli M, Visco V, Dawson D, Hamdani N, Van Laake LW, Lezoualc'h F, Linke WA, Lunde IG, Rainer PP, Abdellatif M, Van der Velden J, Cosentino N, Paldino A, Pompilio G, Zacchigna S, Heymans S, Thum T, Tocchetti CG. Mechanisms of myocardial reverse remodelling and its clinical significance: A scientific statement of the ESC Working Group on Myocardial Function. Eur J Heart Fail 2024; 26:1454-1479. [PMID: 38837573 DOI: 10.1002/ejhf.3264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 03/22/2024] [Accepted: 04/18/2024] [Indexed: 06/07/2024] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of morbimortality in Europe and worldwide. CVD imposes a heterogeneous spectrum of cardiac remodelling, depending on the insult nature, that is, pressure or volume overload, ischaemia, arrhythmias, infection, pathogenic gene variant, or cardiotoxicity. Moreover, the progression of CVD-induced remodelling is influenced by sex, age, genetic background and comorbidities, impacting patients' outcomes and prognosis. Cardiac reverse remodelling (RR) is defined as any normative improvement in cardiac geometry and function, driven by therapeutic interventions and rarely occurring spontaneously. While RR is the outcome desired for most CVD treatments, they often only slow/halt its progression or modify risk factors, calling for novel and more timely RR approaches. Interventions triggering RR depend on the myocardial insult and include drugs (renin-angiotensin-aldosterone system inhibitors, beta-blockers, diuretics and sodium-glucose cotransporter 2 inhibitors), devices (cardiac resynchronization therapy, ventricular assist devices), surgeries (valve replacement, coronary artery bypass graft), or physiological responses (deconditioning, postpartum). Subsequently, cardiac RR is inferred from the degree of normalization of left ventricular mass, ejection fraction and end-diastolic/end-systolic volumes, whose extent often correlates with patients' prognosis. However, strategies aimed at achieving sustained cardiac improvement, predictive models assessing the extent of RR, or even clinical endpoints that allow for distinguishing complete from incomplete RR or adverse remodelling objectively, remain limited and controversial. This scientific statement aims to define RR, clarify its underlying (patho)physiologic mechanisms and address (non)pharmacological options and promising strategies to promote RR, focusing on the left heart. We highlight the predictors of the extent of RR and review the prognostic significance/impact of incomplete RR/adverse remodelling. Lastly, we present an overview of RR animal models and potential future strategies under pre-clinical evaluation.
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Affiliation(s)
- Inês Falcão-Pires
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Ana Filipa Ferreira
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Fábio Trindade
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Luc Bertrand
- Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Pôle of Cardiovascular Research, Brussels, Belgium
- WELBIO, Department, WEL Research Institute, Wavre, Belgium
| | - Michele Ciccarelli
- Cardiovascular Research Unit, Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
| | - Valeria Visco
- Cardiovascular Research Unit, Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
| | - Dana Dawson
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - Nazha Hamdani
- Department of Cellular and Translational Physiology, Institute of Physiology, Ruhr University Bochum, Bochum, Germany
- Institut für Forschung und Lehre (IFL), Molecular and Experimental Cardiology, Ruhr University Bochum, Bochum, Germany
- HCEMM-SU Cardiovascular Comorbidities Research Group, Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Department of Physiology, Cardiovascular Research Institute Maastricht University Maastricht, Maastricht, the Netherlands
| | - Linda W Van Laake
- Division Heart and Lungs, Department of Cardiology and Regenerative Medicine Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank Lezoualc'h
- Institut des Maladies Métaboliques et Cardiovasculaires, Inserm, Université Paul Sabatier, UMR 1297-I2MC, Toulouse, France
| | - Wolfgang A Linke
- Institute of Physiology II, University Hospital Münster, Münster, Germany
| | - Ida G Lunde
- Oslo Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway
- KG Jebsen Center for Cardiac Biomarkers, Campus Ahus, University of Oslo, Oslo, Norway
| | - Peter P Rainer
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed Graz, Graz, Austria
- St. Johann in Tirol General Hospital, St. Johann in Tirol, Austria
| | - Mahmoud Abdellatif
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed Graz, Graz, Austria
| | | | - Nicola Cosentino
- Centro Cardiologico Monzino IRCCS, Milan, Italy
- Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Alessia Paldino
- Cardiovascular Biology Laboratory, International Centre for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Giulio Pompilio
- Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Serena Zacchigna
- Cardiovascular Biology Laboratory, International Centre for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Stephane Heymans
- Department of Cardiology, CARIM Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
- Centre of Cardiovascular Research, University of Leuven, Leuven, Belgium
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies, Hannover Medical School, Hannover, Germany
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences (DISMET), Center for Basic and Clinical Immunology Research (CISI), Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
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3
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Li X, Yang JJ, Xu D. The role of inflammation in takotsubo syndrome: A new therapeutic target? J Cell Mol Med 2024; 28:e18503. [PMID: 38896112 PMCID: PMC11186299 DOI: 10.1111/jcmm.18503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 05/23/2024] [Accepted: 06/05/2024] [Indexed: 06/21/2024] Open
Abstract
Takotsubo syndrome (TTS) is a particular form of acute heart failure that can be challenging to distinguish from acute coronary syndrome at presentation. TTS was previously considered a benign self-limiting condition, but it is now known to be associated with substantial short- and long-term morbidity and mortality. Because of the poor understanding of its underlying pathophysiology, there are few evidence-based interventions to treat TTS. The hypotheses formulated so far can be grouped into endogenous adrenergic surge, psychological stress or preexisting psychiatric illness, coronary vasospasm with microvascular dysfunction, metabolic and energetic alterations, and inflammatory mechanisms. Current evidence demonstrates that the infiltration of immune cells such as macrophages and neutrophils play a pivotal role in TTS. At baseline, resident macrophages were the dominant subset in cardiac macrophages, however, it underwent a shift from resident macrophages to monocyte-derived infiltrating macrophages in TTS. Depletion of macrophages and monocytes in mice strongly protected them from isoprenaline-induced cardiac dysfunction. It is probable that immune cells, especially macrophages, may be new targets for the treatment of TTS.
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Affiliation(s)
- Xiao Li
- Department of Internal Cardiovascular MedicineSecond Xiangya Hospital, Central South UniversityChangshaHunanChina
| | - Jingmin Jing Yang
- Department of Internal Cardiovascular MedicineSecond Xiangya Hospital, Central South UniversityChangshaHunanChina
| | - Danyan Xu
- Department of Internal Cardiovascular MedicineSecond Xiangya Hospital, Central South UniversityChangshaHunanChina
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4
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Wang Y, Tang X, Cui J, Wang P, Yang Q, Chen Y, Zhang T. Ginsenoside Rb1 mitigates acute catecholamine surge-induced myocardial injuries in part by suppressing STING-mediated macrophage activation. Biomed Pharmacother 2024; 175:116794. [PMID: 38776673 DOI: 10.1016/j.biopha.2024.116794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/14/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
Stress cardiomyopathy (SCM) is associated with cardiovascular mortality rates similar to acute coronary syndrome. Myocardial injuries driven by inflammatory mechanisms may in part account for the dismal prognosis of SCM. Currently, no inflammation-targeted therapies are available to mitigate SCM-associated myocardial injuries. In this study, acute catecholamine surge-induced SCM was modeled by stimulating the ovariectomized (OVX) mice with isoproterenol (ISO). The effects of ginsenoside Rb1 (Rb1) on SCM-associated myocardial injuries were assessed in the OVX-ISO compound mice. RAW 264.7 macrophages stimulated with calf thymus DNA (ctDNA) or STING agonist DMXAA were adopted to further understand the anti-inflammatory mechanisms of Rb1. The results show that estrogen deprivation increases the susceptibility to ISO-induced myocardial injuries. Rb1 mitigates myocardial injuries and attenuates cardiomyocyte necrosis as well as myocardial inflammation in the OVX-ISO mice. Bioinformatics analysis suggests that cytosolic DNA-sensing pathway is closely linked with ISO-triggered inflammatory responses and cell death in the heart. In macrophages, Rb1 lowers ctDNA-stimulated production of TNF-α, IL-6, CCL2 and IFN-β. RNA-seq analyses uncover that Rb1 offsets DNA-stimulated upregulation in multiple inflammatory response pathways and cytosolic DNA-sensing pathway. Furthermore, Rb1 directly mitigates DMXAA-stimulated STING activation and inflammatory responses in macrophages. In conclusion, the work here demonstrates for the first time that Rb1 protects against SCM-associated myocardial injuries in part by counteracting acute ISO stress-triggered cardiomyocyte necrosis and myocardial inflammation. Moreover, by evidencing that Rb1 downregulates cytosolic DNA-sensing machineries in macrophages, our findings warrant further investigation of therapeutic implications of the anti-inflammatory Rb1 in the treatment of SCM.
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Affiliation(s)
- Yujue Wang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China
| | - Xinmiao Tang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China
| | - Jingang Cui
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China; Clinical Research Institute of Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China
| | - Peiwei Wang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China; Clinical Research Institute of Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China
| | - Qinbo Yang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China; Clinical Research Institute of Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China
| | - Yu Chen
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China; Clinical Research Institute of Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China; Laboratory of Clinical and Molecular Pharmacology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China.
| | - Teng Zhang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China; Clinical Research Institute of Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, 110 Ganhe Rd, Shanghai 200437, China.
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5
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Zulfaj E, Nejat A, Haamid A, Elmahdy A, Espinosa A, Redfors B, Omerovic E. Animal models of Takotsubo syndrome: bridging the gap to the human condition. Front Cardiovasc Med 2024; 11:1351587. [PMID: 38841261 PMCID: PMC11152046 DOI: 10.3389/fcvm.2024.1351587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/18/2024] [Indexed: 06/07/2024] Open
Abstract
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.
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Affiliation(s)
- Ermir Zulfaj
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - AmirAli Nejat
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Abdulhussain Haamid
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ahmed Elmahdy
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Aaron Espinosa
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Björn Redfors
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
- Core Facilities - Experimental Biomedicine, Sahlgrenska Academy, Gothenburg, Sweden
| | - Elmir Omerovic
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
- Core Facilities - Experimental Biomedicine, Sahlgrenska Academy, Gothenburg, Sweden
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6
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Rudd AE, Horgan G, Khan H, Gamble DT, McGowan J, Sood A, McGeoch R, Irving J, Watt J, Leslie SJ, Petrie M, Lang C, Mills NL, Newby DE, Dawson DK. Cardiovascular and Noncardiovascular Prescribing and Mortality After Takotsubo Comparison With Myocardial Infarction and General Population. JACC. ADVANCES 2024; 3:100797. [PMID: 38774915 PMCID: PMC7615966 DOI: 10.1016/j.jacadv.2023.100797] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/24/2023] [Accepted: 11/10/2023] [Indexed: 05/24/2024]
Abstract
Background Takotsubo syndrome is an increasingly common cardiac emergency with no known evidence-based treatment. Objectives The purpose of this study was to investigate cardiovascular mortality and medication use after takotsubo syndrome. Methods In a case-control study, all patients with takotsubo syndrome in Scotland between 2010 and 2017 (n = 620) were age, sex, and geographically matched to individuals in the general population (1:4, n = 2,480) and contemporaneous patients with acute myocardial infarction (1:1, n = 620). Electronic health record data linkage of mortality outcomes and drug prescribing were analyzed using Cox proportional hazard regression models. Results Of the 3,720 study participants (mean age, 66 years; 91% women), 153 (25%) patients with takotsubo syndrome died over the median of 5.5 years follow-up. This exceeded mortality rates in the general population (N = 374 [15%]; HR: 1.78 [95% CI: 1.48-2.15], P < 0.0001), especially for cardiovascular (HR: 2.47 [95% CI: 1.81-3.39], P < 0.001) but also noncardiovascular (HR: 1.48 [95% CI: 1.16-1.87], P = 0.002) deaths. Mortality rates were lower for patients with takotsubo syndrome than those with myocardial infarction (31%, 195/620; HR: 0.76 [95% CI: 0.62-0.94], P = 0.012), which was attributable to lower rates of cardiovascular (HR: 0.61 [95% CI: 0.44-0.84], P = 0.002) but not non-cardiovascular (HR: 0.92 [95% CI: 0.69-1.23], P = 0.59) deaths. Despite comparable medications use, cardiovascular therapies were consistently associated with better survival in patients with myocardial infarction but not in those with takotsubo syndrome. Diuretic (P = 0.01), anti-inflammatory (P = 0.002), and psychotropic (P < 0.001) therapies were all associated with worse outcomes in patients with takotsubo syndrome. Conclusions In patients with takotsubo syndrome, cardiovascular mortality is the leading cause of death, and this is not associated with cardiovascular therapy use.
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Affiliation(s)
- Amelia E. Rudd
- Aberdeen Cardiovascular and Diabetes Centre, University of Aberdeen and NHS Grampian, Aberdeen, United Kingdom
| | - Graham Horgan
- Biomathematics & Statistics Scotland, Aberdeen, United Kingdom
| | - Hilal Khan
- Aberdeen Cardiovascular and Diabetes Centre, University of Aberdeen and NHS Grampian, Aberdeen, United Kingdom
| | - David T. Gamble
- Aberdeen Cardiovascular and Diabetes Centre, University of Aberdeen and NHS Grampian, Aberdeen, United Kingdom
| | - Jim McGowan
- University Hospital Ayr, NHS Ayrshire and Arran, Ayr, United Kingdom
| | - Arvind Sood
- Hairmyres Hospital, NHS Lanarkshire, East Kilbride, United Kingdom
| | - Ross McGeoch
- Hairmyres Hospital, NHS Lanarkshire, East Kilbride, United Kingdom
| | - John Irving
- NHS Tayside, University of Dundee and Ninewells Hospital, Dundee, United Kingdom
| | - Jonathan Watt
- NHS Highland, Raigmore Hospital, Inverness, United Kingdom
| | | | - Mark Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Chim Lang
- NHS Tayside, University of Dundee and Ninewells Hospital, Dundee, United Kingdom
| | - Nicholas L. Mills
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
- Centre for Cardiovascular Science and Usher Institute, University of Edinburgh and NHS Lothian, Edinburgh, United Kingdom
| | - David E. Newby
- Centre for Cardiovascular Science and Usher Institute, University of Edinburgh and NHS Lothian, Edinburgh, United Kingdom
| | - Dana K. Dawson
- Aberdeen Cardiovascular and Diabetes Centre, University of Aberdeen and NHS Grampian, Aberdeen, United Kingdom
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7
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Abusnina W, Elhouderi E, Walters RW, Al-Abdouh A, Mostafa MR, Liu JL, Mazozy R, Mhanna M, Ben-Dor I, Dufani J, Kabach A, Michos ED, Aboeata A, Mamas MA. Sex Differences in the Clinical Outcomes of Patients With Takotsubo Stress Cardiomyopathy: A Meta-Analysis of Observational Studies. Am J Cardiol 2024; 211:316-325. [PMID: 37923154 DOI: 10.1016/j.amjcard.2023.10.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 10/13/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023]
Abstract
The incidence of takotsubo stress cardiomyopathy (TSCM) in males is low compared with females. Gender-based differences in clinical outcomes of TSCM are not well characterized. The aim of this meta-analysis was to analyze whether gender-based differences are observed in TSCM clinical outcomes. A comprehensive literature search of PubMed, Embase, Cochrane Library database, and Web of Science was performed from inception to June 20, 2022, for studies comparing the clinical outcomes between male and female patients with TSCM. The primary outcome of interest was in-hospital all-cause mortality and cardiogenic shock. The secondary outcomes were cardiovascular mortality, receipt of mechanical ventilation, intra-aortic balloon pump, occurrence of ventricular arrhythmia, and left ventricular thrombus. A random-effects model was used to calculate the risk ratios (RR) and confidence intervals (CI). Heterogenicity was assessed using the Higgins I2 index. Twelve observational studies involving 51,213 patients (4,869 males and 46,344 females) were included in the meta-analysis. Male gender was associated with statistically significant higher in-hospital all-cause mortality compared with females in patients with TSCM (RR 2.17, 95% CI 1.77 to 2.67, p <0.001). The rate of cardiogenic shock was significantly higher in males with TSCM compared with females (RR 1.66, 95% CI 1.29 to 2.12, p <0.001). Our meta-analysis showed a difference in the clinical outcomes of TSCM between men and women. Male gender was associated with a two-fold greater in-hospital all-cause mortality risk compared with female gender. The higher mortality risk associated with male gender deserves further study, particularly whether it represents later recognition of the condition and disparities in treatments.
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Affiliation(s)
- Waiel Abusnina
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, USA; Section of Interventional Cardiology, Medstar Washington Hospital Center, Washington DC.
| | - Eiman Elhouderi
- Department of Medicine, Beaumont Hospital, Dearborn, MI, USA
| | - Ryan W Walters
- Department of Clinical Research and Public Health, Creighton University School of Medicine, Omaha, NE, USA
| | - Ahmad Al-Abdouh
- Division of Hospital Medicine, University of Kentucky, Lexington, KY, USA
| | - Mostafa R Mostafa
- Department of Medicine, Rochester Regional Health/Unity Hospital, Rochester, New York, USA
| | - John L Liu
- Creighton University School of Medicine, Omaha, NE, USA
| | - Ruqayah Mazozy
- Department of Cardiology, Zliten Medical Center, Zliten, Libya
| | - Mohammed Mhanna
- Division of Cardiology, Department of Medicine, University of Iowa, IA, USA
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, Medstar Washington Hospital Center, Washington DC
| | - Jalal Dufani
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, USA
| | - Amjad Kabach
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, USA
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahemd Aboeata
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, USA
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8
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Silverio A, Bossone E, Parodi G, Scudiero F, Di Maio M, Vriz O, Bellino M, Zito C, Provenza G, Iuliano G, Cristiano M, Novo G, Mauro C, Rigo F, Innelli P, Salerno-Uriarte J, Cameli M, Tremiterra G, Vecchione C, Antonini-Canterin F, Galasso G, Citro R. Arterial hypertension in patients with takotsubo syndrome: prevalence, long-term outcome, and secondary preventive strategies: a report from the Takotsubo Italian Network register. Eur J Prev Cardiol 2023; 30:1998-2005. [PMID: 37463434 DOI: 10.1093/eurjpc/zwad237] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 06/18/2023] [Accepted: 07/14/2023] [Indexed: 07/20/2023]
Abstract
AIMS The aim of this study was to investigate the long-term outcome of takotsubo syndrome (TTS) patients with and without hypertension (HT) and to evaluate the effectiveness of treatment with beta-blockers (BBs) and/or renin-angiotensin-aldosterone system inhibitors (RAASi). METHODS AND RESULTS The study population includes a register-based, multicentre cohort of consecutive patients with TTS, divided into two groups according to the history of HT. Further stratification was performed for BB/RAASi prescription at discharge. The primary outcome was the composite of all-cause death and TTS recurrence at the longest available follow-up. The propensity score weighting technique was used to account for potential confounding. In the overall population (903 patients, mean age 70 ± 11 years), HT was reported in 66% of cases. At a median 2-year follow-up, there was no difference in the risk of the primary composite outcome between patients with and without HT. The adjusted Cox regression analysis showed a significantly lower risk for the primary outcome [adjusted hazard ratio (aHR): 0.69; 95% confidence interval (CI): 0.49-0.99] in patients who received BB vs. those who did not. Renin-angiotensin-aldosterone system inhibitors treatment was not associated with the primary study outcome. The lower risk for the primary outcome with BB treatment was confirmed in patients with HT (aHR: 0.37; 95% CI: 0.24-0.56) but not in patients without (aHR: 1.83; 95% CI: 0.92-3.64; Pinteraction < 0.001). CONCLUSION In this TTS study, HT did not affect the long-term risk of adverse events but increased the probability of benefit from BB treatment after discharge. Owing to the favourable outcome impact of BB prescription in TTS patients with HT, a tailored pharmacological therapy should be considered in this cohort.
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Affiliation(s)
- Angelo Silverio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Eduardo Bossone
- Division of Cardiology, Antonio Cardarelli Hospital, Naples, Italy
| | - Guido Parodi
- Department of Cardiology, ASL4 Liguria, Lavagna, Italy
| | | | - Marco Di Maio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Olga Vriz
- Heart Centre, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- College of Medicine, Al Faisal University, Riyadh, Saudi Arabia
| | - Michele Bellino
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Concetta Zito
- Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, University Hospital 'Policlinico G. Martino', Messina, Italy
| | - Gennaro Provenza
- Division of Cardiology, Cardiovascular and Thoracic Department, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Heart Tower Room 807, Largo Città d'Ippocrate, Salerno 84131, Italy
| | - Giuseppe Iuliano
- Division of Cardiology, Cardiovascular and Thoracic Department, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Heart Tower Room 807, Largo Città d'Ippocrate, Salerno 84131, Italy
| | - Mario Cristiano
- Division of Cardiology, Cardiovascular and Thoracic Department, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Heart Tower Room 807, Largo Città d'Ippocrate, Salerno 84131, Italy
| | - Giuseppina Novo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Ciro Mauro
- Division of Cardiology, Antonio Cardarelli Hospital, Naples, Italy
| | - Fausto Rigo
- Cardiology Department, Ospedale dell'Angelo Mestre-Venice, Venice, Italy
| | - Pasquale Innelli
- Department of Cardiovascular Imaging, San Carlo Hospital, Potenza, Italy
| | | | - Matteo Cameli
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Giuliana Tremiterra
- Healtcare Management, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy
| | - Carmine Vecchione
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
- Vascular Physiopathology Unit, IRCCS Neuromed, Via Atinense 18, 86077 Pozzilli, Isernia, Italy
| | - Francesco Antonini-Canterin
- Cardiology Unit, High Specialization Rehabilitation Hospital Motta di Livenza, Motta di Livenza, Treviso, Italy
| | - Gennaro Galasso
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Rodolfo Citro
- Division of Cardiology, Cardiovascular and Thoracic Department, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Heart Tower Room 807, Largo Città d'Ippocrate, Salerno 84131, Italy
- Vascular Physiopathology Unit, IRCCS Neuromed, Via Atinense 18, 86077 Pozzilli, Isernia, Italy
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9
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Watanabe Y, Yoshikawa T, Isogai T, Sakata K, Yamaguchi T, Arao K, Takaoka Y, Inohara T, Imori Y, Mochizuki H, Yamamoto T, Asai K, Nagao K, Takayama M. Impact of hypoalbuminemia on in-hospital mortality in patients with takotsubo syndrome: A multicenter registry of the Tokyo Cardiovascular Care Unit Network. J Cardiol 2023; 82:356-362. [PMID: 37343932 DOI: 10.1016/j.jjcc.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/23/2023] [Accepted: 05/27/2023] [Indexed: 06/23/2023]
Abstract
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.
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Affiliation(s)
- Yukihiro Watanabe
- Tokyo Cardiovascular Care Unit Network Scientific Committee, Tokyo, Japan; Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan.
| | - Tsutomu Yoshikawa
- Tokyo Cardiovascular Care Unit Network Scientific Committee, Tokyo, Japan
| | - Toshiaki Isogai
- Tokyo Cardiovascular Care Unit Network Scientific Committee, Tokyo, Japan
| | - Konomi Sakata
- Tokyo Cardiovascular Care Unit Network Scientific Committee, Tokyo, Japan
| | - Tetsuo Yamaguchi
- Tokyo Cardiovascular Care Unit Network Scientific Committee, Tokyo, Japan
| | - Kenshiro Arao
- Tokyo Cardiovascular Care Unit Network Scientific Committee, Tokyo, Japan
| | - Yoshimitsu Takaoka
- Tokyo Cardiovascular Care Unit Network Scientific Committee, Tokyo, Japan
| | - Taku Inohara
- Tokyo Cardiovascular Care Unit Network Scientific Committee, Tokyo, Japan
| | - Yoichi Imori
- Tokyo Cardiovascular Care Unit Network Scientific Committee, Tokyo, Japan; Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Hiroki Mochizuki
- Tokyo Cardiovascular Care Unit Network Scientific Committee, Tokyo, Japan
| | - Takeshi Yamamoto
- Tokyo Cardiovascular Care Unit Network Scientific Committee, Tokyo, Japan; Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Kuniya Asai
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Ken Nagao
- Tokyo Cardiovascular Care Unit Network Scientific Committee, Tokyo, Japan
| | - Morimasa Takayama
- Tokyo Cardiovascular Care Unit Network Scientific Committee, Tokyo, Japan
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10
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Mtour S, Abu-Hilal LH, Barghouthi DI, Njoum Y, Jabbarin F, Adwan B, Abu Asbeh I, Mtour A, Alsallamin I. Takotsubo cardiomyopathy prevalence and associated factors in patients presenting with a clinical picture of acute myocardial infarction in Palestine. Egypt Heart J 2023; 75:71. [PMID: 37578674 PMCID: PMC10425303 DOI: 10.1186/s43044-023-00399-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/09/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND Takotsubo cardiomyopathy (TC) is a transient cardiac syndrome that manifests with symptoms resembling acute myocardial infarction (MI). It is characterized by temporary wall-motion abnormalities predominantly affecting the apical and mid-portions of the left ventricle, despite the absence of significant obstructive coronary disease. TC poses diagnostic challenges due to its resemblance to ST-segment elevation myocardial infarction. Our study aimed to determine the prevalence of TC and identify the factors associated with its occurrence in patients presenting with acute MI in Palestine. RESULTS A retrospective analysis was conducted on a cohort of patients diagnosed with TC at Al-Makassed hospital. Women accounted for 90.7% of TC cases (95% CI 88.2-93.2%). The mean age of affected individuals ranged from 62 to 76 years. The most common presenting symptoms were chest pain (83.4%, 95% CI 80.0-86.7%) and dyspnea (20.4%, 95% CI 16.3-24.5%), often following an emotionally or physically stressful event. Electrocardiography (ECG) on admission indicated ST-segment elevations in 71.1% of cases (95% CI 67.2-75.1%), accompanied by mild elevations of Troponins in 85.0% of cases (95% CI 80.8-89.1%). Despite the initial severity, left ventricular ejection fraction (LVEF) improved from 20-49.9 to 59-76% within a mean time of 7-37 days. The in-hospital mortality rate was 1.7% (95% CI 0.5-2.8%), with complete recovery observed in 95.9% of cases (95% CI 93.8-98.1%) and rare recurrence. The underlying etiology is believed to involve exaggerated sympathetic stimulation. CONCLUSIONS TC should be considered as a significant differential diagnosis in acute coronary syndrome (ACS) cases, particularly among postmenopausal women with a preceding stressful event. Our study provides insights into the prevalence and characteristics of TC in the Palestinian population. While stress has been recognized as a potential trigger for TC, further research is needed to explore if there are specific associations between occupation and other unique stressors in the Palestinian context and the prevalence of TC. The study's results can raise awareness among healthcare professionals in Palestine about the prevalence and characteristics of TC in their patient population.
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Affiliation(s)
- Sameer Mtour
- Cardiology Department, Al-Makassed Hospital, Jerusalem, Palestine
| | | | | | - Yumna Njoum
- Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
| | - Farah Jabbarin
- Cardiology Department, Al-Makassed Hospital, Jerusalem, Palestine
| | - Bilal Adwan
- Cardiology Department, Al-Makassed Hospital, Jerusalem, Palestine
| | | | - Ali Mtour
- Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
| | - Isaac Alsallamin
- Cardiology Department, Al-Makassed Hospital, Jerusalem, Palestine
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11
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Campana N, Gioi A, Marchetti MF, Giusti M, Angius S, Caggiari L, Biddau M, Montisci R. Catecholamine-induced Takotsubo syndrome: a case series. Eur Heart J Case Rep 2023; 7:ytad284. [PMID: 37457052 PMCID: PMC10347675 DOI: 10.1093/ehjcr/ytad284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/05/2023] [Accepted: 06/22/2023] [Indexed: 07/18/2023]
Abstract
Background Catecholamine-induced Takotsubo Syndrome (cat-TS) is a type of secondary Takotsubo syndrome, characterized by rapid onset of symptoms, high rate of complications during the acute phase, good short-term prognosis, and frequent apical sparing at echocardiogram. We present two clinical cases of cat-TS treated in our department. Case summary Case one: 78-year-old man, admitted to Ear Nose and Throat Unit for surgical removal of oral squamous cellular carcinoma. During surgery, the occurrence of hypotensive episode was treated with catecholamines. After surgery, the occurrence of atrial fibrillation was followed by evidence of phasic increase of troponin levels and akinesia of midventricular segments. Angiography showed the absence of significant coronary stenoses, and during hospital stay, we observed rapid recovery of wall motion abnormalities. Case two: 64-year-old woman, admitted for hysteropexy surgery, during which cardiac arrest occurred, treated with epinephrine i.v.1 mg and DC shock. Two hours after resuscitation, the patient developed pulmonary oedema, troponin levels increased progressively, and the echocardiogram demonstrated hypokinesia in all midventricular segments with apical sparing. Afterwards, an urgent angiography highlighted normal coronary anatomy. Cardiac magnetic resonance imaging (MRI) revealed oedema corresponding to hypokinetic areas. On the seventh day, echocardiogram showed a complete remission of wall motion abnormalities. Discussion These cases warn the physicians about the importance of routinely screening myocardial impairment through clinical assessment, electrocardiogram (ECG) monitoring, and serial cardiac troponin testing after catecholamine i.v. bolus administration. In case of alterations of these exams, performing a prompt echocardiogram allows early detection of cat-TS, to provide immediate suitable medical support and avoid complications.
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Affiliation(s)
| | | | - Maria Francesca Marchetti
- Department of Medical Sciences and Public Health, Cardiology Unit, University Hospital Duilio Casula—Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, SS 554 4,5 km, Cagliari 09042, Italy
| | - Martina Giusti
- Department of Medical Sciences and Public Health, Cardiology Unit, University Hospital Duilio Casula—Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, SS 554 4,5 km, Cagliari 09042, Italy
| | - Simone Angius
- Department of Medical Sciences and Public Health, Cardiology Unit, University Hospital Duilio Casula—Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, SS 554 4,5 km, Cagliari 09042, Italy
| | - Ludovica Caggiari
- Department of Medical Sciences and Public Health, Cardiology Unit, University Hospital Duilio Casula—Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, SS 554 4,5 km, Cagliari 09042, Italy
| | - Mattia Biddau
- Department of Medical Sciences and Public Health, Cardiology Unit, University Hospital Duilio Casula—Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, SS 554 4,5 km, Cagliari 09042, Italy
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12
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Akhtar MM, Cammann VL, Templin C, Ghadri JR, Lüscher TF. Takotsubo syndrome: getting closer to its causes. Cardiovasc Res 2023:7161872. [PMID: 37183265 DOI: 10.1093/cvr/cvad053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 01/18/2023] [Accepted: 02/07/2023] [Indexed: 05/16/2023] Open
Abstract
Takotsubo syndrome (TTS) accounts for between 1 and 4% of cases presenting clinically as an acute coronary syndrome. It typically presents as a transient cardiac phenotype of left ventricular dysfunction with spontaneous recovery. More dramatic presentations may include cardiogenic shock or cardiac arrest. Despite progress in the understanding of the condition since its first description in 1990, considerable questions remain into understanding underlying pathomechanisms. In this review article, we describe the current published data on potential underlying mechanisms associated with the onset of TTS including sympathetic nervous system over-stimulation, structural and functional alterations in the central nervous system, catecholamine secretion, alterations in the balance and distribution of adrenergic receptors, the additive impact of hormones including oestrogen, epicardial coronary or microvascular spasm, endothelial dysfunction, and genetics as potentially contributing to the cascade of events leading to the onset. These pathomechanisms provide suggestions for novel potential therapeutic strategies in patients with TTS including the role of cognitive behavioural therapy, beta-blockers, and endothelin-A antagonists. The underlying mechanism of TTS remains elusive. In reality, physical or emotional stressors likely trigger through the amygdala and hippocampus a central neurohumoral activation with the local and systemic secretion of excess catecholamine and other neurohormones, which exert its effect on the myocardium through a metabolic switch, altered cellular signalling, and endothelial dysfunction. These complex pathways exert a regional activation in the myocardium through the altered distribution of adrenoceptors and density of autonomic innervation as a protective mechanism from myocardial apoptosis. More research is needed to understand how these different complex mechanisms interact with each other to bring on the TTS phenotype.
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Affiliation(s)
- Mohammed Majid Akhtar
- Royal Brompton and Harefield Hospitals, Imperial College and King's College, London SW3 6NP, UK
| | - Victoria L Cammann
- University Heart Center, Department of Cardiology, University Hospital Zürich, Zürich 8091, Switzerland
| | - Christian Templin
- University Heart Center, Department of Cardiology, University Hospital Zürich, Zürich 8091, Switzerland
| | - Jelena R Ghadri
- University Heart Center, Department of Cardiology, University Hospital Zürich, Zürich 8091, Switzerland
| | - Thomas F Lüscher
- Royal Brompton and Harefield Hospitals, Imperial College and King's College, London SW3 6NP, UK
- Center for Molecular Cardiology, University of Zürich, Zürich 8952, Switzerland
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13
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Panday P, Hausvater A, Pleasure M, Smilowitz NR, Reynolds HR. Cancer and Myocardial Infarction in Women. Am J Cardiol 2023; 194:27-33. [PMID: 36931164 PMCID: PMC10984272 DOI: 10.1016/j.amjcard.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 03/19/2023]
Abstract
Women who present with myocardial infarction (MI) are more likely to be diagnosed with nonobstructive coronary arteries (MINOCAs), spontaneous coronary artery dissection (SCAD), and takotsubo syndrome (TS) than men. Malignancy may predispose to MI and TS through shared risk factors and inflammatory mediators. This study aimed to determine the prevalence of cancer in women presenting with clinical syndrome of MI and the association between cancer and mechanism of MI presentation. Among 520 women with MI who underwent coronary angiography at NYU Langone Health from March 2016 to March 2020 or September 2020 to September 2021, 122 (23%) had a previous diagnosis of cancer. Patients with cancer were older at MI presentation but had similar co-morbidity to those without a cancer history. The most common cancers were breast (39%), gynecologic (15%), and gastrointestinal (13%). Women with cancer history were more likely to have TS (17% vs 11% without cancer history p = 0.049). Among women with a final diagnosis of MI, the type of MI (MINOCA, MI-coronary artery disease, or SCAD) was not significantly different between groups (p = 0.374). History of cancer was present in nearly a quarter of women presenting with MI and was associated with a greater likelihood of TS than MI. MINOCA and SCAD were not more common among women with a cancer history.
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Affiliation(s)
- Priya Panday
- Sarah Ross Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, New York University Grossman School of Medicine, New York, New York
| | - Anaïs Hausvater
- Sarah Ross Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, New York University Grossman School of Medicine, New York, New York
| | - Mitchell Pleasure
- Sarah Ross Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, New York University Grossman School of Medicine, New York, New York
| | - Nathaniel R Smilowitz
- Sarah Ross Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, New York University Grossman School of Medicine, New York, New York
| | - Harmony R Reynolds
- Sarah Ross Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, New York University Grossman School of Medicine, New York, New York.
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14
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Vriz O, Alzahrani T, Landi I, Mushtaq AH, Shaik A, Elshaer AN. Age-sex effect on in-hospital complications and mortality in patients with Takotsubo syndrome. Insights from the National Inpatient Sample. Monaldi Arch Chest Dis 2023; 94. [PMID: 37070781 DOI: 10.4081/monaldi.2023.2558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/29/2023] [Indexed: 04/19/2023] Open
Abstract
Age and sex differences in Takotsubo syndrome (TTS) are still a matter of debate. The present study aimed to evaluate the difference in cardiovascular (CV) risk factors, CV disease, in-hospital complications, and death within different sex-age groups. Using the National Inpatient Sample database between 2012 and 2016, 32,474 patients older than 18 years of age hospitalized with the primary diagnosis of TTS were identified. A total of 32,474 patients were enrolled; 27,611 (85.04%) were female. CV risk factors were higher in females, while CV diseases and in-hospital complications were significantly higher in males. The mortality in males was twice as high as that of female patients (9.83% versus 4.58%, p<0.01), and in the logistic regression model after adjustment for confounders, the odds ratio (OR) was 1.79, the confidence interval was 1.60-2.02, and p<0.01. After dividing the group based on age, in-hospital complications were inversely related to age in both sexes, and the length of in-hospital stay was double in the youngest group compared to the oldest one. Mortality increased progressively with age in both groups but was constantly higher in males for each age group. Multiple logistic regression analysis for mortality was performed for the two sexes separately and for the three age groups, considering the youngest one as the reference group. In females, the OR was 1.59 and 2.88, respectively, for groups 2 and 3; for males, the OR was 1.92 and 3.15, all of them statistically significant (p<0.01). In-hospital complications were more common in younger patients with TTS, particularly in males. Mortality was positively correlated with age for both sexes, but mortality was higher in males compared to females in all age groups.
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Affiliation(s)
- Olga Vriz
- Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh.
| | - Talal Alzahrani
- Department of Medicine, College of Medicine, Taibah University, Madinah.
| | - Irene Landi
- Department of Translational Medicine, Università del Piemonte Orientale, Novara.
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15
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Farina LA, Tibrewala A, Meng Z, Baldridge AS, Voit JM, Raissi SR, Lu M, Khan SS, Freed BH, Akhter N. Echocardiographic correlates of major adverse cardiac events at 1 year in patients with apical ballooning takotsubo syndrome. Echocardiography 2023; 40:86-95. [PMID: 36632682 DOI: 10.1111/echo.15524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 11/15/2022] [Accepted: 12/03/2022] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Takotsubo syndrome (TTS) is characterized by transient left ventricular dysfunction and associated with considerable morbidity and mortality. We sought to evaluate the association between change in cardiac mechanics after diagnosis of TTS with 1-year incidence of major adverse cardiovascular events (MACE). METHODS We retrospectively identified 85 patients with apical TTS based on ICD 9/10 codes and chart adjudication, who had a follow-up echocardiogram within 6 months of diagnosis. Echocardiograms were analyzed for left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), GLS ratio, global circumferential strain (GCS), and global radial strain (GRS). Multivariable logistic regression was performed to identify parameters associated with MACE (all-cause mortality, heart failure, stroke, and coronary artery disease [CAD] requiring percutaneous coronary intervention [PCI]) at 1 year. Event-free survival was assessed in patients with GLS (≤-18% vs. >18%) and LVEF (≥53% vs. <53%). RESULTS Within 1 year of diagnosis, MACE occurred in 15 (18%) patients. Between baseline and follow-up echocardiogram (median 15 [range 1-151] days), there were significant differences in change in LVEF and GLS in patients with versus without incident MACE. In multivariate analysis, change in LVEF (odds ratio [OR] = .93 [.87, .98], p = .013) and change in GLS (OR = 1.32 [1.04, 1.67], p = .022) were independently associated with MACE; however, the association with change in GLS was attenuated (odds ratio [OR] = 1.13 [.94, 1.36], p = .21) after adjustment for baseline and change in LVEF. Among patients with normalized LVEF at follow-up, there were five (14.7%) MACE; whereas, there were no events among patients with normalized GLS. CONCLUSIONS In patients with apical TTS, recovery in GLS and LVEF at follow-up was associated with significantly lower MACE at 1 year. Normalization of GLS at follow-up was better able to discriminate event-free survival than normalization of LVEF.
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Affiliation(s)
- Lauren A Farina
- Department of Medicine, Division of Cardiology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Anjan Tibrewala
- Department of Medicine, Division of Cardiology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Zhiying Meng
- Department of Medicine, Division of Cardiology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Abigail S Baldridge
- Department of Medicine, Division of Cardiology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jay M Voit
- Department of Medicine, Division of Cardiology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sasan R Raissi
- Department of Medicine, Division of Cardiology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michelle Lu
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sadiya S Khan
- Department of Medicine, Division of Cardiology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Benjamin H Freed
- Department of Medicine, Division of Cardiology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nausheen Akhter
- Department of Medicine, Division of Cardiology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
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16
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Abstract
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.
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Affiliation(s)
| | | | - Helen Melita
- 69106Central Laboratories, Onassis Cardiac Surgery Center, Athens, Greece
| | - Antonis S Manolis
- First Department of Cardiology, Athens University School of Medicine, Athens, Greece
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17
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Ruddy J, Santee K. A Rare Case of Cardiogenic Shock Induced by Choking. Chest 2023; 163:e91-e95. [PMID: 36759124 DOI: 10.1016/j.chest.2022.02.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/06/2022] [Accepted: 02/17/2022] [Indexed: 02/10/2023] Open
Affiliation(s)
- Jonah Ruddy
- UNECOM / Kent Emergency Medicine Residency Program, Warwick, RI.
| | - Kyle Santee
- UNECOM / Kent Emergency Medicine Residency Program, Warwick, RI
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18
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Ahn HJ, Kang J, Lee SR, Park JJ, Lee HY, Choi DJ, Cho HJ. Neutrophil-to-lymphocyte ratio as a predictor of in-hospital complications and overall mortality in Takotsubo syndrome preceded by physical triggers. BMC Cardiovasc Disord 2023; 23:51. [PMID: 36703129 PMCID: PMC9881304 DOI: 10.1186/s12872-023-03078-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 01/18/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Takotsubo syndrome (TTS) with physical triggers has worse short- and long-term clinical courses than those with emotional triggers. However, predictive factors associated with poor outcomes of TTS with physical triggers are unknown. METHODS We included 231 patients identified as TTS preceded by physical triggers at two tertiary referral hospitals from 2010 to 2019. In-hospital complications (IHC)-a composite of malignant arrhythmia, need for mechanical circulatory support or mechanical ventilation, and in-hospital death-and overall mortality were retrospectively reviewed. The associations with clinical features were evaluated by multivariable logistic and Cox regression analyses. RESULTS The mean age was 69.3 ± 11.6 years, and 85 (36.8%) were male. The in-hospital complications rate was 46.8%. During a median follow-up of 883 days, 96 (41.6%) had died, and overall mortality was 13.6% per patient-year. Higher neutrophil-to-lymphocyte ratio (NLR) was associated with a higher risk of IHC (area under the receiver operating characteristic curve = 0.73; positive and negative predictive value = 60.9% and 67.2% for NLR ≤ 12); odds ratio (OR) with 95% confidence interval (CI) was 1.03 (1.01-1.05), p = 0.010. Subsequently, higher NLR was also related to a greater risk of overall mortality; patients with high NLR (NLR > 12) exhibited poor long-term survival than those with low NLR (NLR ≤ 5): hazard ratio (95% CI), 3.70 (1.72-7.94) with p < 0.001. CONCLUSIONS A high NLR at initial presentation is associated with an increased risk of IHC and overall mortality in TTS preceded by physical triggers. Given that the treatment of TTS is mainly supportive, intensive monitoring with careful follow-up would be warranted in patients with high NLR.
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Affiliation(s)
- Hyo-Jeong Ahn
- grid.412484.f0000 0001 0302 820XDivision of Cardiology, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Jeehoon Kang
- grid.412484.f0000 0001 0302 820XDivision of Cardiology, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea ,grid.412484.f0000 0001 0302 820XDepartment of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - So-Ryoung Lee
- grid.412484.f0000 0001 0302 820XDivision of Cardiology, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Jin Joo Park
- grid.412480.b0000 0004 0647 3378Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hae-Young Lee
- grid.412484.f0000 0001 0302 820XDivision of Cardiology, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Dong-Ju Choi
- grid.412480.b0000 0004 0647 3378Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyun-Jai Cho
- grid.412484.f0000 0001 0302 820XDivision of Cardiology, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
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19
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Yildiz M, Ashokprabhu N, Shewale A, Pico M, Henry TD, Quesada O. Myocardial infarction with non-obstructive coronary arteries (MINOCA). Front Cardiovasc Med 2022; 9:1032436. [PMID: 36457805 PMCID: PMC9705379 DOI: 10.3389/fcvm.2022.1032436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/17/2022] [Indexed: 11/17/2022] Open
Abstract
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is evident in up to 15% of all acute myocardial infarctions (AMI) and disproportionally affects females. Despite younger age, female predominance, and fewer cardiovascular risk factors, MINOCA patients have a worse prognosis than patients without cardiovascular disease and a similar prognosis compared to patients with MI and obstructive coronary artery disease (CAD). MINOCA is a syndrome with a broad differential diagnosis that includes both ischemic [coronary artery plaque disruption, coronary vasospasm, coronary microvascular dysfunction, spontaneous coronary artery dissection (SCAD), and coronary embolism/thrombosis] and non-ischemic mechanisms (Takotsubo cardiomyopathy, myocarditis, and non-ischemic cardiomyopathy)-the latter called MINOCA mimickers. Therefore, a standardized approach that includes multimodality imaging, such as coronary intravascular imaging, cardiac magnetic resonance, and in selected cases, coronary reactivity testing, including provocation testing for coronary vasospasm, is necessary to determine underlying etiology and direct treatment. Herein, we review the prevalence, characteristics, prognosis, diagnosis, and treatment of MINOCA -a syndrome often overlooked.
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Affiliation(s)
- Mehmet Yildiz
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital, Cincinnati, OH, United States
| | - Namrita Ashokprabhu
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital, Cincinnati, OH, United States
| | - Aarushi Shewale
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital, Cincinnati, OH, United States
| | - Madison Pico
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital, Cincinnati, OH, United States
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital, Cincinnati, OH, United States
| | - Odayme Quesada
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital, Cincinnati, OH, United States
- Women’s Heart Center, The Christ Hospital Heart and Vascular Institute, Cincinnati, OH, United States
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20
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Osman AF, Khor SY, Abdelazeem B, Barham W. Recurrent biventricular takotsubo cardiomyopathy with fatal outcome. BMJ Case Rep 2022; 15:e249910. [PMID: 36123009 PMCID: PMC9486218 DOI: 10.1136/bcr-2022-249910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A woman in her 60s presented initially with nausea, vomiting and abdominal pain. She rapidly progressed to respiratory failure requiring intubation. ECG demonstrated no significant ST segment changes. Troponin I and brain natriuretic peptide were elevated. Chest CT angiography demonstrated small non-occlusive segmental pulmonary emboli. Transthoracic echocardiogram findings suggested biventricular takotsubo cardiomyopathy (TCM) with left ventricular ejection fraction of less than 20%. She improved with aggressive management and was discharged on carvedilol, lisinopril, atorvastatin and apixaban. Follow-up echocardiogram revealed complete resolution of the left and right ventricular wall motion abnormalities at 9 weeks. She had symptoms recurrence after 7 months from the initial presentation. Repeated echocardiogram was consistent with biventricular TCM recurrence. Despite aggressive medical therapy, multiorgan failure developed and patient care was later transitioned to palliative care.
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Affiliation(s)
- Abdul-Fatawu Osman
- Internal Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Si Yuan Khor
- Internal Medicine, Michigan State University College of Human Medicine, East Lansing, Michigan, USA
| | - Basel Abdelazeem
- Internal Medicine, McLaren Health Care Corp, Flint, Michigan, USA
| | - Waseem Barham
- Department of Cardiology, Michigan State University, East Lansing, Michigan, USA
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21
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Silverio A, Parodi G, Scudiero F, Bossone E, Di Maio M, Vriz O, Bellino M, Zito C, Provenza G, Radano I, Baldi C, D'Andrea A, Novo G, Mauro C, Rigo F, Innelli P, Salerno-Uriarte J, Cameli M, Vecchione C, Antonini Canterin F, Galasso G, Citro R. Beta-blockers are associated with better long-term survival in patients with Takotsubo syndrome. Heart 2022; 108:1369-1376. [PMID: 35361673 DOI: 10.1136/heartjnl-2021-320543] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/07/2022] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE The advantage of beta-blockers has been postulated in patients with Takotsubo syndrome (TTS) given the pathophysiological role of catecholamines. We hypothesised that beta-blocker treatment after discharge may improve the long-term clinical outcome in this patient population. METHODS This was an observational, multicentre study including consecutive patients with TTS diagnosis prospectively enrolled in the Takotsubo Italian Network (TIN) register from January 2007 to December 2018. TTS was diagnosed according to the TIN, Heart Failure Association and InterTAK Diagnostic Criteria. The primary study outcome was the occurrence of all-cause death at the longest available follow-up; secondary outcomes were TTS recurrence, cardiac and non-cardiac death. RESULTS The study population included 825 patients (median age: 72.0 (63.0-78.0) years; 91.9 % female): 488 (59.2%) were discharged on beta-blockers and 337 (40.8%) without beta-blockers. The median follow-up was 24.0 months. The adjusted Cox regression analysis showed a significantly lower risk for all-cause death (adjusted HR: 0.563; 95% CI: 0.356 to 0.889) and non-cardiac death (adjusted HR: 0.525; 95% CI: 0.309 to 0.893) in patients receiving versus those not receiving beta-blockers, but no significant differences in terms of TTS recurrence (adjusted HR: 0.607; 95% CI: 0.311 to 1.187) and cardiac death (adjusted HR: 0.699; 95% CI: 0.284 to 1.722). The positive survival effect of beta-blockers was higher in patients with hypertension than in those without (pinteraction=0.014), and in patients who developed cardiogenic shock during the acute phase than in those who did not (pinteraction=0.047). CONCLUSIONS In this real-world register population, beta-blockers were associated with a significantly higher long-term survival, particularly in patients with hypertension and in those who developed cardiogenic shock during the acute phase.
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Affiliation(s)
- Angelo Silverio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (Salerno), Italy
| | - Guido Parodi
- Department of Cardiology, ASL4 Liguria, Lavagna, Italy
| | - Fernando Scudiero
- Cardiology Department, Azienda Ospedaliera Bolognini Seriate, Seriate, Italy
| | - Eduardo Bossone
- Department of Cardiology, Antonio Cardarelli Hospital, Naples, Italy
| | - Marco Di Maio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (Salerno), Italy
| | - Olga Vriz
- Cardiology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Michele Bellino
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (Salerno), Italy
| | - Concetta Zito
- Department of Clinical and Experimental Medicine - Cardiology, University of Messina, Messina, Italy
| | - Gennaro Provenza
- Cardiovascular Department, Azienda Ospedaliera Universitaria 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Ilaria Radano
- Cardiovascular Department, Azienda Ospedaliera Universitaria 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Cesare Baldi
- Cardiovascular Department, Azienda Ospedaliera Universitaria 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | | | - Giuseppina Novo
- Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza (PROMISE), Università degli Studi di Palermo, Palermo, Italy
| | - Ciro Mauro
- Department of Cardiology, Antonio Cardarelli Hospital, Naples, Italy
| | - Fausto Rigo
- Department of Cardiology, Ospedale dell'Angelo Mestre-Venice, Mestre, Italy
| | - Pasquale Innelli
- Department of Cardiovascular Imaging, San Carlo Hospital, Potenza, Italy
| | | | - Matteo Cameli
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Carmine Vecchione
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (Salerno), Italy
- Vascular Physiopathology Unit, IRCCS Neuromed, Pozzilli, Italy
| | - Francesco Antonini Canterin
- Department of Cardiology, High Specialization Rehabilitation Hospital Motta di Livenza, Motta di Livenza, Italy
| | - Gennaro Galasso
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (Salerno), Italy
| | - Rodolfo Citro
- Cardiovascular Department, Azienda Ospedaliera Universitaria 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
- Vascular Physiopathology Unit, IRCCS Neuromed, Pozzilli, Italy
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22
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Ruiz P, Gabarre P, Chenevier-Gobeaux C, François H, Kerneis M, Cidlowski JA, Oakley RH, Lefèvre G, Boissan M. Case report: Changes in the levels of stress hormones during Takotsubo syndrome. Front Cardiovasc Med 2022; 9:931054. [PMID: 35935637 PMCID: PMC9354975 DOI: 10.3389/fcvm.2022.931054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/04/2022] [Indexed: 12/02/2022] Open
Abstract
Background Takotsubo syndrome is an acute cardiac condition usually involving abnormal regional left ventricular wall motion and impaired left ventricular contractility. It is due mainly to hyper-stimulation of the sympathetic nerve system, inducing an excess of catecholamines, usually triggered by intense psychological or physiological stress. The relationship between Takotsubo syndrome and the circulating stress hormones cortisol and copeptin (a surrogate marker of arginine vasopressin) has not been well documented. Case summary Here, we describe the dynamic changes in circulating cortisol and copeptin during an entire episode of Takotsubo syndrome in a post-partum woman after spontaneous vaginal delivery. The patient was diagnosed with inverted Takotsubo syndrome accompanied by HELLP syndrome. We found qualitative and quantitative changes in cortisol: a loss of circadian rhythm and a three-fold elevation in the plasma concentration of the hormone with a peak appearing several hours before circulating cardiac biomarkers began to rise. By contrast, levels of copeptin remained normal during the entire episode. Discussion Our findings indicate that the levels of cortisol change during Takotsubo syndrome whereas those of copeptin do not. This association between elevated cortisol and Takotsubo syndrome suggests that aberrant levels of this stress hormone may contribute to the observed cardiac pathology. We conclude that biochemical assays of circulating cortisol and cardiac biomarkers may be a useful complement to the diagnosis of Takotsubo syndrome by non-invasive cardiac imaging.
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Affiliation(s)
- Pablo Ruiz
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Tenon, Laboratoire de Biochimie, Paris, France
| | - Paul Gabarre
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Tenon, Soins Intensifs Néphrologiques et Rein Aigu (SINRA), Paris, France
| | - Camille Chenevier-Gobeaux
- Assistance Publique-Hôpitaux de Paris (AP-HP)-Centre Université de Paris, Hôpital Cochin, Department of Automated Biological Diagnostic, Paris, France
| | - Hélène François
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Tenon, Soins Intensifs Néphrologiques et Rein Aigu (SINRA), Paris, France
- Sorbonne Université, Inserm, UMR_S1155, Paris, France
| | - Mathieu Kerneis
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie (AP-HP), Paris, France
| | - John A. Cidlowski
- Signal Transduction Laboratory, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, United States
| | - Robert H. Oakley
- Signal Transduction Laboratory, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, United States
| | - Guillaume Lefèvre
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Tenon, Laboratoire de Biochimie, Paris, France
| | - Mathieu Boissan
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Tenon, Laboratoire de Biochimie, Paris, France
- Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine (CRSA), Paris, France
- *Correspondence: Mathieu Boissan
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23
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Shang Z, Zhao M, Cai J, Wu C, Xu Y, Zeng L, Cai H, Xu M, Fan Y, Li Y, Gao W, Xu W, Zu L. Peri-operative Takotsubo syndrome after non-cardiac surgery: a retrospective nested case-control study. ESC Heart Fail 2022; 9:3149-3159. [PMID: 35757924 DOI: 10.1002/ehf2.14015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 05/09/2022] [Accepted: 06/03/2022] [Indexed: 11/11/2022] Open
Abstract
AIMS Takotsubo syndrome (TTS) is an acute reversible cardiac dysfunction that may occur during the peri-operative period and among patients with serious illness. We aimed to evaluate the clinical characteristics, peri-operative management, and prognosis of peri-operative TTS (pTTS) and explore the factors associated with pTTS. METHODS We conducted a retrospective nested case-control study using the database of patients who underwent in-hospital non-cardiac surgeries between January 2017 and December 2020 in Peking University Third hospital. Cases were adult patients diagnosed TTS at discharge who were matched with four controls based on operative types. Multivariable conditional logistic regression was used to identified the factors associated with pTTS. The area under the curve (AUC) was used to evaluate the diagnostic efficacy. RESULTS Among the 128 536 patients underwent non-cardiac surgery, 20 patients with pTTS and 80 patients without were enrolled in this study. The incidence of pTTS was about 0.016% in our centre. The median age of patients with pTTS was 52.5 (38.25, 76.25) years, although 90% of them were female. Fifty per cent (9 cases) of female patients were pre-menopausal. Caesarean section has the highest proportion of pTTS (30% of the pTTS cases) with the incidence of caesarean section-related pTTS of 0.06% in our centre. A high prevalence of non-apical ballooning pattern of regional wall motion abnormality (seven cases, 35%) and a high mortality (two cases, 10%) were observed. Left ventricular ejection fraction (LVEF) of patients with pTTS was significantly decreased (41.7 ± 8.8%). In the acute phase, supportive treatments aiming to reduce life-threatening complications were main treatment strategies. After receiving systematic treatment, significant improvements were observed in LVEF (63.1 ± 13.5%), with median recovery time of LVEF of 7.48 days. Leucocyte count [odds ratio (OR): 4.59; 95% confidence interval (CI): 1.10-19.15], haemoglobin (HGB) (OR: 10.52; 95% CI: 1.04-106.36), and the revised cardiac risk index (RCRI) score (OR: 6.30; 95% CI: 1.05-37.88) were the factors significantly associated with pTTS. The RCRI score performed poorly in the prediction of pTTS (AUC: 0.630; 95% CI: 0.525-0.735). After adding leucocyte count and HGB into the RCRI score, the AUC was significantly improved (AUC: 0.768; 95% CI: 0.671-0.865; P = 0.001). CONCLUSIONS Patients with pTTS have some differences compared with common TTS, including higher proportion of pre-menopausal female, higher prevalence during caesarean section, higher prevalence of non-apical ballooning pattern of regional wall motion abnormality, and higher mortality. The RCRI score performed poorly in the evaluation of pTTS. Adding HGB and leucocyte count into the RCRI score could significantly improve its predictive performance.
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Affiliation(s)
- Zhi Shang
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Menglin Zhao
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Jiageng Cai
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Cencen Wu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Yuan Xu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Lin Zeng
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Hong Cai
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Mao Xu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Yuanyuan Fan
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Yanguang Li
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Wei Gao
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Weixian Xu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Lingyun Zu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
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24
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Reverse Takutsubo Cardiomyopathy in a Patient with Phlegmasia Cerulea Dolens. Case Rep Cardiol 2022; 2022:5413237. [PMID: 35783160 PMCID: PMC9242792 DOI: 10.1155/2022/5413237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/11/2022] [Indexed: 11/17/2022] Open
Abstract
Reverse takotsubo cardiomyopathy (rTTC) is a rare variant of takotsubo cardiomyopathy (TTC) which is characterized by reversible left ventricular (LV) dysfunction. Emotional and physical stress have been implicated in triggering TTC especially in postmenopausal women. TTC and its variants are becoming more recognized due to the widespread adoption of early coronary angiography in the setting of acute coronary syndromes. A man in his late 50s presented to the emergency department with left lower extremity pain, swelling, and cyanosis. Clinical assessment was consistent with phlegmasia cerulea dolens, with deep venous thrombosis detected by venous duplex ultrasound. During his admission, he developed clinical and EKG findings suggestive of acute coronary syndrome. Emergent coronary angiography and ventriculography revealed basal and midventricular hypokinesis with hyperdynamic left ventricular apex, depressed LV dysfunction without coronary artery obstruction diagnostic of reverse takotsubo cardiomyopathy. Venous thromboembolism is a rare finding but has been associated with takotsubo cardiomyopathy and should be considered in the appropriate setting.
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25
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Arcari L, Núñez Gil IJ, Stiermaier T, El-Battrawy I, Guerra F, Novo G, Musumeci B, Cacciotti L, Mariano E, Caldarola P, Parisi G, Montisci R, Vitale E, Sclafani M, Volpe M, Corbì-Pasqual M, Martinez-Selles M, Almendro-Delia M, Sionis A, Uribarri A, Akin I, Thiele H, Brunetti ND, Eitel I, Santoro F. Gender Differences in Takotsubo Syndrome. J Am Coll Cardiol 2022; 79:2085-2093. [PMID: 35618345 DOI: 10.1016/j.jacc.2022.03.366] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND Male sex in takotsubo syndrome (TTS) has a low incidence and it is still not well characterized. OBJECTIVES The aim of the present study is to describe TTS sex differences. METHODS TTS patients enrolled in the international multicenter GEIST (GErman Italian Spanish Takotsubo) registry were analyzed. Comparisons between sexes were performed within the overall cohort and using an adjusted analysis with 1:1 propensity score matching for age, comorbidities, and kind of trigger. RESULTS In total, 286 (11%) of 2,492 TTS patients were men. Male patients were younger (age 69 ± 13 years vs 71 ± 11 years; P = 0.005), with higher prevalence of comorbid conditions (diabetes mellitus 25% vs 19%; P = 0.01; pulmonary diseases 21% vs 15%; P = 0.006; malignancies 25% vs 13%; P < 0.001) and physical trigger (55 vs 32% P < 0.01). Propensity-score matching yielded 207 patients from each group. After 1:1 propensity matching, male patients had higher rates of cardiogenic shock and in-hospital mortality (16% vs 6% and 8% vs 3%, respectively; both P < 0.05). Long-term mortality rate was 4.3% per patient-year (men 10%, women 3.8%). Survival analysis showed higher mortality rate in men during the acute phase in both cohorts (overall: P < 0.001; matched: P = 0.001); mortality rate after 60 days was higher in men in the overall (P = 0.002) but not in the matched cohort (P = 0.541). Within the overall population, male sex remained independently associated with both in-hospital (OR: 2.26; 95% CI: 1.16-4.40) and long-term mortality (HR: 1.83; 95% CI: 1.32-2.52). CONCLUSIONS Male TTS is featured by a distinct high-risk phenotype requiring close in-hospital monitoring and long-term follow-up.
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Affiliation(s)
- Luca Arcari
- Institute of Cardiology, Madre Giuseppina Vannini Hospital, Rome, Italy
| | - Iván J Núñez Gil
- Interventional Cardiology, Cardiovascular Institute, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Thomas Stiermaier
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine) and German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Ibrahim El-Battrawy
- Department of Cardiology, University of Mannheim, Mannheim, Germany; Department of Cardiology and Angiology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, Germany
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Umberto I - Lancisi - Salesi", Ancona, Italy
| | - Giuseppina Novo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Cardiology Unit, University of Palermo, University Hospital P. Giaccone, Palermo, Italy
| | - Beatrice Musumeci
- Cardiology, Clinical and Molecular Medicine Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Luca Cacciotti
- Institute of Cardiology, Madre Giuseppina Vannini Hospital, Rome, Italy
| | - Enrica Mariano
- Division of Cardiology, University of Rome Tor Vergata, Rome, Italy
| | | | | | - Roberta Montisci
- Clinical Cardiology, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Enrica Vitale
- University of Foggia, Department of Medical and Surgical Sciences, Foggia, Italy
| | - Matteo Sclafani
- Cardiology, Clinical and Molecular Medicine Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Massimo Volpe
- Cardiology, Clinical and Molecular Medicine Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | | | - Manuel Martinez-Selles
- Department of Cardiology, Hospital General Universitario Gregorio Marañon, CIBERCV, and Universidad Europea, Universidad Complutense, Madrid, Spain
| | | | - Alessandro Sionis
- Unidad de Cuidados Intensivos Cardiológicos, Servicio de Cardiología, Hospital de Sant Pau, Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Aitor Uribarri
- Department of Cardiology, Hospital vall d'hebron, Barcelona, Spain
| | - Ibrahim Akin
- Department of Cardiology, University of Mannheim, Mannheim, Germany
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Department of Internal Medicine/Cardiology, Leipzig, Germany
| | | | - Ingo Eitel
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine) and German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Francesco Santoro
- University of Foggia, Department of Medical and Surgical Sciences, Foggia, Italy
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26
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Singh T, Khan H, Gamble DT, Scally C, Newby DE, Dawson D. Takotsubo Syndrome: Pathophysiology, Emerging Concepts, and Clinical Implications. Circulation 2022; 145:1002-1019. [PMID: 35344411 PMCID: PMC7612566 DOI: 10.1161/circulationaha.121.055854] [Citation(s) in RCA: 103] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Takotsubo syndrome is a condition characterized by acute transient left ventricular systolic dysfunction, which at presentation can be challenging to distinguish from acute myocardial infarction. Although previously thought to be a benign, self-limiting condition, recent studies have confirmed that patients with takotsubo syndrome have persistent subtle ongoing cardiac dysfunction, and many continue to have limiting symptoms despite restoration of left ventricular ejection fraction. Moreover, these patients have a substantial burden of morbidity as well as mortality with high rates of subsequent major adverse cardiovascular events that approach those of patients with acute coronary syndrome. The mechanisms behind this condition remain elusive. Despite substantial research, the medical community continues to have an incomplete understanding of its underlying etiology and pathophysiology. Catecholamine-induced myocardial injury is the most established and well-known theory, but this does not explain all of the clinical features and presentations of the condition, and numerous other pathways and abnormalities are emerging. Because of the poor understanding of its underlying pathophysiology, there is a lack of evidence-based interventions to treat the acute episode, to avoid recurrences and to prevent major adverse cardiovascular events. This highlights the need for further research to gain a better understanding of the underlying pathophysiology in order to inform appropriate randomized controlled trials of interventions targeting the causative pathways. Only then can evidence-based management strategies be established to improve clinical outcomes of this potentially lethal condition.
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Affiliation(s)
- Trisha Singh
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (T.S., C.S., D.E.N.).,Aberdeen Cardiovascular and Diabetes Centre, University of Aberdeen, United Kingdom (H.K., D.T.G., D.D.)
| | - Hilal Khan
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (T.S., C.S., D.E.N.).,Aberdeen Cardiovascular and Diabetes Centre, University of Aberdeen, United Kingdom (H.K., D.T.G., D.D.)
| | - David T Gamble
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (T.S., C.S., D.E.N.).,Aberdeen Cardiovascular and Diabetes Centre, University of Aberdeen, United Kingdom (H.K., D.T.G., D.D.)
| | - Caroline Scally
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (T.S., C.S., D.E.N.).,Aberdeen Cardiovascular and Diabetes Centre, University of Aberdeen, United Kingdom (H.K., D.T.G., D.D.)
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (T.S., C.S., D.E.N.).,Aberdeen Cardiovascular and Diabetes Centre, University of Aberdeen, United Kingdom (H.K., D.T.G., D.D.)
| | - Dana Dawson
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (T.S., C.S., D.E.N.).,Aberdeen Cardiovascular and Diabetes Centre, University of Aberdeen, United Kingdom (H.K., D.T.G., D.D.)
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27
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Looi JL, Chan C, Bridgman P, Kerr AJ. Takotsubo Syndrome in New Zealand: Current Knowledge and Future Challenges. Intern Med J 2022; 52:1863-1876. [PMID: 35289058 DOI: 10.1111/imj.15749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/12/2022] [Accepted: 03/04/2022] [Indexed: 11/28/2022]
Abstract
Takotsubo syndrome (TS), also known as apical ballooning syndrome is a transient stress-related cardiomyopathy characterised by acute but reversible left ventricular dysfunction. The condition tends to occur in postmenopausal women after a stressful event. At presentation TS typically mimics acute myocardial infarction (MI) and the incidence of TS has been increasing worldwide. This is likely a consequence of an improved awareness of the existence of this syndrome and easier access to early echocardiography and coronary angiography. However, its aetiology remains poorly understood and it is probably still underdiagnosed. Similar to other countries. TS is being increasingly recognised in New Zealand. In this review, we discuss the demographics, clinical features and outcomes of patients with TS in New Zealand. Doing so informs us not only of the pattern of disease in New Zealand but it also provides insights into the condition itself. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jen-Li Looi
- Department of Cardiology, Middlemore Hospital, Private Bag 933111, Otahuhu, Auckland, New Zealand
| | - Christina Chan
- Department of Cardiology, Christchurch Hospital, Riccarton Avenue, Private Bag 4710, Christchurch, New Zealand
| | - Paul Bridgman
- Department of Cardiology, Christchurch Hospital, Riccarton Avenue, Private Bag 4710, Christchurch, New Zealand
| | - Andrew J Kerr
- Department of Cardiology, Middlemore Hospital, Private Bag 933111, Otahuhu, Auckland, New Zealand
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28
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Qiao L, Fan X, Yang Z, El-Battrawy I, Zhou X, Akin I. Glucose Counteracts Isoprenaline Effects on Ion Channel Functions in Human-Induced Pluripotent Stem Cell-Derived Cardiomyocytes. J Cardiovasc Dev Dis 2022; 9:jcdd9030076. [PMID: 35323624 PMCID: PMC8955312 DOI: 10.3390/jcdd9030076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 02/01/2023] Open
Abstract
Recent studies indicate that the disorder of glucose metabolism in myocardial tissue is involved in the development of Takotsubo syndrome (TTS). This study investigated the effects of a high level of glucose on the pathogenesis of TTS, focusing on the electrophysiological mechanisms. Human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) were treated with toxic concentration of isoprenaline (Iso, 1 mM) and a high level of glucose (22 mM) to mimic the setting of TTS and diabetes mellitus (DM). Iso prolonged action potential duration (APD) through enhancing the late sodium channel current and suppressing the transient outward potassium current (Ito). However, a high level of glucose prevented the APD prolongation and the change in Ito. High-level glucose reduced the expression levels of PI3K/Akt, β1-adrenoceptors, Gs-protein, and PKA, suggesting their involvement in the protective effects of high-level glucose against toxic effects of catecholamine. High glucose level did not influence Iso-induced ROS-generation, suggesting that the protective effects of high-level glucose against Iso did not result from changes in ROS generation. High-level glucose may protect cardiomyocytes from the toxic effects of catecholamine excess through suppressing β1-adrenoceptor-Gs-PKA signaling. DM may reduce the risk for occurrence of arrhythmias due to QT prolongation in TTS patients.
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Affiliation(s)
- Lin Qiao
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (L.Q.); (X.F.); (Z.Y.); (I.E.-B.); (I.A.)
| | - Xuehui Fan
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (L.Q.); (X.F.); (Z.Y.); (I.E.-B.); (I.A.)
- Key Laboratory of Medical Electrophysiology of Ministry of Education and Medical Electrophysiological Key Laboratory of Sichuan Province, Collaborative Innovation Center for Prevention of Cardiovascular Diseases, Institute of Cardiovascular Research, Southwest Medical University, Luzhou 646000, China
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Zhen Yang
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (L.Q.); (X.F.); (Z.Y.); (I.E.-B.); (I.A.)
| | - Ibrahim El-Battrawy
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (L.Q.); (X.F.); (Z.Y.); (I.E.-B.); (I.A.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Xiaobo Zhou
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (L.Q.); (X.F.); (Z.Y.); (I.E.-B.); (I.A.)
- Key Laboratory of Medical Electrophysiology of Ministry of Education and Medical Electrophysiological Key Laboratory of Sichuan Province, Collaborative Innovation Center for Prevention of Cardiovascular Diseases, Institute of Cardiovascular Research, Southwest Medical University, Luzhou 646000, China
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
- Correspondence: ; Tel.: +49-621-383-1448; Fax: +49-621-383-1474
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (L.Q.); (X.F.); (Z.Y.); (I.E.-B.); (I.A.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
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29
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Fan X, Yang G, Kowitz J, Akin I, Zhou X, El-Battrawy I. Takotsubo Syndrome: Translational Implications and Pathomechanisms. Int J Mol Sci 2022; 23:ijms23041951. [PMID: 35216067 PMCID: PMC8875072 DOI: 10.3390/ijms23041951] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/04/2022] [Accepted: 02/05/2022] [Indexed: 02/07/2023] Open
Abstract
Takotsubo syndrome (TTS) is identified as an acute severe ventricular systolic dysfunction, which is usually characterized by reversible and transient akinesia of walls of the ventricle in the absence of a significant obstructive coronary artery disease (CAD). Patients present with chest pain, ST-segment elevation or ischemia signs on ECG and increased troponin, similar to myocardial infarction. Currently, the known mechanisms associated with the development of TTS include elevated levels of circulating plasma catecholamines and their metabolites, coronary microvascular dysfunction, sympathetic hyperexcitability, inflammation, estrogen deficiency, spasm of the epicardial coronary vessels, genetic predisposition and thyroidal dysfunction. However, the real etiologic link remains unclear and seems to be multifactorial. Currently, the elusive pathogenesis of TTS and the lack of optimal treatment leads to the necessity of the application of experimental models or platforms for studying TTS. Excessive catecholamines can cause weakened ventricular wall motion at the apex and increased basal motion due to the apicobasal adrenoceptor gradient. The use of beta-blockers does not seem to impact the outcome of TTS patients, suggesting that signaling other than the beta-adrenoceptor-associated pathway is also involved and that the pathogenesis may be more complex than it was expected. Herein, we review the pathophysiological mechanisms related to TTS; preclinical TTS models and platforms such as animal models, human-induced pluripotent stem cell-derived cardiomyocyte (hiPSC-CM) models and their usefulness for TTS studies, including exploring and improving the understanding of the pathomechanism of the disease. This might be helpful to provide novel insights on the exact pathophysiological mechanisms and may offer more information for experimental and clinical research on TTS.
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Affiliation(s)
- Xuehui Fan
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, 68167 Mannheim, Germany; (X.F.); (J.K.); (I.A.)
- Key Laboratory of Medical Electrophysiology, Ministry of Education and Medical Electrophysiological Key Laboratory of Sichuan Province, Collaborative Innovation Center for Prevention of Cardiovascular Diseases, Institute of Cardiovascular Research, Southwest Medical University, Luzhou 646000, China
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, 68167 Mannheim, Germany
| | - Guoqiang Yang
- Department of Acupuncture and Rehabilitation, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou 646000, China;
- Research Unit of Molecular Imaging Probes, Department of Radiologic Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Jacqueline Kowitz
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, 68167 Mannheim, Germany; (X.F.); (J.K.); (I.A.)
| | - Ibrahim Akin
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, 68167 Mannheim, Germany; (X.F.); (J.K.); (I.A.)
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, 68167 Mannheim, Germany
| | - Xiaobo Zhou
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, 68167 Mannheim, Germany; (X.F.); (J.K.); (I.A.)
- Key Laboratory of Medical Electrophysiology, Ministry of Education and Medical Electrophysiological Key Laboratory of Sichuan Province, Collaborative Innovation Center for Prevention of Cardiovascular Diseases, Institute of Cardiovascular Research, Southwest Medical University, Luzhou 646000, China
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, 68167 Mannheim, Germany
- Correspondence: (X.Z.); (I.E.-B.)
| | - Ibrahim El-Battrawy
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, 68167 Mannheim, Germany; (X.F.); (J.K.); (I.A.)
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, 68167 Mannheim, Germany
- Correspondence: (X.Z.); (I.E.-B.)
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30
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Liao X, Chang E, Tang X, Watanabe I, Zhang R, Jeong HW, Adams RH, Jain MK. Cardiac macrophages regulate isoproterenol-induced Takotsubo-like cardiomyopathy. JCI Insight 2022; 7:156236. [PMID: 35132957 PMCID: PMC8855841 DOI: 10.1172/jci.insight.156236] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/15/2021] [Indexed: 12/24/2022] Open
Abstract
Takotsubo syndrome (TTS) is an acute, stress-induced cardiomyopathy that occurs predominantly in women after extreme physical and/or emotional stress. To date, our understanding of the molecular basis for TTS remains unknown and, consequently, specific therapies are lacking. Myocardial infiltration of monocytes and macrophages in TTS has been documented in clinical studies. However, the functional importance of these findings remains poorly understood. Here, we show that a single high dose of isoproterenol (ISO) in mice induced a TTS-like cardiomyopathy phenotype characterized by female predominance, severe cardiac dysfunction, and robust myocardial infiltration of macrophages. Single-cell RNA-Seq studies of myocardial immune cells revealed that TTS-like cardiomyopathy is associated with complex activation of innate and adaptive immune cells in the heart, and macrophages were identified as the dominant immune cells. Global macrophage depletion (via clodronate liposome administration) or blockade of macrophage infiltration (via a CCR2 antagonist or in CCR2-KO mice) resulted in recovery of cardiac dysfunction in ISO-challenged mice. In addition, damping myeloid cell activation by HIF1α deficiency or exposure to the immunomodulatory agent bortezomib ameliorated ISO-induced cardiac dysfunction. Collectively, our findings identify macrophages as a critical regulator of TTS pathogenesis that can be targeted for therapeutic gain.
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Affiliation(s)
- Xudong Liao
- Case Cardiovascular Research Institute, Case Western Reserve University School of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Eugene Chang
- Case Cardiovascular Research Institute, Case Western Reserve University School of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Xinmiao Tang
- Case Cardiovascular Research Institute, Case Western Reserve University School of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.,Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ippei Watanabe
- Case Cardiovascular Research Institute, Case Western Reserve University School of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Rongli Zhang
- Case Cardiovascular Research Institute, Case Western Reserve University School of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Hyun-Woo Jeong
- Max Planck Institute for Molecular Biomedicine, Department of Tissue Morphogenesis, Münster, Germany
| | - Ralf H Adams
- Max Planck Institute for Molecular Biomedicine, Department of Tissue Morphogenesis, Münster, Germany
| | - Mukesh K Jain
- Case Cardiovascular Research Institute, Case Western Reserve University School of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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31
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Butt JH, Bang LE, Rørth R, Schou M, Kristensen SL, Yafasova A, Havers-Borgersen E, Vinding NE, Jessen N, Kragholm K, Torp-Pedersen C, Køber L, Fosbøl EL. Long-term Risk of Death and Heart Failure Hospitalization in Patients With Takotsubo Syndrome: Insights from a Nationwide Cohort. J Card Fail 2022; 28:1534-1544. [DOI: 10.1016/j.cardfail.2022.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 01/27/2022] [Accepted: 02/02/2022] [Indexed: 01/03/2023]
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32
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Li P, Li C, Mishra AK, Cai P, Lu X, Sherif AA, Jin L, Wang B. Impact of malnutrition on in-hospital outcomes in takotsubo cardiomyopathy. Nutrition 2022; 93:111495. [PMID: 34735920 DOI: 10.1016/j.nut.2021.111495] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 08/01/2021] [Accepted: 09/15/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This study assesses the effect of malnutrition on the in-hospital outcomes of patients with takotsubo cardiomyopathy (TCM). METHODS We performed a retrospective cohort analysis using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for a primary diagnosis of TCM from the National Inpatient Sample database (2016-2018). A concurrent diagnosis of malnutrition was then identified, and these patients were divided into the malnutrition group and non-malnutrition group. To adjust for underlying risk factors, a multivariable logistic regression model was employed followed by a propensity score matching analysis for the malnutrition and the non-malnutrition group. We then compared the in-hospital outcomes between these two groups. RESULTS Among 4733 patients with a primary diagnosis of TCM, 221 (4.7%) patients with TCM were found to be malnourished. After propensity score matching, patients with TCM with malnutrition were found to have a higher mortality rate (8.3% versus 2.0%, P < 0.001), a higher rate of complications including cardiogenic shock (16.1% versus 7.0%, P < 0.001), ventricular arrhythmia (8.8% versus 3.9%, P = 0.01), acute kidney injury (24.9% versus 10.6%, P < 0.001), and acute respiratory failure (32.7% versus 17.8%, P < 0.001). There was no statistically significant difference in the incidence of cardiac arrest between the two groups. Malnutrition of severe degree was associated with a sevenfold (odds ratio 6.8, 95% confidence interval, 3.2-13.4) increased risk of in-hospital mortality compared with those without malnutrition. CONCLUSION Patients with malnutrition who were admitted with TCM were associated with higher rates of in-hospital mortality and complications compared with those without malnutrition.
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Affiliation(s)
- Pengyang Li
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Chenlin Li
- Department of Cardiology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Ajay Kumar Mishra
- Department of Medicine, Saint Vincent Hospital, 123 Summer Street, Worcester, Massachusetts, USA
| | - Peng Cai
- Department of Mathematical Sciences, Worcester Polytechnic Institute, Worcester, Massachusetts, USA
| | - Xiaojia Lu
- Department of Cardiology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Akil Adrian Sherif
- Department of Medicine, Saint Vincent Hospital, 123 Summer Street, Worcester, Massachusetts, USA
| | - Ling Jin
- Department of Medicine, Metrowest Medical Center, Framingham, Massachusetts, USA
| | - Bin Wang
- Department of Cardiology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
- Clinical Research Center, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
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Ito M, Fukui K, Miyamoto N, Kato H, Miki K, Shiobara K, Nagai T. Takotsubo cardiomyopathy in a bedridden patient with dementia and communication difficulties due to Alzheimer’s disease. J Rural Med 2022; 17:89-93. [PMID: 35432639 PMCID: PMC8984618 DOI: 10.2185/jrm.2021-055] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/18/2021] [Indexed: 11/27/2022] Open
Abstract
Takotsubo cardiomyopathy is a transient wall motion abnormality of the left ventricular
apex, accompanied by emotional or physical stress. Although Takotsubo cardiomyopathy is
generally considered a benign disease, severe clinical complications may occur, and early
detection of the disease is important. In this report, we present the case of an
86-year-old bedridden woman with a history of bronchial asthma who was transferred to our
hospital because of wheezing. She was diagnosed with Alzheimer’s disease and had
communication difficulties. After an asthma attack and improvement, Takotsubo
cardiomyopathy was identified via electrocardiography. She was unable to complain of any
symptoms but showed serial electrocardiographic changes, elevated myocardial markers, and
transient left ventricular apical ballooning. The prevalence of dementia increases
dramatically with age. This case indicates that Takotsubo cardiomyopathy may occur even in
patients with severe dementia, who are bedridden and show communication difficulties in a
clinical setting.
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Affiliation(s)
- Masahiro Ito
- Department of Internal Medicine, Nagaoka-Nishi Hospital, Japan
| | - Kazuhito Fukui
- Department of Internal Medicine, Nagaoka-Nishi Hospital, Japan
| | - Niichi Miyamoto
- Department of Internal Medicine, Nagaoka-Nishi Hospital, Japan
| | - Hiroshi Kato
- Department of Internal Medicine, Nagaoka-Nishi Hospital, Japan
| | - Kenji Miki
- Department of Neurology, Nagaoka-Nishi Hospital, Japan
| | | | - Tsuneo Nagai
- Department of Internal Medicine, Nagaoka-Nishi Hospital, Japan
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Kwon SS, Bang DW, Park BW, Lee MH, Hyon MS, Lee SS, Park S. Association of low T3 level with increased in-hospital mortality in patients with stress cardiomyopathy. Acta Cardiol 2021; 76:1052-1060. [PMID: 32835614 DOI: 10.1080/00015385.2020.1807124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Stress cardiomyopathy (SCMP) is an acute but reversible heart failure syndrome with varying clinical outcomes. Although low triiodothyronine (T3) levels are closely associated with heart failure, it is uncertain whether total T3 levels on admission might be correlated with clinical outcomes in patients with SCMP. The aim of this study was to investigate the prognostic value of total T3 level for in-hospital mortality in patients with SCMP. METHODS Patients presenting with SCMP at a single tertiary hospital between January 2013 and May 2019 were retrospectively reviewed. The diagnosis of SCMP was confirmed using the International Takotsubo Diagnostic Criteria and echocardiography was performed at least twice at the time of admission. Comorbidities, antecedent triggers, and other cardiac and metabolic parameters were measured in the survivor group compared with the non-survivor group. We evaluated the correlation between these parameters, especially total T3 and the prevalence of in-hospital mortality and the predictive values of total T3. RESULTS Of the 134 SCMP patients (69.4 ± 15.5 years old, 94 women), 29 (21.6%) died during hospitalisation. The median follow-up period (interquartile range) was 480 days (63.25-1052.50). Total T3 levels were significantly lower in the non-survival group than in the survival group (33.38 ± 22.58 ng/dL vs. 65.72 ± 34.68 ng/dL, p < 0.0001). Receiver operating characteristic curve analysis showed the cut-offs of total T3 levels (≤64.37 ng/dL) for in-hospital mortality (area under curve [AUC] = 0.764, p < 0.001). In multivariable analysis, the T3 level (odds ratio [OR], 0.957; 95% confidential interval [CI], 0.934 to 0.982; p < 0.001), left ventricular ejection in follow-up echocardiography (OR, 0.935; 95% CI, 0.889-0.983; p = 0.008), and shock at initial presentation (OR, 3.389; 95% CI, 1.076-10.669; p = 0.037) were independent predictors for in-hospital mortality in SCMP patients. In patients with low T3 (<64.37 ng/dL), the 30-day survival rate was also significantly lower (81.58 vs. 100%, Log rank p = 0.001). CONCLUSIONS Lower levels of total T3 were strongly correlated with in-hospital mortality in patients with SCMP. A low T3 level might suggest poor prognosis in patients with SCMP.
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Affiliation(s)
- Seong Soon Kwon
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Korea
| | - Duk Won Bang
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Korea
| | - Byoung-Won Park
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Korea
| | - Min-Ho Lee
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Korea
| | - Min-Su Hyon
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Korea
| | - Seong Soo Lee
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Korea
| | - Suyeon Park
- Department of Biostatistics, Soonchunhyang University Hospital, Seoul, Korea
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35
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Citro R, Radano I, Bellino M, Mauro C, Okura H, Bossone E, Akashy YJ. Epidemiology, Pathogenesis, and Clinical Course of Takotsubo Syndrome. Heart Fail Clin 2021; 18:125-137. [PMID: 34776074 DOI: 10.1016/j.hfc.2021.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Takotsubo syndrome is an acute reversible heart failure syndrome, most frequently seen in postmenopausal women and precipitated generally by significant emotional stress or physical illness. A sudden sympathetic activation seems to play a key role in the pathophysiology, but growing evidence is emerging about the role of inflammation in the subacute and chronic phases. An incidence of life-threatening complications occurring in the acute phase and at long-term follow-up has been demonstrated, comparable with the acute coronary syndrome. Multimodality imaging could be useful to stratify in-hospital and long-term prognosis. The efficacy of specific medical treatments in long-term follow-up should be investigated.
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Affiliation(s)
- Rodolfo Citro
- A.O.U. San Giovanni di Dio e Ruggi d'Aragona, Largo Città d'Ippocrate 1, CAP 84131, Salerno, Italy.
| | - Ilaria Radano
- A.O.U. San Giovanni di Dio e Ruggi d'Aragona, Largo Città d'Ippocrate 1, CAP 84131, Salerno, Italy
| | - Michele Bellino
- A.O.U. San Giovanni di Dio e Ruggi d'Aragona, Largo Città d'Ippocrate 1, CAP 84131, Salerno, Italy
| | - Ciro Mauro
- Division of Cardiology, A.O.R.N. Antonio Cardarelli Hospital, Via Antonio cardarelli 9, 80131 Naples, Italy
| | - Hiroyuky Okura
- Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Yanagido 1-1, Gifu, Gifu 501-1194, Japan
| | - Eduardo Bossone
- Division of Cardiology, A.O.R.N. Antonio Cardarelli Hospital, Via Antonio cardarelli 9, 80131 Naples, Italy
| | - Yoshihiro J Akashy
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2 Chome-16-1 Sugao, Miyamae Ward, Kawasaki, Kanagawa 216-8511, Japan
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Kim JH, Jeong YJ, Park J, Lee PH, Jang JY, Lee S, Kim DH, Song JM, Kang DH, Song JK. Different Clinical Features between Definite and Possible Takotsubo Syndrome in a Tertiary Referral Hospital. Cardiology 2021; 147:154-164. [PMID: 34763341 DOI: 10.1159/000520472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 10/17/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although imaging examination to exclude coronary artery disease (CAD) is an indispensable step for a definite diagnosis of Takotsubo syndrome (TTS), this step may be overlooked in a substantial proportion of patients with secondary TTS admitted to a tertiary hospital. However, the clinical profiles and outcomes of these patients with "possible TTS" have rarely been investigated. METHODS Among 420 consecutive TTS patients with characteristic transient ventricular ballooning on repeated echocardiography, 244 patients (58.1%) who underwent an imaging study for CAD were diagnosed with "definite TTS", whereas the remaining 176 were designated with "possible TTS". RESULTS Overall, hypoxia (67.6%) and dyspnea (55.5%) were predominant presentations. The possible group was characterized by higher prevalence of male gender (46.6% vs. 35.2%, p = 0.019), secondary TTS (97.2% vs. 86.5%, p <0.001), cancer (43.2% vs. 29.1%, p = 0.003), sepsis (46.0% vs. 32.0%, p = 0.003), and non-apical ballooning pattern (30.7% vs. 21.3%, p = 0.001) with less common ST-segment elevation on electrocardiogram (18.8% vs. 34.0%, p = 0.001). The possible group showed higher frequency of mechanical ventilation (56.2% vs. 40.2%, p = 0.001), pulmonary edema (72.2% vs. 61.5%, p = 0.023) and shock management (70.5% vs. 54.1%, p = 0.001) with similar in-hospital mortality (17.2% vs. 17.0%, p = 0.964). CONCLUSIONS In real-world clinical practice, coronary evaluation for strict diagnosis of TTS is not frequently feasible. Addition of the possible group without coronary evaluation to the clinical spectrum of TTS would be helpful for fair estimation of clinical implication of TTS.
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Affiliation(s)
- Ju Hyeon Kim
- Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeong Jin Jeong
- Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jino Park
- Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Pil Hyung Lee
- Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong Yoon Jang
- Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sahmin Lee
- Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dae-Hee Kim
- Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong-Min Song
- Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Duk-Hyun Kang
- Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae-Kwan Song
- Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Looi JL, Verryt T, McLeod P, Chan C, Pemberton J, Webster M, To A, Lee M, Kerr AJ. Type of Stressor and Medium-Term Outcomes After Takotsubo Syndrome: What Becomes of the Broken Hearted? (ANZACS-QI 59). Heart Lung Circ 2021; 31:499-507. [PMID: 34742642 DOI: 10.1016/j.hlc.2021.09.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 06/07/2021] [Accepted: 09/11/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Takotsubo syndrome (TS) is often triggered by an acute physical or emotional stressor. We hypothesised that medium-term prognosis may be better for TS patients with an associated emotional stressor than for those with an acute physical illness. METHODS We identified consecutive TS patients presenting in New Zealand (2006-2018). The clinical presentation and outcomes of TS patients according to types of stressor (physical, emotional or no stressor) were assessed. Post-discharge survival after TS was compared with age- and gender-matched patients after myocardial infarction (MI) and people in the community without known cardiovascular disease (CVD). RESULTS Of 632 TS patients (95.9% women, mean age 65.0±11.1 years), 27.4% had an associated acute physical stressor, 46.4% an emotional stressor and 26.2% no evident stressor. In-hospital mortality was similar for each group (1.7%, 1.2%, 0.3% respectively, p=0.29). In a median 4.4 years post-discharge there were 54 deaths (53 non-cardiac). Compared with patients without known CVD, TS patients with physical stress and those with MI were less likely to survive (HR 4.46, 95%CI 3.10-6.42; HR 4.23, 95%CI 3.81-4.70 respectively) but survival for TS patients associated with emotional stress or no stressor was similar (HR 1.11, 95%CI 0.66-1.85; HR 1.08, 95%CI 0.54-2.18, respectively). Recurrence was similar among the three groups (p=0.14). CONCLUSION Takotsubo syndrome associated with physical stressor has a post-discharge mortality risk as high as after MI. In contrast, prognosis for TS triggered by an emotional stressor is excellent, and similar to that of those without known CVD.
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Affiliation(s)
- Jen-Li Looi
- Department of Cardiology, Middlemore Hospital, Otahuhu, Auckland, New Zealand.
| | - Toby Verryt
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Peter McLeod
- Department of Cardiology, Dunedin Hospital, Dunedin, New Zealand
| | - Christina Chan
- Department of Cardiology, Dunedin Hospital, Dunedin, New Zealand
| | - James Pemberton
- Department of Cardiology, Dunedin Hospital, Dunedin, New Zealand
| | - Mark Webster
- Green Lane Cardiovascular Service, Auckland City Hospital, Grafton, Auckland, New Zealand
| | - Andrew To
- Cardiovascular Division, North Shore Hospital, Takapuna, Auckland, New Zealand
| | - Mildred Lee
- Department of Cardiology, Middlemore Hospital, Otahuhu, Auckland, New Zealand
| | - Andrew J Kerr
- Department of Cardiology, Middlemore Hospital, Otahuhu, Auckland, New Zealand
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38
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Lu X, Li P, Teng C, Cai P, Jin L, Li C, Liu Q, Pan S, Dixon RA, Wang B. Prognostic factors of Takotsubo cardiomyopathy: a systematic review. ESC Heart Fail 2021; 8:3663-3689. [PMID: 34374223 PMCID: PMC8497208 DOI: 10.1002/ehf2.13531] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/04/2021] [Accepted: 07/05/2021] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Xiaojia Lu
- Department of Cardiologythe First Affiliated Hospital of Shantou University Medical College57 Changping RoadShantou515041China
| | - Pengyang Li
- Division of CardiologyPauley Heart Center, Virginia Commonwealth UniversityRichmondVAUSA
| | - Catherine Teng
- Department of MedicineYale New Haven Health Greenwich HospitalGreenwichCTUSA
| | - Peng Cai
- Department of Mathematical SciencesWorcester Polytechnic InstituteWorcesterMAUSA
| | - Ling Jin
- Department of MedicineMetrowest Medical CenterFraminghamMAUSA
| | - Chenlin Li
- Department of Cardiologythe First Affiliated Hospital of Shantou University Medical College57 Changping RoadShantou515041China
| | - Qi Liu
- Wafic Said Molecular Cardiology Research LaboratoryTexas Heart InstituteHoustonTXUSA
| | - Su Pan
- Wafic Said Molecular Cardiology Research LaboratoryTexas Heart InstituteHoustonTXUSA
| | - Richard A.F. Dixon
- Wafic Said Molecular Cardiology Research LaboratoryTexas Heart InstituteHoustonTXUSA
| | - Bin Wang
- Department of Cardiologythe First Affiliated Hospital of Shantou University Medical College57 Changping RoadShantou515041China
- Clinical Research Centerthe First Affiliated Hospital of Shantou University Medical CollegeShantouChina
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39
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Per T, Hans JP. Reproductive History in Takotsubo Syndrome, A Register-Based Cohort Study. Front Cardiovasc Med 2021; 8:692122. [PMID: 34552962 PMCID: PMC8450348 DOI: 10.3389/fcvm.2021.692122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Takotsubo syndrome (TS) is a recently recognized serious heart condition that mainly affects women. Despite that 80–90% of the patients are women, few studies have focused on sex-specific characteristics such as female sex hormones and reproductive history. The aim of the study was to compare reproductive history in patients with TS with controls. Methods: This register-based cohort study compared reproductive history and off-spring birth characteristics between 158 TS patients without coronary artery stenoses and 236 age- and sex-matched controls (C) with coronary artery stenoses because of acute coronary syndrome (ACS-C), respectively, 285 without coronary artery stenoses with chest pain (CP-C). Results: There were no differences in pregnancy complications between TS and CP-C. Gestational length did not differ, but infants born to TS patients had lower birth weight for gestational age than CP-C with an odds ratio of 1.7 (95% confidence interval 1.2–2.5) for infants born small. Conclusion: The results showing an association between birth weight for gestational age and TS later in life are hypothesis-generating. The association is not likely causal and before delivery of small for gestational age infants can be considered as a risk marker for TS later in life the results need to be confirmed in independent studies
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Affiliation(s)
- Tornvall Per
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Järnbert Pettersson Hans
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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40
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Redfors B, Jha S, Thorleifsson S, Jernberg T, Angerås O, Frobert O, Petursson P, Tornvall P, Sarno G, Ekenbäck C, Ravn-Fisher A, Y-Hassan S, Lyon AR, James S, Erlinge D, Omerovic E. Short- and Long-Term Clinical Outcomes for Patients With Takotsubo Syndrome and Patients With Myocardial Infarction: A Report From the Swedish Coronary Angiography and Angioplasty Registry. J Am Heart Assoc 2021; 10:e017290. [PMID: 34465127 PMCID: PMC8649294 DOI: 10.1161/jaha.119.017290] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Takotsubo syndrome (TS) is a potentially life‐threatening acute cardiac syndrome with a clinical presentation similar to myocardial infarction and for which the natural history, management, and outcome remain incompletely understood. Our aim was to assess the relative short‐term mortality risk of TS, ST‐segment–elevation myocardial infarction (STEMI), and non‐STEMI (NSTEMI) and to identify predictors of in‐hospital complications and poor prognosis in patients with TS. Methods and Results This is an observational cohort study based on the data from the SCAAR (Swedish Coronary Angiography and Angioplasty Registry). We included all patients (n=117 720) who underwent coronary angiography in Sweden attributed to TS (N=2898 [2.5%]), STEMI (N=48 493 [41.2%]), or NSTEMI (N=66 329 [56.3%]) between January 2009 and February 2018. We compared patients with TS to those with NSTEMI or STEMI. The primary end point was all‐cause mortality at 30 days. Secondary outcomes were acute heart failure (Killip Class ≥2) and cardiogenic shock (Killip Class 4) at the time of angiography. Patients with TS were more often women compared with patients with STEMI or NSTEMI. TS was associated with unadjusted and adjusted 30‐day mortality risks lower than STEMI (adjusted hazard ratio [adjHR], 0.60; 95% CI, 0.48–0.76; P<0.001), but higher than NSTEMI (adjHR, 2.70; 95% CI, 2.14–3.41; P<0.001). Compared with STEMI, TS was associated with a similar risk of acute heart failure (adjHR, 1.26; 95% CI, 0.91–1.76; P=0.16) but a lower risk of cardiogenic shock (adjHR, 0.55; 95% CI, 0.34–0.89; P=0.02). The relative 30‐day mortality risk for TS versus STEMI and NSTEMI was higher for smokers than nonsmokers (adjusted P interaction STEMI=0.01 and P interaction NSTEMI=0.01). Conclusions The 30‐day mortality rate in TS was higher than in NSTEMI but lower than STEMI despite a similar risk of acute heart failure in TS and STEMI. Among patients with TS, smoking was an independent predictor of mortality.
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Affiliation(s)
- Björn Redfors
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Sandeep Jha
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | | | - Tomas Jernberg
- Department of Clinical Sciences Danderyd University HospitalKarolinska Institutet Stockholm Sweden
| | - Oskar Angerås
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Ole Frobert
- The Department of Cardiology Faculty of Health Örebro University Örebro Sweden
| | - Petur Petursson
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Per Tornvall
- Department of Clinical Science and Education Södersjukhuset Karolinska Institute Stockholm Sweden
| | - Giovanna Sarno
- The Department of Medical Sciences, Cardiology Uppsala University Uppsala Sweden
| | - Christina Ekenbäck
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine Karolinska Institutet Stockholm Sweden
| | - Annika Ravn-Fisher
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Shams Y-Hassan
- The Department of Medicine Karolinska University Hospital Huddinge Stockholm Sweden
| | - Alexander R Lyon
- NIHR Cardiovascular Biomedical Research Unit Royal Brompton Hospital London United Kingdom.,National Heart and Lung InstituteImperial College London United Kingdom
| | - Stefan James
- The Department of Medical Sciences, Cardiology Uppsala University Uppsala Sweden
| | - David Erlinge
- The Department of Cardiology Skåne University Hospital Lund Sweden
| | - Elmir Omerovic
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
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41
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(Atypical manifestation of Takotsubo syndrome during COPD exacerbation). COR ET VASA 2021. [DOI: 10.33678/cor.2021.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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42
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Thirty-Day Readmission Rates after Takotsubo Syndrome with or without Malignancy: A Nationwide Readmissions Database Analysis. J Clin Med 2021; 10:jcm10163701. [PMID: 34441995 PMCID: PMC8397058 DOI: 10.3390/jcm10163701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 08/14/2021] [Accepted: 08/18/2021] [Indexed: 11/22/2022] Open
Abstract
The association between malignancy and readmission after Takotsubo syndrome (TTS) hospitalization has not been fully described. We sought to examine the rates, cause, and cost of 30-day readmissions of TTS, with or without malignancy, by utilizing Nationwide Readmissions Databases from 2010 to 2014. We identified 61,588 index hospitalizations for TTS. TTS patients with malignancy tended to be older (70.6 ± 0.2 vs. 66.1 ± 0.1, p < 0.001), and the overall burden of comorbidities was higher than in those without malignancy. TTS patients with malignancy had significantly higher 30-day readmission rates than those without malignancy (15.9% vs. 11.0%; odds ratio (OR), 1.35; 95% confidence interval (CI), 1.18–1.56). Non-cardiac causes were the most common causes of readmission for TTS patients with malignancy versus without malignancy (75.5% vs. 68.1%, p < 0.001). The 30-day readmission rate due to recurrent TTS was very low in both groups (0.4% and 0.5%; p = 0.47). The total costs were higher by 25% (p < 0.001) in TTS patients with vs. without malignancy. In summary, among patients hospitalized with TTS, the presence of malignancy was associated with increased risk of 30-day readmission and increased costs. These findings highlight the importance of optimized management for TTS patients with malignancy.
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43
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Lin J, Wu B, Lin L, Ding Y, Zhong B, Huang Z, Lin M, Xu DP. Effect of aspirin in takotsubo syndrome: protocol of a systematic review and meta-analysis. BMJ Open 2021; 11:e046727. [PMID: 34376444 PMCID: PMC8356185 DOI: 10.1136/bmjopen-2020-046727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Takotsubo syndrome (TTS) is a sudden reversible weakening of the left ventricle function induced by severe stress and resembles many features as acute coronary syndrome. Even though many guidelines had been published about TTS, there is no consensus regarding the long-term treatment. Aspirin is one of the most common prescribed medicines at discharge for patients with the intention to reduce thrombus events and improve the overall prognosis. However, existing studies yielded conflicting results concerning its effects. This study aims to evaluate the impact of long-term maintenance treatment of aspirin in TTS and provides insights in clinical management. METHODS AND ANALYSIS After searching through electronic databases (PubMed, Embase, Cochrane Library, Web of Science, National Library of Medicine Gateway, CNKI, Wanfang and VIP), grey literatures, conference abstract and trial registries for clinical studies investigating the impact of aspirin on patients with TTS, a systemic review and meta-analysis will be conducted. The search will be limited from inception of each database to 1 August 2020. The outcomes including all-cause death, TTS recurrence, stroke, transient ischaemic attack or myocardial infarction at 30-day and 5-year follow-up will be examined. Risk of bias will be assessed by Newcastle-Ottawa quality assessment scale for observational studies and Cochrane Effective Practice and Organization of Care evaluation tool for interventional studies. Grading of Recommendations Assessment, Development and Evaluations method will be applied to assess the quality of evidence. If available, the effects of aspirin on the above outcomes for patients with TTS will be evaluated using random-effect modelling with relative risk at 95% CIs. Subgroup analysis and sensitivity analysis will also be performed when possible. ETHICS AND DISSEMINATION Ethics approval was not required due to the retrospective nature of the study. Results of the review will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42020212729.
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Affiliation(s)
- Jinhai Lin
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Bingxin Wu
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Luoqi Lin
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yining Ding
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Biying Zhong
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhiwei Huang
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Miaoyang Lin
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Dan-Ping Xu
- Department of Traditional Chinese Medicine, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
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44
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Kim KH. Level of Troponin Release Can Aid in Early Exclusion of Stress-induced (Takotsubo) Cardiomyopathy. J Cardiovasc Imaging 2021; 29:234-235. [PMID: 34313410 PMCID: PMC8318813 DOI: 10.4250/jcvi.2021.0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/25/2021] [Accepted: 06/27/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
- Kyung Hee Kim
- Division of Cardiology, Heart Stroke Vascular Center, Incheon Sejong Hospital, Incheon, Korea.
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45
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Graham FJ, Jenkins SMM. Acute Takotsubo cardiomyopathy as a complication of transoesophageal echocardiogram. THE BRITISH JOURNAL OF CARDIOLOGY 2021; 28:33. [PMID: 35747706 PMCID: PMC8988798 DOI: 10.5837/bjc.2021.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
A 52-year-old woman, referred for transoesophageal echocardiography, developed acute Takotsubo cardiomyopathy during the examination as a result of emotional distress beforehand. Asymptomatic left ventricular apical ballooning with severe systolic dysfunction within minutes of the emotional trigger was the first sign of any abnormality.
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Affiliation(s)
| | - Shona M M Jenkins
- Consultant Cardiologist Department of Cardiology, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF
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46
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Fridlund B, Bruteig E, Dahlviken RM, Fålun N, Norekvål TM. Women's Initial Experiences and up to a Year in Retrospect of Their Life Situation With a Confirmed Takotsubo Syndrome Diagnosis: A Single Case Study Literature Review. J Holist Nurs 2021; 40:146-156. [PMID: 34029129 PMCID: PMC9121527 DOI: 10.1177/08980101211018343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: To describe women's initial experiences and up to a year in
retrospect of their life situation with a confirmed Takotsubo syndrome (TS) diagnosis.
Method: A single case study literature review based on nine articles
published by nurses was analyzed deductively using a nursing life dimension model.
Results: All but one case was conducted on the North American continent and
TS had largely affected women with previous cardiac history and had been triggered by one
or two stressful life events. The biophysical life dimension manifested in distinct and
troublesome inconvenience and in retrospect in fretting and grievous ailments. The
emotional dimension manifested in pronounced ways and attitude-related sensations,
feelings or moods while the intellectual dimension manifested in an unmanageable world of
thought. The spiritual–existential dimension manifested in a life-denying view of life and
the socio-cultural dimension manifested in an asocial life. Conclusions: With
TS best practice in mind and a person-centered care and holistic approach, comprehensive
descriptions are needed of how women identify, interpret, and use knowledge to manage
their life situation. Cardiac nurses need further comprehensive descriptions to implement
actions. Prior to implementation of such programs, this knowledge needs to be disseminated
among cardiac nurses and evaluated in international randomized controlled trials.
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Affiliation(s)
| | | | | | | | - Tone M Norekvål
- 1658University of Bergen.,60498Haukeland University Hospital
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47
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Ethnic comparison in takotsubo syndrome: novel insights from the International Takotsubo Registry. Clin Res Cardiol 2021; 111:186-196. [PMID: 34013386 PMCID: PMC8816760 DOI: 10.1007/s00392-021-01857-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/12/2021] [Indexed: 01/08/2023]
Abstract
Background Ethnic disparities have been reported in cardiovascular disease. However, ethnic disparities in takotsubo syndrome (TTS) remain elusive. This study assessed differences in clinical characteristics between Japanese and European TTS patients and determined the impact of ethnicity on in-hospital outcomes. Methods TTS patients in Japan were enrolled from 10 hospitals and TTS patients in Europe were enrolled from 32 hospitals participating in the International Takotsubo Registry. Clinical characteristics and in-hospital outcomes were compared between Japanese and European patients. Results A total of 503 Japanese and 1670 European patients were included. Japanese patients were older (72.6 ± 11.4 years vs. 68.0 ± 12.0 years; p < 0.001) and more likely to be male (18.5 vs. 8.4%; p < 0.001) than European TTS patients. Physical triggering factors were more common (45.5 vs. 32.0%; p < 0.001), and emotional triggers less common (17.5 vs. 31.5%; p < 0.001), in Japanese patients than in European patients. Japanese patients were more likely to experience cardiogenic shock during the acute phase (15.5 vs. 9.0%; p < 0.001) and had a higher in-hospital mortality (8.2 vs. 3.2%; p < 0.001). However, ethnicity itself did not appear to have an impact on in-hospital mortality. Machine learning approach revealed that the presence of physical stressors was the most important prognostic factor in both Japanese and European TTS patients. Conclusion Differences in clinical characteristics and in-hospital outcomes between Japanese and European TTS patients exist. Ethnicity does not impact the outcome in TTS patients. The worse in-hospital outcome in Japanese patients, is mainly driven by the higher prevalence of physical triggers. Trial Registration URL: https://www.clinicaltrials.gov; Unique Identifier: NCT01947621. Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01857-4.
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48
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Farina LA, Tibrewala A, Voit JM, Raissi SR, Chen L, Welty LJ, Khan SS, Freed BH, Akhter N. Echocardiographic parameters associated with in-hospital adverse outcomes in patients with Takotsubo syndrome. Echocardiography 2021; 38:878-884. [PMID: 33983652 DOI: 10.1111/echo.15069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/05/2021] [Accepted: 04/24/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Takotsubo syndrome (TTS) is an acute heart failure syndrome that leads to significant morbidity and mortality. We sought to evaluate the association of cardiac mechanics on presentation with in-hospital adverse outcomes in patients with apical TTS. METHODS We retrospectively identified 468 patients with TTS based on ICD-9/10 codes between 2006 and 2017. The association of echocardiographic parameters with a composite outcome of heart failure and all-cause mortality during the index hospitalization was analyzed. RESULTS One hundred and forty one patients with the apical subtype and adequate imaging were included. 113 (80.1%) were female, left ventricular ejection fraction (LVEF) was 41.7% ± 12.4%, and global longitudinal strain was -10.1% ± 3.2%. The composite outcome occurred in 58 patients (41%), with heart failure occurring in 55 patients and death occurring in nine patients. Global longitudinal strain, global circumferential strain, global radial strain, right ventricular fractional area change, tricuspid annular plane systolic excursion, and right ventricular free wall strain were significantly worse in patients who experienced the composite outcome in univariate analyses. However, only LVEF was independently associated with the composite outcome in multivariable-adjusted analysis. CONCLUSIONS In patients with apical TTS, the strain has limited prognostic utility in the acute setting compared to LVEF, which was the only echocardiographic parameter associated with in-hospital heart failure and all-cause mortality.
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Affiliation(s)
- Lauren A Farina
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anjan Tibrewala
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jay M Voit
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Sasan R Raissi
- Cardiovascular Medicine, Saint Thomas West Hospital, Nashville, TN, USA
| | - Liqi Chen
- Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Leah J Welty
- Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sadiya S Khan
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Benjamin H Freed
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nausheen Akhter
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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49
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Barnicle R, Bracey A, Secko M. Early Identification of Takotsubo syndrome in the emergency department using point-of-care echocardiography: A case series. JOURNAL OF CLINICAL ULTRASOUND : JCU 2021; 49:413-419. [PMID: 32924171 DOI: 10.1002/jcu.22918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/23/2020] [Accepted: 09/03/2020] [Indexed: 06/11/2023]
Abstract
Takotsubo syndrome (TS) is an incompletely understood, transient dysfunction of the left ventricle. While acute coronary syndrome must be at the forefront of the differential diagnosis and ruled out appropriately, the possibility of TS can be identified early with point-of-care ultrasonography. The formal diagnostic criteria for TS rely on invasive diagnostic procedures and resolution of symptoms, typically relegating it to a diagnosis of exclusion. However, the acute complications are potentially lethal, and rapid identification is therefore beneficial because these patients can be risk-stratified to higher levels of care. Our case series of three patients, each with early suspected and subsequently confirmed TS, explores how early emergency department ultrasonography can suggest the diagnosis during the emergent workup, and potentially influence disposition decisions, subsequent interventions, and possibly even outcomes.
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Affiliation(s)
- Ryan Barnicle
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Alexander Bracey
- Department of Emergency Medicine, Albany Medical Center, Albany, New York, USA
| | - Michael Secko
- Division Chief, Emergency and Clinical Ultrasound, Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York, USA
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50
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Kato K, Cammann VL, Napp LC, Szawan KA, Micek J, Dreiding S, Levinson RA, Petkova V, Würdinger M, Patrascu A, Sumalinog R, Gili S, Clarenbach CF, Kohler M, Wischnewsky M, Citro R, Vecchione C, Bossone E, Neuhaus M, Franke J, Meder B, Jaguszewski M, Noutsias M, Knorr M, Heiner S, D'Ascenzo F, Dichtl W, Burgdorf C, Kherad B, Tschöpe C, Sarcon A, Shinbane J, Rajan L, Michels G, Pfister R, Cuneo A, Jacobshagen C, Karakas M, Koenig W, Pott A, Meyer P, Roffi M, Banning A, Wolfrum M, Cuculi F, Kobza R, Fischer TA, Vasankari T, Airaksinen KEJ, Budnik M, Dworakowski R, MacCarthy P, Kaiser C, Osswald S, Galiuto L, Chan C, Bridgman P, Beug D, Delmas C, Lairez O, Gilyarova E, Shilova A, Gilyarov M, El-Battrawy I, Akin I, Kozel M, Tousek P, Winchester DE, Galuszka J, Ukena C, Poglajen G, Carrilho-Ferreira P, Hauck C, Paolini C, Bilato C, Sano M, Ishibashi I, Takahara M, Himi T, Kobayashi Y, Prasad A, Rihal CS, Liu K, Schulze PC, Bianco M, Jörg L, Rickli H, Pestana G, Nguyen TH, Böhm M, Maier LS, Pinto FJ, Widimský P, Felix SB, Opolski G, Braun-Dullaeus RC, Rottbauer W, Hasenfuß G, Pieske BM, Schunkert H, Borggrefe M, Thiele H, Bauersachs J, Katus HA, Horowitz JD, Di Mario C, Münzel T, Crea F, Bax JJ, Lüscher TF, Ruschitzka F, Ghadri JR, Templin C. Prognostic impact of acute pulmonary triggers in patients with takotsubo syndrome: new insights from the International Takotsubo Registry. ESC Heart Fail 2021; 8:1924-1932. [PMID: 33713566 PMCID: PMC8120351 DOI: 10.1002/ehf2.13165] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 02/01/2023] Open
Abstract
AIMS Acute pulmonary disorders are known physical triggers of takotsubo syndrome (TTS). This study aimed to investigate prevalence of acute pulmonary triggers in patients with TTS and their impact on outcomes. METHODS AND RESULTS Patients with TTS were enrolled from the International Takotsubo Registry and screened for triggering factors and comorbidities. Patients were categorized into three groups (acute pulmonary trigger, chronic lung disease, and no lung disease) to compare clinical characteristics and outcomes. Of the 1670 included patients with TTS, 123 (7%) were identified with an acute pulmonary trigger, and 194 (12%) had a known history of chronic lung disease. The incidence of cardiogenic shock was highest in patients with an acute pulmonary trigger compared with those with chronic lung disease or without lung disease (17% vs. 10% vs. 9%, P = 0.017). In-hospital mortality was also higher in patients with an acute pulmonary trigger than in the other two groups, although not significantly (5.7% vs. 1.5% vs. 4.2%, P = 0.13). Survival analysis demonstrated that patients with an acute pulmonary trigger had the worst long-term outcome (P = 0.002). The presence of an acute pulmonary trigger was independently associated with worse long-term mortality (hazard ratio 2.12, 95% confidence interval 1.33-3.38; P = 0.002). CONCLUSIONS The present study demonstrates that TTS is related to acute pulmonary triggers in 7% of all TTS patients, which accounts for 21% of patients with physical triggers. The presence of acute pulmonary trigger is associated with a severe in-hospital course and a worse long-term outcome.
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Affiliation(s)
- Ken Kato
- Department of Cardiology, University Heart Center, University Hospital of Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Victoria L Cammann
- Department of Cardiology, University Heart Center, University Hospital of Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - L Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Konrad A Szawan
- Department of Cardiology, University Heart Center, University Hospital of Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Jozef Micek
- Department of Cardiology, University Heart Center, University Hospital of Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Sara Dreiding
- Department of Cardiology, University Heart Center, University Hospital of Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Rena A Levinson
- Department of Cardiology, University Heart Center, University Hospital of Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Vanya Petkova
- Department of Cardiology, University Heart Center, University Hospital of Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Michael Würdinger
- Department of Cardiology, University Heart Center, University Hospital of Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Alexandru Patrascu
- Department of Cardiology, University Heart Center, University Hospital of Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Rafael Sumalinog
- Department of Cardiology, University Heart Center, University Hospital of Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | | | | | - Malcolm Kohler
- Pulmonary Division, University Hospital of Zurich, Zurich, Switzerland
| | | | - Rodolfo Citro
- Heart Department, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Carmine Vecchione
- Heart Department, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Eduardo Bossone
- Division of Cardiology, Antonio Cardarelli Hospital, Naples, Italy
| | - Michael Neuhaus
- Department of Cardiology, Kantonsspital Frauenfeld, Frauenfeld, Switzerland
| | - Jennifer Franke
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Benjamin Meder
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Milosz Jaguszewski
- First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Michel Noutsias
- Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Maike Knorr
- Center for Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany
| | - Susanne Heiner
- Center for Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Wolfgang Dichtl
- University Hospital for Internal Medicine III (Cardiology and Angiology), Medical University Innsbruck, Innsbruck, Austria
| | | | - Behrouz Kherad
- Department of Cardiology, Charité, Campus Rudolf Virchow, Berlin, Germany
| | - Carsten Tschöpe
- Department of Cardiology, Charité, Campus Rudolf Virchow, Berlin, Germany
| | - Annahita Sarcon
- Section of Cardiac Electrophysiology, Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Jerold Shinbane
- Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Guido Michels
- Department of Internal Medicine III, Heart Center University of Cologne, Cologne, Germany
| | - Roman Pfister
- Department of Internal Medicine III, Heart Center University of Cologne, Cologne, Germany
| | - Alessandro Cuneo
- Krankenhaus 'Maria Hilf' Medizinische Klinik, Stadtlohn, Germany
| | - Claudius Jacobshagen
- Clinic for Cardiology and Pneumology, Georg August University of Goettingen, Goettingen, Germany
| | - Mahir Karakas
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Alexander Pott
- Department of Internal Medicine II - Cardiology, University of Ulm, Medical Center, Ulm, Germany
| | - Philippe Meyer
- Service de Cardiologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Marco Roffi
- Service de Cardiologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Adrian Banning
- Department of Cardiology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Mathias Wolfrum
- Department of Cardiology, Kantonsspital Lucerne, Lucerne, Switzerland
| | - Florim Cuculi
- Department of Cardiology, Kantonsspital Lucerne, Lucerne, Switzerland
| | - Richard Kobza
- Department of Cardiology, Kantonsspital Lucerne, Lucerne, Switzerland
| | - Thomas A Fischer
- Department of Cardiology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Tuija Vasankari
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | | | - Monika Budnik
- Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | | | - Christoph Kaiser
- Department of Cardiology, University Hospital of Basel, Basel, Switzerland
| | - Stefan Osswald
- Department of Cardiology, University Hospital of Basel, Basel, Switzerland
| | - Leonarda Galiuto
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Christina Chan
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Paul Bridgman
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Daniel Beug
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Greifswald, Greifswald, Germany
| | - Clément Delmas
- Department of Cardiology and Cardiac Imaging Center, University Hospital of Rangueil, Toulouse, France
| | - Olivier Lairez
- Department of Cardiology and Cardiac Imaging Center, University Hospital of Rangueil, Toulouse, France
| | - Ekaterina Gilyarova
- Intensive Coronary Care Unit, Moscow City Hospital # 1 named after N. Pirogov, Moscow, Russia
| | - Alexandra Shilova
- Intensive Coronary Care Unit, Moscow City Hospital # 1 named after N. Pirogov, Moscow, Russia
| | - Mikhail Gilyarov
- Intensive Coronary Care Unit, Moscow City Hospital # 1 named after N. Pirogov, Moscow, Russia
| | - Ibrahim El-Battrawy
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Martin Kozel
- Cardiocenter, Third Faculty of Medicine, Charles University in Prague, University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Petr Tousek
- Cardiocenter, Third Faculty of Medicine, Charles University in Prague, University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - David E Winchester
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jan Galuszka
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Christian Ukena
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Gregor Poglajen
- Advanced Heart Failure and Transplantation Center, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Pedro Carrilho-Ferreira
- Cardiology Department, Santa Maria University Hospital (CHLN), Lisbon Academic Medical Centre and Cardiovascular Centre of the University of Lisbon (CCUL), Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
| | - Christian Hauck
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Carla Paolini
- Local Health Unit n.8, Cardiology Unit, Arzignano, Vicenza, Italy
| | - Claudio Bilato
- Local Health Unit n.8, Cardiology Unit, Arzignano, Vicenza, Italy
| | - Masanori Sano
- Department of Cardiology, Chiba Emergency Medical Center, Chiba, Japan
| | - Iwao Ishibashi
- Department of Cardiology, Chiba Emergency Medical Center, Chiba, Japan
| | | | - Toshiharu Himi
- Division of Cardiology, Kimitsu Central Hospital, Kisarazu, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Abhiram Prasad
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Kan Liu
- Division of Cardiology, Heart and Vascular Center, University of Iowa, Iowa City, Iowa, USA
| | - P Christian Schulze
- Department of Internal Medicine I, JenaUniversity Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Matteo Bianco
- Division of Cardiology, A.O.U San Luigi Gonzaga, Turin, Italy
| | - Lucas Jörg
- Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Hans Rickli
- Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Gonçalo Pestana
- Department of Cardiology, Centro Hospitalar Universitário de São João, E.P.E, Porto, Portugal
| | - Thanh H Nguyen
- Department of Cardiology, Basil Hetzel Institute, Queen Elizabeth Hospital, University of Adelaide, Adelaide, Australia
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Lars S Maier
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Fausto J Pinto
- Cardiology Department, Santa Maria University Hospital (CHLN), Lisbon Academic Medical Centre and Cardiovascular Centre of the University of Lisbon (CCUL), Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
| | - Petr Widimský
- Cardiocenter, Third Faculty of Medicine, Charles University in Prague, University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Stephan B Felix
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Greifswald, Greifswald, Germany
| | - Grzegorz Opolski
- Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | - Wolfgang Rottbauer
- Department of Internal Medicine II - Cardiology, University of Ulm, Medical Center, Ulm, Germany
| | - Gerd Hasenfuß
- Clinic for Cardiology and Pneumology, Georg August University of Goettingen, Goettingen, Germany
| | - Burkert M Pieske
- Department of Cardiology, Charité, Campus Rudolf Virchow, Berlin, Germany
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Martin Borggrefe
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig - University Hospital, Leipzig, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Hugo A Katus
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | - John D Horowitz
- Department of Cardiology, Basil Hetzel Institute, Queen Elizabeth Hospital, University of Adelaide, Adelaide, Australia
| | - Carlo Di Mario
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | - Thomas Münzel
- Center for Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany
| | - Filippo Crea
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Thomas F Lüscher
- Center for Molecular Cardiology, Schlieren Campus, University of Zurich, Zurich, Switzerland.,Royal Brompton and Harefield Hospitals Trust and Imperial College, London, UK
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital of Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Jelena R Ghadri
- Department of Cardiology, University Heart Center, University Hospital of Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Christian Templin
- Department of Cardiology, University Heart Center, University Hospital of Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
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