Complications in the clinical course of tako-tsubo cardiomyopathy

doi:10.1016/j.ijcard.2014.07.002

International Journal of Cardiology

Volume 176, Issue 1, September 2014, Pages 199-205

https://doi.org/10.1016/j.ijcard.2014.07.002 Get rights and content

Abstract

Objective

This study evaluated the frequency, severity and outcome of complications in the clinical course of tako-tsubo cardiomyopathy (TTC).

Background

TTC is regarded as a benign disease since left ventricular (LV) function returns to normal within a short time. However, severe complications have been reported in selected patients.

Methods

From 37 hospitals, 209 patients (189 female, age 69 ± 12 years) were prospectively included in a TTC registry.

Results

Complications developed in 108/209 patients (52%); 23 (11%) had > 2 complications. Complications occurred median 1 day after symptom onset, and 77% were seen within 3 days. Arrhythmias were documented in 45/209 patients (22%) including atrial fibrillation in 32 (15%) and ventricular tachycardia in 17 (8%). Of 8 patients resuscitated (4%), 6 survived. Additional complications were right ventricular involvement (24%), pulmonary edema (13%), cardiogenic shock (7%), transient intraventricular pressure gradients (5%), LV thrombi (3%) and stroke (1%). During hospitalization, 5/209 patients (2.5%) died. Patients with complications were older (70 ± 13 vs 67 ± 10 years, p = 0.012), had a higher heart rate (91 ± 26 vs 83 ± 19/min, p = 0.025), more frequently Q\ waves on the admission ECG (36% vs 21%, p = 0.019) and a lower LV ejection fraction (47 ± 15 vs 54 ± 14%, p = 0.002). Multivariate regression analysis identified Q-waves on admission (OR 2.49, 95% CI 1.23–5.05, p = 0.021) and ejection fraction ≤ 30% (OR 4.03, 95% CI 1.04–15.67, p = 0.022) as independent predictors for complications.

Conclusions

TTC may be associated with severe complications in half of the patients. Since the majority of complications occur up to day 3, monitoring is advisable for this time period.

Introduction

Tako-tsubo cardiomyopathy (TTC) is regarded as a reversible and relatively benign disease [1], [2]. However, some authors reported a high mortality of up to 12% [3], [4], [5], [6], [7] related mainly to the occurrence of malignant arrhythmias and cardiogenic shock [1], [8]. Moreover, other complications such as pulmonary edema, intraventricular pressure gradients sometimes associated with acute mitral regurgitation [1], [9], [10], right ventricular involvement with pleural effusions [3], [11], and intraventricular thrombi resulting in acute stroke [12], [13] or arterial embolism [14] have been described. Due to the fact that most reports comprise relatively small patient numbers, the complication rate varies considerably.

In this study we report the frequency and the spectrum of complications in a large cohort of patients with TTC prospectively included in the registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK).

Section snippets

Patients

Between February 2006 and August 2009, patients were prospectively enrolled in the TTC registry according to the following criteria: 1) acute chest symptoms (angina, dyspnea), syncope or other symptoms in combination with 2) ischemic ECG changes with ST-segment elevation ± T-wave inversion, 3) reversible left ventricular regional wall motion abnormality not corresponding to a single coronary artery territory, and 4) absence of significant coronary artery stenoses > 50% by coronary angiography.

Patient characteristics

A total of 324 patients from 36 German hospitals and 1 hospital in Austria were included in the registry. Complete data on acute treatment and complications were available for the last 209 patients after updating the initial CRF for all more recently published complications in TTC. These 209 patients constitute the study population. Compared to the initial cohort of 115 patients there was no significant difference with regard to age, sex, symptoms, cardiac markers, heart rate, Q waves or

Discussion

This registry prospectively including patients with TTC represents one of the largest patient cohorts with this entity. Our results indicate that TTC is not the benign disease; it was initially thought to be since complications were observed in 52% of the patients. Fortunately, most complications could be treated successfully.

Clinical presentation was an ACS in 86% of our patients with TTC most of whom were women. In this registry, TTC patients both without and with ST segment elevation had a

Conflict of interest statement

There is no potential conflict of interest.

Acknowledgments

The following institutions and investigators participated in the Tako-Tsubo registry initiated by the ALKK: Klinikum Aschaffenburg (W. Pistner, R. Uebis), HELIOS Klinikum Aue (T. Ketteler), Klinikum Augsburg (T. Müller-Honold, W. von Scheidt), Herz- und Gefäß-Klinik Bad Neustadt a. d. Saale (R. Schamberger, S. Kerber), DRK Kliniken Berlin Köpenick (A. Bublak, H.-F. Vöhringer), DRK Kliniken Berlin Westend (R. Schoeller), Unfallkrankenhaus Berlin (G. Calmez), Vivantes Klinikum Am Urban und Im

References (41)

K. Tsuchihashi et al.
Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction
J Am Coll Cardiol
(2001)
A.A. Elesber et al.
Transient cardiac apical ballooning syndrome: prevalence and clinical implications of right ventricular involvement
J Am Coll Cardiol
(2006)
V. Kurowski et al.
Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): frequency, mechanisms, and prognosis
Chest
(2007)
G. Parodi et al.
Left ventricular apical ballooning syndrome as a novel cause of acute mitral regurgitation
J Am Coll Cardiol
(2007)
S.W. Sharkey et al.
Natural history and expansive clinical profile of stress (tako-tsubo) cardiomyopathy
J Am Coll Cardiol
(2010)
C. de Gregorio et al.
Left ventricular thrombus formation and cardioembolic complications in patients with Takotsubo-like syndrome: a systematic review
Int J Cardiol
(2008)
G. Andò et al.
Systemic embolism in takotsubo syndrome
Int J Cardiol
(2009)
B. Schneider et al.
Gender differences in the manifestation of tako-tsubo cardiomyopathy
Int J Cardiol
(2013)
T. Heer et al.
Gender differences in acute myocardial infarction in the era of reperfusion (the MITRA registry)
Am J Cardiol
(2002)
T. Heer et al.
Gender differences in acute non-ST-segment elevation myocardial infarction
Am J Cardiol
(2006)

J.D. Abbott et al.

Comparison of outcome in patients with ST-elevation versus non-ST-elevation acute myocardial infarction treated with percutaneous coronary intervention (from the National Heart, Lung, and Blood Institute Dynamic Registry)

Am J Cardiol

(2007)

F.A. Spencer et al.

Impact of aspirin on presentation and hospital outcomes in patients with acute coronary syndromes (The Global Registry of Acute Coronary Events [GRACE])

Am J Cardiol

(2002)

S.H. Konety et al.

Arrhythmias in tako-tsubo syndrome — benign or malignant?

Int J Cardiol

(2007)

A.A. Elesber et al.

Four-year recurrence rate and prognosis of the apical ballooning syndrome

J Am Coll Cardiol

(2007)

J.Y. Hahn et al.

The clinical features of transient left ventricular nonapical ballooning syndrome: comparison with apical ballooning syndrome

Am Heart J

(2007)

T. Yoshioka et al.

Clinical implications of midventricular obstruction and intravenous propranolol use in transient left ventricular apical ballooning (tako-tsubo cardiomyopathy)

Am Heart J

(2008)

W. Mitsuma et al.

Thromboembolism in takotsubo cardiomyopathy

Int J Cardiol

(2010)

T. Yoshida et al.

Tako-tsubo cardiomyopathy complicated by apical thrombus formation: a case report

Int J Cardiol

(2009)

R. Citro et al.

Echocardiographic correlates of acute heart failure, cardiogenic shock, and in-hospital mortality in tako-tsubo cardiomyopathy

J Am Coll Cardiol Img

(2014)

K. Singh et al.

Meta-analysis of clinical correlates of acute mortality in takotsubo cardiomyopathy

Am J Cardiol

(2014)

Cited by (128)

Stress cardiomyopathy following thyroidectomy in a postmenopausal patient: A case report
2024, International Journal of Surgery Case Reports
First described in 1990 in Japan, Stress cardiomyopathy (SC) is characterized by transient systolic and diastolic left ventricular (LV) dysfunction with a variety of wall-motion abnormalities. It predominantly affects postmenopausal women and is often preceded by an emotional or physical trigger. SC is an increasingly recognized form of transient LV dysfunction that is often completely reversible.
We report a case of SC induced by thyroidectomy in a postmenopausal woman with a good outcome for the patient.
The pathogenesis of SC remains obscure, several possible hypotheses include catecholamine induced myocardial spasm or catecholamine related myocardial stunning, metabolic disorders and coronary microvascular damage. It is described as a disease with a 6-fold female–male predominance, affecting elderly postmenopausal women leading researchers to an estrogen-based theory for the pathogenesis. Thera are also increasing evidences for link between SC and thyroid pathology. There is no consensus on the diagnostic criteria for SC.
SC should be kept in mind especially in women with postmenopausal syndrome in perioperative period.
Takotsubo syndrome and stroke risk: A nationwide register-based study
2023, International Journal of Cardiology
Previous small-scale studies have indicated a short-term stroke incidence of 1.0–1.3% following Takotsubo (syndrome). In this nationwide register-based study, we investigated the 90-day risk of ischemic stroke (IS) or transient ischemia attack (TIA) and mortality of patients with Takotsubo.
Patients with incident Takotsubo between January 1st 2009 to September 30th 2018 were identified from Danish nationwide registries. Takotsubo patients were age- and sex-matched with background-, atrial fibrillation/flutter- (AF) and myocardial infarction (MI) cohorts. Cumulative incidences and Cox proportional-hazard regression models were used to analyze the following outcomes: 1) composite of IS/TIA and 2) all-cause mortality. A total of 890 patients with Takotsubo were followed for 90 days. The cumulative 90-day incidence of IS/TIA in the Takotsubo-, background-, AF- and MI cohort, was 2.1% (n = 19), 0.1% (n = 4), 1.1% (n = 47) and 1.5% (n = 66), respectively. The cumulative 90-day mortality in the Takotsubo-, background-, AF- and MI cohort was 5.1% (n = 45), 0.3% (n = 13), 1.7% (n = 75) and 5.6% (n = 230), respectively.
The adjusted hazard ratio (HR) for 90-day IS/TIA was when compared to the background-, AF- and MI cohort, 26.43 (95% CI: 8.82–79.24), 1.91 (95% CI: 1.09–3.35) and 2.06 (95% CI: 1.12–3.79), respectively. The adjusted HR for 90-day mortality was when compared to the background-, AF- and MI cohort, 14.19 (95% CI: 7.43–27.09), 0.73 (95% CI: 0.52–1.02) and 1.96 (95% CI: 1.25–3.07), respectively.
Patients with Takotsubo had an increased 90-day hazard for IS/TIA when compared to age- and sex-matched background-, AF- and MI cohorts.
The impact of ST-segment elevation on the prognosis of patients with Takotsubo cardiomyopathy
2022, Journal of Electrocardiology
Citation Excerpt :
Second, the high rate of beta-blocker usage in our study may have reduced the frequency of LVOTO, since it has been shown that administration of these drugs reduces LVOT gradient in this setting [16,17]; in our study, approximately 84% of patients were discharged on beta-blockers while 30% were receiving these agents at admission. Knowledge regarding the association of initial EKG findings and LV thrombus is limited, although both STE and T-wave inversion have been reported [13,18,19]. Thrombus is found more frequently in TC patients with apical ballooning, supporting our finding that STE group had a trend toward higher LV thrombus formation since patients in this group was more likely to have apical dyskinesia/akinesia [13,18].
Takotsubo cardiomyopathy (TC) has a variety of electrocardiographic expressions such as ST-segment elevation (STE), T-wave inversion, QTc-prolongation, left bundle branch block, presence of anterior Q waves and rarely ST-segment depression. In contrast to acute myocardial infarction, the impact of STE on the initial electrocardiogram (EKG), on TC outcomes, remains largely unknown.
To evaluate the significance of STE on the index EKG of patients with takotsubo cardiomyopathy (TC) in terms of prognosis.
We examined retrospectively the data of 436 patients diagnosed with TC who were admitted to the Minneapolis Heart Institute between August 2001 and November 2019.
Of 436 patients, 145 (33%) presented with STE on the index EKG. Typical apical ballooning pattern was encountered more frequently in the STE group (66% vs 51%; p = 0.005), on the contrary to the mid-ventricular ballooning which was more common in the non-STE group (31% vs 45%; p = 0.005) while initial left ventricular ejection fraction was similar between the two groups (31% ± 9 vs 33% ± 11; p = 0.163). The composite endpoint of TC-related complications, defined as left ventricular outflow tract obstruction (LVOTO), left ventricular (LV) thrombus, hemodynamic instability requiring mechanical or intravenous vasopressor support, cardiac arrest or in-hospital death, was higher for the STE group (37% vs 24%; p = 0.006). Left ventricular outflow obstruction (LVOTO) was more frequent in patients with STE (13% vs 3%; p < 0.001) while there was a trend toward higher rates of LV thrombus formation in the same group (5% vs 1%; p = 0.057). On multivariable analysis, STE remained an independent predictor of TC-related complications. In-hospital mortality (2.8% vs 3.4%; p = 1.000) and five-year mortality were similar between the two groups (23% vs 20%; p = 0.612).
Patients with TC presenting with STE on the initial EKG, were more likely to develop disease related complications, thus, careful in-hospital monitoring including imaging evaluation for LVOTO and LV thrombus may be warranted for these patients. Nevertheless, both groups had similar in-hospital and five-year mortality.
Takotsubo Syndrome in Intensive Cardiac Care Unit: Challenges in Diagnosis and Management
2022, Current Problems in Cardiology
Takotsubo syndrome (TTS) is an acute reversible form of myocardial dysfunction that is often associated with serious adverse in-hospital complications, including acute heart failure, cardiogenic shock and life-threatening arrythmias. In the absence of randomized clinical trials, its management in the acute phase is based on empirical supportive pharmacological and non-pharmacological measures.In this review article, we aimed at providing an overview of the acute clinical manifestations of patients presenting with TTS, highlighting the predictors of a worse short-term outcome, along with the challenges in therapeutic management of TTS-related complications in the acute care setting.
Ventricular septal perforation naturally reduced in takotsubo cardiomyopathy
2022, Journal of Cardiology Cases
An 80-year-old female was transferred to our hospital with dyspnea. Chest X-ray showed severe pulmonary congestion and electrocardiogram showed ST-segment elevation, abnormal Q, and negative T waves in leads V1–4. Transthoracic echocardiography demonstrated left ventricular apical akinesia with apical ventricular septal perforation. Emergent coronary angiography showed no coronary artery stenosis, and right-heart catheterization revealed a pulmonary to systemic flow ratio (Qp/Qs) of 2.2 on oximetry run. She was diagnosed with takotsubo cardiomyopathy with an associated complication of ventricular septal perforation. Her cardiac function gradually improved with nonsurgical treatment. An oximetry run performed 67 days later revealed that Qp/Qs decreased to 1.2. The size of ventricular septal perforation associated with takotsubo cardiomyopathy reduces naturally by conservative treatment, unlike that in acute myocardial infarction.
<Learning objective: Ventricular septal perforation (VSP) has been reported as a rare complication of takotsubo cardiomyopathy (TCM). No specific treatment course has yet been established. The size of VSP associated with TCM may naturally reduce following conservative treatment, unlike that in acute myocardial infarction. Conservative treatment may be a better option if the patient is hemodynamically stable.>
Meta-analysis of incidence and outcomes of life-threatening arrhythmias in takotsubo cardiomyopathy
2022, Indian Heart Journal
Takotsubo cardiomyopathy (TC) or stress-induced cardiomyopathy is a transient heart condition that clinically resembles an acute coronary syndrome. This study aims to assess the incidence of life-threatening arrhythmias in patients with Takotsubo cardiomyopathy and evaluate the outcomes of patients with life-threatening arrhythmias (LTAs) in Takotsubo cardiomyopathy compared with those without LTA.
We comprehensively searched the PubMed, Google Scholar, and Embase databases from inception to February 2021. The primary aim of the study was to determine the incidence of LTAs in TC patients. Other outcomes of interest were the odds of in-hospital, long-term mortality, and cardiogenic shock (CS) in TC patients with LTAs versus those without LTAs. For all statistical analyses, ReviewManager and MedCalc were used.
Eighteen studies were included in this study involving 55,557 participants (2,185 with LTAs and 53,372 without LTAs). The pooled incidence of LTAs in the patients of TC was found to be 6.29% (CI: 4.70–8.08%; I2 = 94.67%). There was a statistically significant increased risk of in-hospital mortality (OR = 4.74; CI: 2.24–10.04; I2 = 77%, p < 0.0001) and cardiogenic shock (OR = 5.60; CI: 3.51–8.95; I2 = 0%, p < 0.00001) in the LTA group versus the non-LTA group. LTA was not associated with long-term mortality (OR = 2.23; CI: 0.94–5.28; I2 = 53%, p = 0.07).
The pooled incidence of life-threatening arrhythmias in the patients of TC was found to be 6.29%. In the group of TC patients with LTAs, the odds of in-hospital mortality and CS, was higher than in the TC patients without LTAs.

View all citing articles on Scopus

^☆: All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

View full text

Complications in the clinical course of tako-tsubo cardiomyopathy☆

Abstract

Objective

Background

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Patient characteristics

Discussion

Conflict of interest statement

Acknowledgments

J Am Coll Cardiol

J Am Coll Cardiol

Chest

J Am Coll Cardiol

J Am Coll Cardiol

Int J Cardiol

Int J Cardiol

Int J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Int J Cardiol

J Am Coll Cardiol

Am Heart J

Am Heart J

Int J Cardiol

Int J Cardiol

J Am Coll Cardiol Img

Am J Cardiol