Physically triggered Takotsubo cardiomyopathy has a higher in-hospital mortality rate

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Abstract

Background

Takotsubo cardiomyopathy (TC) is a myopathy triggered by severe stressful events. However, little is known about the determinants of in-hospital outcomes. We prospectively determined the effect of different triggers on the prognosis of TC.

Methods and results

We enrolled patients who were admitted for suspected acute coronary syndrome (ACS) from January 2008 to December 2015. TC was diagnosed according to the Mayo Clinic diagnosis criteria. The outcome was in-hospital death. Among 1861 consecutive patients with suspected ACS, 82 (4.4%) patients were diagnosed with TC. There were 43 patients (52%) with physical triggers (Physical), 26 (31%) with emotional triggers, and 13 (17%) with no identifiable triggers. The latter two groups were combined and categorized as the Non-physical trigger group. Compared with non-physical triggered TC, patients with physical triggered TC were more likely to have a malignancy (p = 0.008), lower blood pressure (p = 0.001), lower hemoglobin (p < 0.001), higher serum creatinine (p < 0.001) and higher norepinephrine levels (p = 0.007). During a mean hospital stay of 16 ± 12 days, 9 (20.9%) of the Physical and 1 (2.6%) of the Non-physical patients died in-hospital (log-rank p = 0.007). After adjusting for the age, gender, trigger, malignancy, and hemoglobin level, being male (hazard ratio 11.9, 95% confidence interval, 2.43–58.5, p = 0.002) and having a physical trigger (14.7, 1.19–166, p = 0.03) were associated with in-hospital mortality.

Conclusion

There was a significant difference in in-hospital mortality depending on the trigger type in TC. Being male and having a physical trigger were independent risk factors of in-hospital mortality from TC.

Introduction

Diagnoses of Takotsubo cardiomyopathy (TC) are increasing. The prevalence is reported to be 1.7% to 2.5% in patients with suspected acute coronary syndrome (ACS) [1], [2]. The disease is characterized by transient systolic and diastolic left ventricular dysfunction with a variety of wall-motion abnormalities, typically with akinesis or dyskinesis of the apex. Mechanisms proposed to underlie the disease include catecholamine cardiotoxicity, microvascular dysfunction and coronary artery spasms, but remain inconclusive [3], [4]. The disease is commonly precipitated by severe stress [5], [6], [7], [8]. However, little is known about the significance of different types of triggers on the prognosis. Therefore, the goal of our study was to determine whether particular types of triggers were associated with the prognosis in TC, using a prospective study design.

Section snippets

Enrollment

We enrolled all patients with suspected ACS from January 2008 to December 2015. All patients underwent a baseline history taking, physical examination, collection of vital signs, laboratory data, 12-lead electrocardiogram (ECG), echocardiography and coronary angiography. A diagnosis of TC was based on the Mayo Clinic diagnosis criteria: the presence of a transient abnormality in the left ventricular wall motion beyond a single epicardial coronary artery perfusion territory, the absence of

Baseline characteristics

We screened 1861 consecutive patients with suspected ACS from January 2008 to December 2015. Of these, 1735 (93.2%) patients were excluded due to diagnosis of ACS with coronary angiography. Of the remaining 126 patients, 44 patients were excluded due to diagnosis of acute myocarditis after chart review. No patient with pheochromocytoma was included in this study. Eighty-two (4.4%) patients were enrolled in this study as diagnosed with TC by the Mayo Clinic diagnostic criteria (Fig. 1). The

Discussion

The major findings of our study are that TC had a higher mortality (10.2%) than has been reported in the past, physical and non-physical triggered TC patients differed in the number of clinical features, and physical triggered TC had a significantly higher mortality.

Conclusions

There was a significant difference in the in-hospital mortality between the triggers in TC. Physical triggers and a male gender were independent risk factors for in-hospital mortality. The pathophysiology may be a direct catecholamine toxicity of the cardiomyocytes.

Disclosure

Dr. Watanabe is a recipient of lecture fees from Daiichi-Sankyo and research funding from Boehringer Ingelheim, Takeda Pharmaceutical Company, Japan Lifeline, Medtronic Japan, Boston Scientific Japan, Biotronik Japan, and St. Jude Medical Japan. This work was supported by JSPS KAKENHI Grant Number 26461094.

Conflict of interest

The authors report no relationships that could be construed as a conflict of interest.

Acknowledgments

We thank Yuki Shiino and Shiho Ishikawa for assistance with the data collection and Dr. Yuka Kiriyama for the technical support with the histological examinations.

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    This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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