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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Takotsubo syndrome &#40;TTS&#41; was first described in the early 1990s by Sato et al&#46; in the Japanese population&#44; as a transient cardiomyopathy after a stressful event in the absence of coronary artery disease&#44; due to multivessel coronary spasm&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> This was the first pathophysiological mechanism put forward to explain this syndrome&#44; but its precise etiology and pathophysiology remain unknown&#44; and there are other hypotheses&#44; including abnormalities in coronary microvascular function and catecholamine-mediated cardiotoxicity&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">TTS predominantly affects women&#46; Its symptoms and signs are similar to those of acute coronary syndrome&#58; chest pain&#44; dyspnea&#44; syncope&#44; electrocardiographic abnormalities&#44; and cardiac enzyme changes&#46; The acute left ventricular dysfunction seen in TTS has varying wall motion patterns&#44; typical apical or midventricular ballooning and rarely&#44; basal and focal forms&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">To differentiate TTS from myocardial infarction&#44; it is necessary to perform coronary angiography in the acute stage&#44; to exclude significant coronary artery disease&#46; Establishing the diagnosis is particularly important if fibrinolytic therapy is being considered for a presumed diagnosis of ST-elevation myocardial infarction&#46; Inappropriate administration of fibrinolytics to a patient with TTS may lead to harm&#44; and it would be reasonable to transfer a patient suspected of the cardiomyopathy for emergency coronary angiography&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In most cases TTS is a benign entity with a good prognosis&#44; but severe complications may occur&#44; including heart failure&#44; cardiogenic shock&#44; arrhythmias&#44; mitral regurgitation&#44; thrombus formation&#44; mechanical complications&#44; and even death&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Because the prevalence of TTS is low&#44; its natural history&#44; management&#44; and outcome are not completely understood&#44; and single-center studies are underpowered to obtain meaningful conclusions&#44; a consortium of 26 centers in Europe and the USA established the InterTAK Registry for Takotsubo Syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> Currently&#44; 48 cardiovascular centers in 15 countries are participating in this unique registry&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The main goals of the InterTAK registry are to compare clinical practice regarding diagnosis and management&#44; to promote medical resource and its impact on outcome in different countries&#44; to prospectively analyze the value of different treatment strategies to predict disease-related outcomes&#44; to observe follow-up status and assess immediate&#44; in-hospital and long-term outcomes&#44; and to assess pathophysiology and to find a biomarker for TTS&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Bento et al&#46; present the results of a Portuguese multicenter study in which all patients diagnosed with TTS between 2002 and 2016 in twelve Portuguese hospitals were included&#44; initially retrospectively and subsequently prospectively&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Patients were selected according to the Mayo Clinic diagnostic criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Short- and medium-term clinical complications and mortality were assessed and independent predictors of hospital complications and prognostic factors were determined&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A total of 234 patients with TTS were included&#44; 90&#37; female&#44; and in 65&#37; of the patients a triggering factor was identified&#46; The apical form was the most frequent &#40;78&#37;&#41;&#44; followed by midventricular &#40;16&#37;&#41;&#46; These results are similar to the InterTAK Registry data&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> During hospitalization&#44; 33&#37; of the patients had complications&#44; of which acute heart failure was the most common &#40;24&#37;&#41;&#46; Forty-nine percent completely recovered left ventricular function and 2&#37; died during hospitalization&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In multivariate analysis&#44; atherosclerotic lesions in the coronary arteries&#44; lower LVEF on admission&#44; chronic kidney disease and clinical presentation with dyspnea were independent predictors of in-hospital clinical complications&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">At the mean follow-up of 33&#177;33 months&#44; 12&#37; of the patients had complications&#46; In 4&#37; there was TTS recurrence&#44; 3&#37; had stroke&#44; all-cause mortality was 4&#37; and cardiac mortality was 0&#46;9&#37;&#46; Prolonged QTc interval on the admission electrocardiogram was a predictor of clinical complications at follow-up&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Bento et al&#46; were able to recruit more patients in this multicenter study than in other similar studies in France<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> and Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> This is therefore a representative sample of TTS patients in Portugal&#46; However&#44; one important limitation of this study was that participating centers did not routinely use laboratory hormone tests or imaging to exclude pheochromocytoma or myocarditis&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">This multicenter study of TTS in Portugal not only increases our knowledge of the natural history of the disease&#44; but may also lead to randomized trials of pharmacotherapy aimed at strategies to promote myocardial recovery and prevent recurrence&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Prognosis of Takotsubo syndrome in Portugal
Prognóstico de síndrome de Takotsubo em Portugal
Jorge Mimoso
Serviço de Cardiologia, Centro Hospitalar e Universitário do Algarve, Faro, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Takotsubo syndrome &#40;TTS&#41; was first described in the early 1990s by Sato et al&#46; in the Japanese population&#44; as a transient cardiomyopathy after a stressful event in the absence of coronary artery disease&#44; due to multivessel coronary spasm&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> This was the first pathophysiological mechanism put forward to explain this syndrome&#44; but its precise etiology and pathophysiology remain unknown&#44; and there are other hypotheses&#44; including abnormalities in coronary microvascular function and catecholamine-mediated cardiotoxicity&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">TTS predominantly affects women&#46; Its symptoms and signs are similar to those of acute coronary syndrome&#58; chest pain&#44; dyspnea&#44; syncope&#44; electrocardiographic abnormalities&#44; and cardiac enzyme changes&#46; The acute left ventricular dysfunction seen in TTS has varying wall motion patterns&#44; typical apical or midventricular ballooning and rarely&#44; basal and focal forms&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">To differentiate TTS from myocardial infarction&#44; it is necessary to perform coronary angiography in the acute stage&#44; to exclude significant coronary artery disease&#46; Establishing the diagnosis is particularly important if fibrinolytic therapy is being considered for a presumed diagnosis of ST-elevation myocardial infarction&#46; Inappropriate administration of fibrinolytics to a patient with TTS may lead to harm&#44; and it would be reasonable to transfer a patient suspected of the cardiomyopathy for emergency coronary angiography&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In most cases TTS is a benign entity with a good prognosis&#44; but severe complications may occur&#44; including heart failure&#44; cardiogenic shock&#44; arrhythmias&#44; mitral regurgitation&#44; thrombus formation&#44; mechanical complications&#44; and even death&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Because the prevalence of TTS is low&#44; its natural history&#44; management&#44; and outcome are not completely understood&#44; and single-center studies are underpowered to obtain meaningful conclusions&#44; a consortium of 26 centers in Europe and the USA established the InterTAK Registry for Takotsubo Syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> Currently&#44; 48 cardiovascular centers in 15 countries are participating in this unique registry&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The main goals of the InterTAK registry are to compare clinical practice regarding diagnosis and management&#44; to promote medical resource and its impact on outcome in different countries&#44; to prospectively analyze the value of different treatment strategies to predict disease-related outcomes&#44; to observe follow-up status and assess immediate&#44; in-hospital and long-term outcomes&#44; and to assess pathophysiology and to find a biomarker for TTS&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Bento et al&#46; present the results of a Portuguese multicenter study in which all patients diagnosed with TTS between 2002 and 2016 in twelve Portuguese hospitals were included&#44; initially retrospectively and subsequently prospectively&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Patients were selected according to the Mayo Clinic diagnostic criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Short- and medium-term clinical complications and mortality were assessed and independent predictors of hospital complications and prognostic factors were determined&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A total of 234 patients with TTS were included&#44; 90&#37; female&#44; and in 65&#37; of the patients a triggering factor was identified&#46; The apical form was the most frequent &#40;78&#37;&#41;&#44; followed by midventricular &#40;16&#37;&#41;&#46; These results are similar to the InterTAK Registry data&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> During hospitalization&#44; 33&#37; of the patients had complications&#44; of which acute heart failure was the most common &#40;24&#37;&#41;&#46; Forty-nine percent completely recovered left ventricular function and 2&#37; died during hospitalization&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In multivariate analysis&#44; atherosclerotic lesions in the coronary arteries&#44; lower LVEF on admission&#44; chronic kidney disease and clinical presentation with dyspnea were independent predictors of in-hospital clinical complications&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">At the mean follow-up of 33&#177;33 months&#44; 12&#37; of the patients had complications&#46; In 4&#37; there was TTS recurrence&#44; 3&#37; had stroke&#44; all-cause mortality was 4&#37; and cardiac mortality was 0&#46;9&#37;&#46; Prolonged QTc interval on the admission electrocardiogram was a predictor of clinical complications at follow-up&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Bento et al&#46; were able to recruit more patients in this multicenter study than in other similar studies in France<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> and Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> This is therefore a representative sample of TTS patients in Portugal&#46; However&#44; one important limitation of this study was that participating centers did not routinely use laboratory hormone tests or imaging to exclude pheochromocytoma or myocarditis&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">This multicenter study of TTS in Portugal not only increases our knowledge of the natural history of the disease&#44; but may also lead to randomized trials of pharmacotherapy aimed at strategies to promote myocardial recovery and prevent recurrence&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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