Recurrent Takotsubo Syndrome: How Frequent, and How Does It Present?

BACKGROUND: Recurrent Takotsubo syndrome (TS) is not uncommon but experience with TS recurrence is inherently limited by the infrequency of the condition itself and incomplete long-term follow-up. There is limited published data on the clinical features and outcomes of patients with recurrent TS. We aimed to describe the clinical characteristics and outcomes of patients with recurrent TS in a large Auckland cohort. METHOD: The clinical profile, in-hospital, and long-term outcomes were prospectively assessed in consecutive patients with recurrent TS presenting to Auckland's three major hospitals between January 2006 and January 2023. RESULTS: During the study period, 472 TS patients were identified. Of the 467 patients discharged alive after the index event, 45 (9.6%) patients (mean age 62.3±11.0 years), all women, experienced recurrent TS. Median time interval from index event to the first recurrence was 3.14 years (range 27 days to 13.8 years). In 27 (60%) of the 45 patients, the subsequent events involved a stressor (physical triggers, n=8; emotional triggers, n=19). The stressor type differed between the index and recurrent event in 18 (40%) of the 45 patients. Thirteen (28.9%) had a different echocardiographic variant of TS at first recurrence. All patients with recurrent TS were discharged alive. Four patients died late after discharge from the first recurrence, all but one from a non-cardiac cause. CONCLUSIONS: One in 10 patients with TS experience recurrent events. These may occur many years later, and both the stressor type and the echocardiographic variant may be different at the recurrent event.

External Validation of a Clinical Score to Differentiate Takotsubo Syndrome From Non-ST-Elevation Myocardial Infarction in Women.

BACKGROUND AND AIMS: Clinical presentation of Takotsubo Syndrome (TS) mimics acute coronary syndrome (ACS). A score to differentiate TS from ACS would be helpful to facilitate appropriate investigation and management. We have previously developed a clinical score (NSTE-Takotsubo Score) to distinguish women with non-ST-segment elevation myocardial infarction (NSTEMI) from TS with non-ST-segment elevation (NSTE-TS). This study sought to assess the diagnostic validity of this score in an external validation cohort. METHODS: The external cohort consisted of women with NSTE-TS (n=110) and NSTEMI (n=113) from two major tertiary hospitals in New Zealand. The five variables in the arithmetic score (range -6 to +5) and their relative weights are: T-wave inversion (TWI) in ≥6 leads (3 points), recent stress (2 points), diabetes mellitus (DM) (-1 point), prior cardiovascular disease (CVD) (-2 points) and presence of ST depression (-3 points). Two clinicians blinded to the diagnoses calculated the score using clinical and electrocardiogram (ECG) data on day 1 post-admission. RESULTS: The NSTE-Takotsubo Score discriminated well between NSTE-TS and NSTEMI. The sensitivity and specificity of a score ≥1 to distinguish NSTE-TS from NSTEMI were 78% and 85%, respectively. The area under the receiver operator curve was 0.78 (95% CI 0.72 to 0.84). CONCLUSION: In an external validation cohort, the NSTE-Takotsubo Score was easy to apply and useful to identify women likely to have NSTE-TS on day 1 post-admission.

Takotsubo syndrome in New Zealand: current knowledge and future challenges.

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.

Type of Stressor and Medium-Term Outcomes After Takotsubo Syndrome: What Becomes of the Broken Hearted? (ANZACS-QI 59).

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.

Clinical Characteristics and Outcomes of Patients with Amphetamine-Associated Cardiomyopathy in South Auckland, New Zealand.

BACKGROUND: Amphetamine-associated cardiomyopathy (AAC) is becoming an increasingly recognised entity. The characteristics and outcomes of these patients are poorly understood. METHODS: Thirty patients admitted with heart failure and echocardiographic evidence of cardiomyopathy between 2005 and 2014 and who had a documented history of amphetamine abuse that was considered an important factor in the causation of their cardiomyopathy were retrospectively identified. RESULTS: Mean age at presentation was 40±10 years with a male predominance (n=25, 83%). The majority were of indigenous Maori ethnicity. At presentation, four patients were in cardiogenic shock. Five patients required intensive care unit (ICU) admission for inotropic support and mechanical ventilation. Fifteen had severe left ventricular (LV) dilation (mean LV end-diastolic dimension 6.8±1.0cm) and all patients had severe LV dysfunction (mean LV ejection fraction 22±8%). Despite optimal heart failure therapy, LV size remained significantly dilated with minimal improvement in LV function. During median follow-up of 18 months, five patients died from end-stage heart failure and 17 had at least one readmission with decompensated heart failure. CONCLUSION: Amphetamine-associated cardiomyopathy was seen predominantly in young indigenous Maori men. They presented with severe cardiomyopathy, often requiring ICU admission. Severe LV dilation and significant LV dysfunction persisted despite treatment and mortality was high.

Quantitative analysis of mitral valve morphology in mitral valve prolapse with real-time 3-dimensional echocardiography: importance of annular saddle shape in the pathogenesis of mitral regurgitation.

BACKGROUND: Few data exist on the relation of the 3-dimensional morphology of mitral valve and degree of mitral regurgitation (MR) in mitral valve prolapse. METHODS AND RESULTS: Real-time 3-dimensional transesophageal echocardiography of the mitral valve was acquired in 112 subjects, including 36 patients with mitral valve prolapse and significant MR (≥3+; MR+ group), 32 patients with mitral valve prolapse but no or mild MR (≤2+; MR- group), 12 patients with significant MR resulting from nonprolapse pathologies (nonprolapse group), and 32 control subjects. The 3-dimensional geometry of mitral valve apparatus was measured with dedicated quantification software. Compared with the normal and MR- groups, the MR+ group had more dilated mitral annulus (P<0.0001), a reduced annular height to commissural width ratio (AHCWR) (P<0.0001) indicating flattening of annular saddle shape, redundant leaflet surfaces (P<0.0001), greater leaflet billow volume (P<0.0001) and billow height (P<0.0001), longer lengths from papillary muscles to coaptation (P<0.0001), and more frequent chordal rupture (P<0.0001). Prevalence of chordal rupture increased progressively with annulus flattening (7% versus 24% versus 42% for AHCWR >20%, 15%-20%, and <15%, respectively; P=0.004). Leaflet billow volume increased exponentially with decreasing AHCWR in patients without chordal rupture (r(2)=0.66, P<0.0001). MR severity correlated strongly with leaflet billow volume (r(2)=0.74, P<0.0001) and inversely with AHCWR (r(2)=0.44, P<0.0001). In contrast, annulus dilatation but not flattening occurred in nonprolapse MR patients. An AHCWR <15% (odds ratio=7.1; P=0.0004) was strongly associated with significant MR in mitral valve prolapse. CONCLUSION: Flattening of the annular saddle shape is associated with progressive leaflet billowing and increased frequencies of chordal rupture and may be important in the pathogenesis of MR in mitral valve prolapse.

Quantification of mitral valve morphology with three-dimensional echocardiography--can measurement lead to better management?

The mitral valve (MV) has complex 3-dimensional (3D) morphology and motion. Advance in real-time 3D echocardiography (RT3DE) has revolutionized clinical imaging of the MV by providing clinicians with realistic visualization of the valve. Thus far, RT3DE of the MV structure and dynamics has adopted an approach that depends largely on subjective and qualitative interpretation of the 3D images of the valve, rather than objective and reproducible measurement. RT3DE combined with image-processing computer techniques provides precise segmentation and reliable quantification of the complex 3D morphology and rapid motion of the MV. This new approach to imaging may provide additional quantitative descriptions that are useful in diagnostic and therapeutic decision-making. Quantitative analysis of the MV using RT3DE has increased our understanding of the pathologic mechanism of degenerative, ischemic, functional, and rheumatic MV disease. Most recently, 3D morphologic quantification has entered into clinical use to provide more accurate diagnosis of MV disease and for planning surgery and transcatheter interventions. Current limitations of this quantitative approach to MV imaging include labor-intensiveness during image segmentation and lack of a clear definition of the clinical significance of many of the morphologic parameters. This review summarizes the current development and applications of quantitative analysis of the MV morphology using RT3DE.

Comparison of electrographic changes, clinical features and outcomes in different variants of Takotsubo syndrome.

BACKGROUND: Dysfunction of the left ventricular (LV) apex (apical variant) is the most common form in Takotsubo syndrome (TS). Several less common non-apical variants have been described - mid-ventricular, basal and focal. We hypothesised that the clinical presentation, and electrocardiographic (ECG) findings may vary between apical and non-apical TS. METHODS: We prospectively identified 194 consecutive patients with TS presenting to Middlemore Hospital, Auckland and obtained clinical, echocardiography, coronary angiography, and long-term follow-up data. ECGs at admission and Day 1 were compared. RESULTS: Of 194 patients with TS, 168 (86.6%) had apical TS, and 26 (13.4%) non-apical TS (11 mid-ventricular TS, 5 basal TS, 10 focal TS). Apical TS patients had more significant LV systolic impairment (p = 0.001) and longer length of stay (p = 0.001). The extent of T-wave inversion (TWI) was similar for both groups on admission (p = 0.88). By Day 1 the extent of TWI was greater in apical TS group (median number of leads 5 vs. 1, p = 0.02). The change in QTc interval between admission and Day 1 was greater in apical TS group (29.7 ms vs. 2.77 ms, p < 0.001). Composite in-hospital complication rate was similar for both groups (13.7% vs. 15.4%, p = 0.77). CONCLUSIONS: Compared with non-apical variants, apical TS patients develop more extensive TWI and greater QT prolongation on ECG, and more significant LV systolic impairment, but in-hospital complications were similar. Clinicians should be aware that there is a sub-group of TS patients who have non-apical regional wall motion abnormalities and who don't develop ECG changes typical of the more common apical variant.

An uncommon complication of infective bacterial endocarditis.

Coronary artery septic embolisation resulting in cardioembolic myocardial infarction (MI) is a rare complication of bacterial infective endocarditis (IE), representing <1% of complications related to IE. Diagnosis requires a combination of high clinical suspicion, coronary angiography, echocardiography and cultures of peripheral blood and/or embolic material. The associated mortality rate remains high despite early diagnosis. Optimal interventional therapy is unknown with published international experience over the past two decades limited to very small case series and individual case reports. We present a case of ST elevation MI resulting from coronary artery septic embolisation with an accompanying comprehensive review of the literature.

Clinical characteristics and outcome of apical ballooning syndrome in Auckland, New Zealand.

BACKGROUND: Apical ballooning syndrome (ABS) mimics myocardial infarction but is characterised by transient left ventricular (LV) dysfunction without significant coronary artery obstruction. METHODS: We prospectively identified 100 consecutive patients presenting in the Auckland region between March 2004 and July 2010 and obtained clinical, laboratory, electrocardiography, echocardiography, coronary angiography and long-term follow-up data. RESULTS: Chest pain or dyspnoea were the most common presenting symptom, 95% were women (mean age 65 ± 11 years). An associated stressor was identified in two-thirds of patients, troponin was elevated in all patients, and one-third had ECG ST-elevation. There was a similar range of initial LV ejection fraction (EF), myocardial damage, LV recovery and prognosis in those with and without ST-elevation, and with and without identifiable stressors. One-quarter had a complicated in-hospital course. Lower admission LVEF, but not peak troponin level or ECG ST-elevation, was associated with a complicated in-hospital course. The mean follow-up was 3.0 ± 1.7 years. One patient died in hospital. Four died late after discharge, all from non-cardiac causes. Seven had recurrent ABS. CONCLUSION: In this large, prospective, New Zealand ABS cohort a quarter of patients had a complicated in-hospital course, but almost all recovered, recurrence was infrequent and long-term prognosis dependent on associated non-cardiac disease.

Cardiac Computed Tomography to exclude left atrial appendage thrombus in atrial arrhythmias prior to electrical cardioversion during the COVID-19 pandemic.

Nil.

Acute Predict: a clinician-led cardiovascular disease quality improvement project (Predict-CVD 12).

BACKGROUND: New Zealand data demonstrate major disparities in cardiovascular health, particularly by ethnicity and socioeconomic deprivation. ACUTE PREDICT AIM: Acute Predict, the secondary care arm of primary care based PREDICT, is a multidisciplinary project based in the coronary care unit, and is jointly led by nursing and medical staff. The project aim is to ensure patients with acute coronary syndromes (ACS) receive appropriate evidence-based secondary prevention management short- and long-term, regardless of age, socioeconomic status or ethnicity. METHODS AND RESULTS: Acute Predict utilises an electronic backbone to provide the following (1) guideline-based patient-specific decision support, (2) data collection as part of routine clinical workflow, (3) linkage of patients to cardiac rehabilitation and primary care chronic care management programs, (4) clinical and management data capture, (5) real-time whole group and sub-group Key Performance Indicators reporting with drill-down to individual patient data, and (6) long-term tracking of individual patient outcome via linkage to national databases. Over the four years of the project in-hospital provision of cardiac rehabilitation has improved and appropriate discharge medication is high. There are no differences according to ethnicity. Despite this, Maori patients in the Acute Predict ACS cohort are twice as likely as Europeans to have recurrent events post-discharge, even after adjustment for known risk factors. CONCLUSIONS: The built-in real-time data reporting and outcomes/prescribing linkage facilitate monitoring of the quality of CVD prevention activity across the continuum of care. It allows early identification of treatment gaps and of persistent disparities in outcome in our patients. We are learning how best to use this real-time data collection and reporting to support the design and assessment of targeted interventions to close gaps and reduce disparity.

A Score to differentiate Takotsubo syndrome from non-ST-elevation myocardial nfarction in women at the bedside.

Objective: A score to distinguish Takotsubo syndrome (TS) from acute coronary syndrome would be useful to facilitate appropriate patient investigation and management. This study sought to derive and validate a simple score using demographic, clinical and ECG data to distinguish women with non-ST elevation myocardial infarction (NSTEMI) from NSTE-TS. Methods: The derivation cohort consisted of women with NSTE-TS (n=100) and NSTEMI (n=100). Logistic regression was used to derive the score using ECG values available on the postacute ward round on day 1 post-hospital admission. The score was then temporally validated in subsequent consecutive patients with NSTE-TS (n=40) and NSTEMI (n=70). Results: The five variables in the score and their relative weights were: T-wave inversion in ≥6 leads (+3), recent stress (+2), diabetes (-1), prior cardiovascular disease (-2) and ST-depression in any lead (-3). When calculated using ECG values obtained at admission, discrimination between conditions was very good (area under the curve (AUC) 0.87 95% CI 0.83 to 0.92). The optimal score cut-point of ≥1 to predict NSTE-TS had 73% sensitivity and 90% specificity. When applied to the validation cohort at admission, AUC was 0.82 (95% CI 0.75 to 0.90) and positive and negative predictive values were 78% and 81%, respectively. On day 1 post-admission, AUC was 0.92 (95% CI 0.87 to 0.97), with positive and negative predictive values of 77% and 91%, respectively. Conclusion: This NSTE-TS score is easy to use and may prove useful in clinical practice to distinguish women with NSTE-TS from NSTEMI. Further validation in external cohorts is needed.

A comparison of the clinical features and outcomes of Takotsubo syndrome across five metropolitan hospitals in New Zealand.

AIM: Takotsubo syndrome (TS) mimics acute coronary syndrome but has a distinct pathophysiology. This study aimed to compare and contrast the clinical presentation, management and outcomes of patients with TS in five large New Zealand hospitals. METHODS: We identified 632 consecutive patients presenting to the five major tertiary hospitals in New Zealand (Middlemore Hospital, Auckland City Hospital, North Shore Hospital, Christchurch Hospital and Dunedin Hospital) between January 2006 and June 2018 and obtained clinical, laboratory, electrocardiography, echocardiography, coronary angiography and long-term follow-up data. RESULTS: Six hundred and thirty-two consecutive patients with TS (606 women, mean age 65.0+11.1 years) were included. An associated stressor was identified in two-thirds of patients, and emotional triggers were more frequent than physical triggers (62.9% and 37.1%, respectively). Overall, 12.7% of patient had depression and 11.7% anxiety but this was more common in patients from Christchurch Hospital (20.4% and 23.4%, respectively). The in-hospital mortality among the five hospitals ranges between 0 to 2.0%. The mean follow-up was 4.9+3.4 years (median 4.4 years). Fifty-four people died post-discharge, all but one from a non-cardiac cause. Forty patients had recurrent TS. Mortality post-discharge (p=0.63) and TS recurrence (p=0.38) did not differ significantly among the five hospitals. CONCLUSION: In this large New Zealand TS cohort, the clinical characteristics and presentation were similar among the five hospitals. A subset of patients had a complicated in-hospital course, but late deaths were almost all from non-cardiac causes and recurrence was infrequent. Mortality post-discharge and recurrence was similar between the hospitals.

Early direct current cardioversion or ablation for atrial fibrillation or atrial flutter and acute decompensated heart failure.

AIMS: Guidelines recommend initial rate control in haemodynamically stable patients with atrial fibrillation (AF) or atrial flutter (AFL) and acute decompensated heart failure (ADHF). There is limited data on early inpatient rhythm control. We investigated the outcomes of patients managed with early TOE-guided DC cardioversion (DCCV) or ablation. METHODS: We retrospectively analysed patients admitted to a single centre with AF or AFL and ADHF with LVEF≤40% that underwent inpatient TOE-guided DCCV or ablation. The primary endpoint was the one year composite outcome of mortality or rehospitalisation for heart failure. RESULTS: We identified 79 patients, including 33 with AF (32 DCCV, one ablation) and 46 with AFL (22 DCCV, 24 ablation). The primary endpoint occurred in 20%. One-year mortality was 2.5%. There were significantly fewer rehospitalisations for arrhythmia or heart failure with AFL-ablation compared to AFL-DCCV (21% vs 64%, p=<0.01). Clinical recurrence of AF or AFL was 43%. At follow-up LV assessment, LVEF>40% was found in 75% (p=<0.01), including 87% of patients without known cardiomyopathy and 82% of patients in sinus rhythm. CONCLUSION: Early inpatient DCCV or ablation for AF or AFL and ADHF had low mortality rates and rehospitalisation for heart failure with substantial improvement in LV function at follow-up.

Poor outcomes in methamphetamine-associated cardiomyopathy-a growing health issue in New Zealand.

BACKGROUND: Methamphetamine-associated cardiomyopathy (MAC) is increasingly recognised as a serious consequence of chronic metamphetamine use. Evidence to guide management and prognostication of patients with MAC compared to other cardiomyopathies remain limited. METHODS: Clinical characteristics, in-hospital and post-discharge outcomes were collected in consecutive MAC patients at Middlemore Hospital from 2006-2018, and compared with a 1:1 age-range matched cohort with non-ischaemic cardiomyopathy (NCM). RESULTS: Sixty-two patients (eight females, median age 41 years) with MAC were included. MAC patients were younger than the NCM cohort, and the majority were of indigenous Maori ethnicity. MAC patients had higher peak N-terminal pro B-type natriuretic peptide (NT-proBNP) and lower left ventricular (LV) ejection fraction at presentation. No patients died during index admission. However, there were more MAC patients (10 versus two, P=0.030) with cardiogenic shock at presentation. There were 15 deaths in the MAC patients and seven deaths in the NCM patients during follow-up. MAC patients were at increased mortality risk (HR 2.7, 95% confidence interval 1.1-6.2, P=0.029), and had a trend to more heart failure re-admissions. (HR 1.6, 95% CI 1.0-2.8, P=0.075) compared to NCM patients. Baseline LV end diastolic diameter and failure of improvement in right ventricular systolic function during follow-up were independent predictors of mortality, while failure of improvement in LV ejection fraction predicted heart failure readmission in MAC patients. CONCLUSIONS: MAC patients were more likely to be younger, male, of Maori ethnicity and have a worse prognosis when compared to patients with other non-ischaemic cardiomyopathies.