Protective effect of acquired long QT syndrome in Takotsubo syndrome.

BACKGROUND: Clinical variables that predict long-term mortality and recurrence of Takotsubo syndrome (TTS) are not completely understood as the role of acquired corrected QT interval (QTc) prolongation. AIM: To detect the prevalence of QTc interval prolongation in patients with TTS and to evaluate its long-term prognostic impact. METHODS: QTc intervals were analysed in 105 patients presenting with symptoms of TTS. These patients were included in an ongoing retrospective cohort database. The cohort was subsequently subdivided into two groups based on the presence (long QT (LQT) group, n = 73, 69.52%) or absence (non-long QT (non-LQT) group, n = 32, 30.43%) of QTc interval prolongation. Patients were followed up over a mean period of 4.2 years. The rate of life-threatening arrhythmia during the first 30 days in the LQT group was comparable with the non-LQT group (10.9 vs 12.5%), whereas in-hospital mortality and 30-day mortality occurred less frequently in the LQT group (2.7 vs 18.75%, P < 0.01). RESULTS: During this time span, 17 (23.3%) patients with acquired LQT syndrome died, whereas 14 (43.7%) patients with non-LQT duration died. Kaplan-Meier survival rates were significantly higher in the LQT group than those in the non-LQT group (Log-rank-test, P = 0.02). On multivariate analysis, the QTc interval was an independent negative predictor of all-cause mortality (P = 0.02). CONCLUSION: The QTc interval at admission is an independent negative predictor of long-term adverse outcome in patients with TTS.

Prevalence of malignant arrhythmia and sudden cardiac death in takotsubo syndrome and its management.

Aims: Recent studies have highlighted that takotsubo syndrome (TTS) is associated with a poor clinical outcome. Our study was conducted to determine the short- and long-term prevalence, recurrence rate and impact of life-threatening arrhythmias (LTA) on the clinical outcome of TTS. Methods and results: Our institutional database constituted a collective of 114 patients diagnosed with TTS between 2003 and 2015. The patient groups, divided according to the presence (n = 13, 11.4%) or absence (n = 101, 88.6%) of LTAs, were followed-up over a period of 3 years so as to determine the clinical outcome. Our analyses suggest that patients comprising the LTA group suffered significantly more often from an acute cardiovascular event including cases of a newly diagnosed atrial fibrillation (38.4% vs. 2.9%), cardiogenic shock with use of inotropic agents (53.8% vs. 14.8%) and cardiopulmonary resuscitation (61.5% vs. 1%). The short-term recurrence rate of a LTA episode was 15.3%, while the long-term recurrence rate of any LTA was around 5%. Whereas, in-hospital mortality was significantly higher in TTS associated with LTAs, the overall survival rate over 3 years was similar. A multivariate Cox regression analysis suggested atrial fibrillation, EF ≤ 35%, cardiogenic shock, and glomerular filtration rate <60 mL/min. as independent predictors of adverse outcome. Conclusion: The short- as well as the long-term prevalence and recurrence of LTAs in TTS patients is high. The long-term mortality rates were similar to the TTS patients presenting without any LTAs. LTAs in TTS could be triggered by a concomitant atrial fibrillation.

Impact and management of left ventricular function on the prognosis of Takotsubo syndrome.

BACKGROUND: Early research has proposed that patients with Takotsubo syndrome (TTS) could have a higher mortality rate than the general population. Our study was conducted to determine the short- and long-term outcome of TTS patients associated with a significantly compromised left ventricular function on hospital admission. MATERIALS AND METHODS: Our institutional database constituted a collective of 112 patients diagnosed with TTS between 2003 and 2015. The patients were classified into two groups based on the left ventricular ejection fraction (LVEF), with those presenting with a LVEF > 35% on admission categorized into one group (n = 65, 58%) and those presenting with LVEF ≤ 35% (n=47, 42%) categorized into another group. The endpoint was the all-cause of mortality over a mean follow-up of 1529 ± 1121 days. RESULTS: Preliminary results indicated that patients with an EF ≤ 35% had a significantly greater risk of developing life-threatening arrhythmias, and were much more likely to suffer from cardiogenic shock. Patients often required varying forms of mechanical respiratory support. The in-hospital mortality, 30-day mortality, 1-year mortality and ongoing long-term mortality was significantly higher in TTS patients with an EF ≤ 35%. In a multivariate Cox regression analysis, an EF ≤ 35% (HR 3·3, 95% CI: 1·2-9·2, P < 0·05) was identified as a strong independent predictor of the primary endpoint. CONCLUSIONS: In-hospital events as well as short- and long-term mortality rates among TTS patients diagnosed with a significantly reduced LVEF on admission were significantly higher. There is an urgent need for randomized trials, which could help define uniform clinical management strategies for high risk TTS patients.

Impact of concomitant atrial fibrillation on the prognosis of Takotsubo cardiomyopathy.

AIMS: Previous studies revealed that patients with Takotsubo cardiomyopathy (TTC) have a higher mortality rate than the general population. Supraventricular tachycardia is a well-known complication of TTC. This study was performed to determine the short- and long-term prognostic impact of atrial fibrillation associated with TTC patients. METHODS AND RESULTS: Our institutional database constituted a collective of 114 patients diagnosed with TTC from 2003 to 2015. The patients were divided into two groups according to the presence (n = 21, 18.4%) or absence (n = 93, 81.5%) of atrial fibrillation. The endpoint was a composite of in-hospital events (thromboembolic events and life-threatening arrhythmias), all-cause mortality, rehospitalization due to heart failure, stroke, and the recurrence of TTC. The in-hospital mortality, 30-day mortality, and long-term mortality were significantly higher in the atrial fibrillation group. Kaplan-Meier analysis indicated a significantly lower event-free survival rate over a mean follow-up of 3 years in the atrial fibrillation group than that in the non-atrial fibrillation group (log-rank, P < 0.01). In a multivariate cox regression analysis, atrial fibrillation (hazard ratio, HR 2.3, 95% confidence interval, CI: 1.1-4.9, P < 0.05) and EF ≤ 35% (HR 2.0, 95% CI: 1.1-3.8, P < 0.05) were the only independent predictors of a primary endpoint. CONCLUSION: Rates of in-hospital events and short- as well as long-term mortality were significantly higher in TTC patients suffering from atrial fibrillation compared with patients without atrial fibrillation.

Comparison and Outcome Analysis of Patients with Takotsubo Cardiomyopathy Triggered by Emotional Stress or Physical Stress.

Background: Previous studies revealed that takotsubo cardiomyopathy (TTC) is triggered by physical and emotional stresses. This study was performed to determine the short- and long-term prognostic impact of emotional- and physical stress associated with TTC. Methods and results: Our institutional database constituted a collective of 84 patients diagnosed with TTC between 2003 and 2015. The patients were divided into two groups as per the presence of emotional stress (n = 24, 21%) or physical stress (n = 60, 52.6%). The endpoint was a composite of in-hospital events (thromboembolic events and life-threatening arrhythmias), myocardial infarction, all-cause of mortality, re-hospitalization due to heart failure, stroke, and recurrence of TTC. A Kaplan-Meier analysis indicated a significantly lower event-free survival rate over a mean follow-up of 5 years in the emotional group than the physical stress group (log-rank, p < 0.01). Multivariate Cox regression analysis revealed only emotional stress (HR 0.4, 95% CI: 0.2-0.9, p < 0.05) as a negative independent predictor of the primary endpoint. Conclusion: Rates of in-hospital events and short- as well as long-term events were significantly lower in TTC patients suffering from emotional stress as compared to patients with physical stress.

Corrigendum: Comparison and Outcome Analysis of Patients with Takotsubo Cardiomyopathy Triggered by Emotional Stress or Physical Stress.

[This corrects the article on p. 527 in vol. 8, PMID: 28496419.].

Age related differences and outcome of patients with Takotsubo syndrome.

BACKGROUND: Takotsubo syndrome (TS) is an important cardiac disease that affects predominantly postmenopausal women. This study was conducted to determine the impact of age on the short- and long-term outcome of TS patients. METHODS & RESULTS: The data from a collective of 114 TS patients with a mean follow-up of 1591 ± 1079 days was retrospectively analysed. The study population was divided into two groups (≤ 65 and > 65 years) so as to evaluate the impact of age on the short- and long-term mortality of TS patients. In-hospital events like life-threatening arrhythmias (14.58% vs. 9.09%; P = 0.036), need for mechanical respiratory support (41.66% vs. 28.78%; P = 0.15) as well as inotropic agent use (22.91% vs. 15.15%; P = 0.29), although not reaching the statistical cut-of, tended to occur more often in the younger group. Heart failure was more common in the elderly age group (P = 0.03). The use of multivariate analysis ruled out age as a significant marker of long term mortality (HR: 1.0; 95% CI: 0.9-1.0; P = 0.60). CONCLUSIONS: Age does not influence the clinical course of TS in terms of the short- as well as long-term outcome. The study revealed a higher incidence of life threatening arrhythmias in the younger patient age-group and a higher incidence of heart failure among the older group of patients.

Incidence and Prognostic Relevance of Cardiopulmonary Failure in Takotsubo Cardiomyopathy.

Recent studies have indicated that patients with takotsubo cardiomyopathy (TTC) have a higher mortality rate than the general population. There is a distinct possibility that TTC could be associated with adverse life-threatening complications like cardiopulmonary failure. Our institutional database constituted a collective of 114 patients diagnosed with TTC. The frequency, determinants and predictors of cardiopulmonary failure were assessed. The patients were subsequently classified into two groups based on the presence (n = 44, 38.6%) or absence (n = 70, 61.4%) of cardiopulmonary failure. Multivariable logistic-regression analysis identified impaired left ventricular function defined as ≤35% at presentation and life-threatening arrhythmia as a positive significant independent predictor of cardiopulmonary failure. A majority of the patients with cardiopulmonary failure were treated with either non-invasive or invasive ventilator support (88%), while 48% of the patients required treatment with catecholamine. The in-hospital mortality rate was greater in the cardiopulmonary failure group. Cardiopulmonary failure patients were at ongoing increased risk of death with a higher mortality at 30-day, 1-year and at 5 years of follow-up. Cardiopulmonary failure is a frequent complication in TTC with an increased short- and long-term mortality. Patient susceptible to this condition could be identified by a reduced ejection fraction and life-threatening arrhythmia.

Characteristics and long-term outcome of right ventricular involvement in Takotsubo cardiomyopathy.

OBJECTIVE: Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy (SCM) resembles a reversible cardiomyopathy that is characterized by localized wall motion abnormalities in the absence of stenotic coronary vascular disease. Patients typically present with apical ballooning of the left ventricle (LV), however the right ventricle (RV) is also affected in up to 50.0% of patients. Long-term prognosis of classical SCM resembles that of patients after ST elevation myocardial infarction. Data on long-term prognosis of biventricular compared to classical SCM is controversial. The aim of this study was therefore to analyze patients with biventricular SCM regarding in-hospital outcome and long-term prognosis. MATERIALS AND METHODS: 114 consecutive patients with SCM were retrospectively analyzed. 88 patients presented with classical SCM, 26 patients (22.8%) were diagnosed with biventricular SCM. Follow-up was conducted for a total of 4.4years. Mean age was 67.1years with 83.3% of patients being female. The primary endpoint was a composite of all-cause mortality, recurrence of SCM and re-hospitalization due to heart failure. RESULTS: Although patients with biventricular SCM presented with a tendency towards an increased rate of cardiogenic shock (30.8% vs. 15.9%; p=0.09) and significantly more usage of inotropic support upon hospital admission (34.6% vs. 13.6%; p=0.01), there was no difference concerning the primary endpoint in both groups (50.0% vs. 44.3%; p=0.31). Furthermore, there was no difference in mortality both in-hospital (7.7% vs. 7.9%; p=0.66) and during long-term follow-up (27.3% vs. 23.1%; p=0.46). CONCLUSION: Patients with biventricular SCM have the same in-hospital and long-term outcome compared to classical SCM.

Clinical and echocardiographic analysis of patients suffering from recurrent takotsubo cardiomyopathy.

BACKGROUND: Recurrence of takotsubo cardiomyopathy (TTC) is a well-known complication. However, current literature lists only a few isolated cases. We aimed to determine the incidence and clinical significance of recurrent TTC. METHODS & RESULTS: Our institutional database constituted a collective of 114 patients diagnosed with TTC since 2003. Close follow-up of these patients revealed a recurrence of TTC in seven of these (6.1%). The time interval between the index event and its recurrence varied between six months and six years. Arterial hypertension was more revealed in the recurrence group of TTC compared to non-recurrence group, (P = 0.02). Chronic obstructive pulmonary disease and/or asthma was more diagnosed in the recurrence group, (P = 0.04). Clinical events like right ventricular involvement, TTC related complications such as life-threatening arrhythmias, pulmonary congestion and in hospital death were observed more frequently in the recurrent episode. Over a mean follow-up of one year the mortality rate was similar in both groups. CONCLUSIONS: Recurrence of TTC within six years after index event is not an uncommon phenomenon. In the event of right ventricular involvement in the relapse phase, it might be associated with a higher complication rate. TTC recurrence should be the first differential diagnosis in patients with a past history of TTC.