Abstract
AimWhether Takotsubo syndrome (TTS) should be classified within myocardial infarction with non-obstructive coronary arteries (MINOCAs) is still controversial. The aim of this work was to evaluate the main differences between TTS and non-TTS MINOCAs.Methods and ResultsA cohort study based on two prospective registries: TTS from the RETAKO registry (N:1,015) and patients with non-TTS MINOCAs from contemporary records of acute myocardial infarction from five 5 national centers (N:1,080). Definitions and management recommended by the ESC were used. Survival analysis was based on the Cox regression analysis; propensity score matching (PS) was created to adjust prognostic variables. Takotsubo syndrome were more often women (85.9 vs. 51.9%; p < 0.001) and older (69.4 ± 12.5 vs. 64.5 ± 14.1 years; p < 0.001). Atrial fibrillation (AF) was more frequent in non-TTS MINOCAs (10.4 vs. 14.4%; p = 0.007). Psychiatric disorders were more prevalent in TTS (15.5 vs. 10.2%, p < 0.001). In-hospital mortality and complications were higher in TTS: 3.4 vs. 1.8%, (p = 0.015), and 25.8 vs. 11.5%, (p < 0.001). Global mortality before PS matching was 16.1% in non-TTS MINOCAs and 8.1% in TTS. Median follow-up was 32.4 months; after PS matching, TTS had fewer major adverse cardiovascular events (MACEs): hazard ratio (HR) 0.59; 95% CI 0.42–0.83. There were no differences in global mortality (HR 0.87; CI: 0.64–1.19), but TTS had lower cardiovascular mortality (HR 0.58; CI: 0.35–0.98).ConclusionCompared to the rest of MINOCAs, TTS presents a different patient profile and a more aggressive acute phase. However, its long-term cardiovascular prognosis is better. These results support that TTS should be considered a separate entity with unique characteristics and prognosis.
Highlights
Retrospective study of two cohorts based on prospective registries of patients with Takotsubo syndrome (TTS) and acute myocardial infarction (AMI), respectively, with the objective of comparing a TTS with a non-TTS myocardial infarction with nonobstructive coronary arteries (MINOCAs) cohort
Its rationale and design have been previously described [14], and in summary, it prospectively includes all consecutive patients with TTS who fulfill the modified Mayo Clinic diagnostic criteria [13]: (a) transient left ventricular dysfunction with apical, midventricular or basal segmental alterations extending beyond the territory supplied by a single coronary artery; (b) absence of significant obstructive coronary artery disease or angiographic evidence of a complicated atheroma plaque; (c) new electrocardiogram (EKG) changes (ST-segment elevation and/or negative T-waves) or moderate elevation of cardiac troponins; (d) absence of myocarditis or pheochromocytoma [13, 14]
Patients with TTS, as compared with non-TTS MINOCAs, were more frequently women (p < 0.001), older (69.4 ± 12.5 vs. 64.5 ± 14.1; p < 0.001), with a higher prevalence of hypertension and no significant differences regarding the rest of cardiovascular risk factors
Summary
To minimize errors caused by this inevitable fact, many classifications have been developed to treat diseases as precisely as possible [1]. Scientific societies have developed guidelines to act as a consensus to standardize best clinical practice [3]. Guidelines must be clear so that physicians can offer patients the best care available. Despite having its chapter in guidelines, myocardial infarction with nonobstructive coronary arteries (MINOCAs) remains an unclear subject [4–9]. Many physiopathological mechanisms are underlying the blurred concept of MINOCAs. Second, MINOCAs being a “working diagnosis” [4] leads to the paradox that the same disease could be a MINOCAs or not depending on the time of diagnosis
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