The Role of Cardioselective versus Non-Cardioselective Beta-Adrenergic Blockade in the Acute Phase of Takotsubo Cardiomyopathy

Abstract

Background Takotsubo cardiomyopathy (TC) has been associated with hyperactivation of sympathetic nervous system leading to transient left ventricular (LV) dysfunction following acute emotional or physical stress. There are no controlled studies or guidelines on how to treat TC and its therapy remains empirical. We aim to study the effects of cardioselective versus non-cardioselective beta-adrenergic blockade on LV recovery in follow-up transthoracic echocardiographic studies in patients with newly diagnosed TC. Methods We performed retrospective chart review analysis of all patients who were admitted to Bronx-Care Health System from January 1, 2007 through December 31, 2017 with the diagnosis of TC. All cases of TC who presented with acute coronary syndrome and angiogram showing apical ballooning with preserved base of the heart were included. We excluded significant coronary artery disease, prior known cardiomyopathy, suspicion of any myocarditis and recent head trauma or intracranial hemorrhage. Primary outcome variables included improvement in LV end-diastolic and end-systolic volumes, LV ejection fraction as well as degree of LV wall motion abnormalities improvement from the baseline transthoracic echocardiography with use of either cardioselective or non-cardioselective beta-adrenergic antagonists. The secondary outcomes included morbidity and mortality including all-cause and HF readmission in 30 days as well as mortality at 6 and 12 months. Results Of the 2010 patients admitted with acute coronary syndrome and underwent coronary angiogram, 60 patients (2.98%) were found to have TC. The mean age for TC patients was 62 (±16) years with more females (75%) than males. Urine drug screen was positive in 38% of our population and 6% had HIV disease. The average BMI in our study subject was 23.54 KG/M2 which was observed 19.45 KG/M2 in subjects with positive drug screen (p value= 0.0213). Beta-blocker was used in 83% of the cases with 63% were on cardioselective beta-adrenergic blockade and 27% were on non-cardioselective beta-adrenergic blockade. The relationship observed between echocardiographic parameters and type of beta-adrenergic blockade did not differ. The 30-day readmission rate and all-cause mortality were found to be similar in both groups. Positive urine drug screen was not associated with 30-day readmission and all-cause mortality in TC. (p value= 0.262) Conclusions Use of Beta-adrenergic blockers did not show any improvement in echocardiographic parameters in TC. It was not associated with improved adverse outcomes such as 30-day readmission rate and all-cause mortality in TC. The study challenges the proposed role of beta-blockers in improving outcomes in patients with TC.