Takotsubo Patients Research Articles

Regional mechanical dyssynchrony and shortened systole are present in people with Takotsubo syndrome

Background:Takotsubo syndrome is characterized by transient regional systolic dysfunction, left ventricular (LV) dilatation, and edema, often occurring without obstructive coronary artery disease. The mechanisms underlying this stress-induced condition, especially the role of mechanical dyssynchrony in affecting systolic function, remain poorly understood.Methods:In our study, we evaluated global LV function and mechanical dyssynchrony in 24 Takotsubo patients compared to 20 controls by analyzing pressure-volume loops and time-varying elastance. Additionally, we monitored changes in LV segmental volume and internal flow.Results:Here we show a significant reduction in global myocardial contractility and pronounced mechanical dyssynchrony in Takotsubo syndrome, particularly in the mid and apical LV segments, without disturbances in electrical conduction.Conclusions:Our findings reveal substantial mechanical dyssynchrony in Takotsubo patients, characterized by increased internal flow and a shortened systolic ejection time. This indicates a mechanical basis for the inefficient LV function in Takotsubo syndrome, independent of electrical conduction abnormalities.

Clinical characteristics and risk factors of in-hospital mortality in patients with Takotsubo syndrome

Takotsubo cardiomyopathy is a condition of transient systolic dysfunction triggered by emotional or physical stress. Nowadays, Takotsubo cardiomyopathy is gaining attention and has been detected more frequently. However, there is no collected data on Vietnamese subjects. This study aims to describe the clinical characteristics of patients diagnosed with Takotsubo cardiomyopathy and determine of rates and independent risk factors for in-hospital mortality. A retrospective andobservational study was conducted at the University Medical Center Ho Chi Minh City, involved 103 patients diagnosed with Takotsubo cardiomyopathy between January 2015 and June 2022. The diagnosis was made based on the revised Mayo Clinic diagnostic criteria. The average age of the study population was 71.2±15.3 years, with females accounting for 64.1% of the patients. The most common comorbidities among the patients were hypertension (57.3%), diabetes mellitus (30.1%), ischemic heart disease (15.5%), and chronic obstructive pulmonary disease (15.5%). Acute heart failure was observed in 30.1% of the patients, while ventricular arrhythmias were present in 17.6% of cases. The majority of triggers were attributed to physical factors, including infection (37.9%), respiratory failure (18.4%), postoperative status (3.9%), and acute neurological disease (2.9%). The in-hospital mortality rate was 17.5%, and the independent risk factors were identified as acute heart failure (OR=20.657, 95%CI 2.306–185.008, p=0.007) and respiratory failure (OR=10.397, 95% CI 1.117–96.795, p=0.040). Takotsubo cardiomyopathy patients have many comorbidities and are often triggered by physical factors. The in-hospital mortality rate is significant, with acute heart failure and respiratory failure identified as independent risk factors.

Clinical characteristics and risk factors of in-hospital mortality in patients with Takotsubo syndrome

Takotsubo cardiomyopathy is a condition of transient systolic dysfunction triggered by emotional or physical stress. Nowadays, Takotsubo cardiomyopathy is gaining attention and has been detected more frequently. However, there is no collected data on Vietnamese subjects. This study aims to describe the clinical characteristics of patients diagnosed with Takotsubo cardiomyopathy and determine of rates and independent risk factors for in-hospital mortality. A retrospective andobservational study was conducted at the University Medical Center Ho Chi Minh City, involved 103 patients diagnosed with Takotsubo cardiomyopathy between January 2015 and June 2022. The diagnosis was made based on the revised Mayo Clinic diagnostic criteria. The average age of the study population was 71.2±15.3 years, with females accounting for 64.1% of the patients. The most common comorbidities among the patients were hypertension (57.3%), diabetes mellitus (30.1%), ischemic heart disease (15.5%), and chronic obstructive pulmonary disease (15.5%). Acute heart failure was observed in 30.1% of the patients, while ventricular arrhythmias were present in 17.6% of cases. The majority of triggers were attributed to physical factors, including infection (37.9%), respiratory failure (18.4%), postoperative status (3.9%), and acute neurological disease (2.9%). The in-hospital mortality rate was 17.5%, and the independent risk factors were identified as acute heart failure (OR=20.657, 95%CI 2.306–185.008, p=0.007) and respiratory failure (OR=10.397, 95% CI 1.117–96.795, p=0.040). Takotsubo cardiomyopathy patients have many comorbidities and are often triggered by physical factors. The in-hospital mortality rate is significant, with acute heart failure and respiratory failure identified as independent risk factors.

Abstract 12000: Prolonged Arterial Phase is Caused of the Chest Pain in Takotsubo Cardiomyopathy A Dynamics Angiography and Artificial Intelligence Analysis

Introduction: Takotsubo Cardiomyopathy (TCM) known as “Broken Heart Syndrome” is triggered by extreme emotional or physical stress. The typical TCM patient features chest pain, ST elevation, elevated troponin, reduced ejection fraction (EF), patent coronary artery, and apical ballooning. Hypothesis: Could abnormal coronary flow explain chest pain in Takotsubo patients? Methods: The patient with severe chest pain, elevated troponin, ST change, patent coronary arteries, and apical ballooning underwent angiography and review with a new dynamic recording technique. Ten patients without ACS, normal EF, and no coronary artery disease served as control. At first, the angiographic recording started when the contrast was injected into the coronary artery. Then the recording continued with the blood in white color moving in until all contrast disappeared from the arteries. The angiogram was recorded at 15 images per second. The review of coronary images focused on the blood flow in white on top of a background of black contrast. The arterial phase (AP) calculation began when the blood moved in and ended when all the contrast was flushed out of the distal arterial vasculature. The two-layer artificial intelligence program was built based on U-net and Densenet-121. The first layer, with a segmentation model and Convolutional neural network is responsible for detecting the starting frame of AP with a full index of contrast. The second layer with a segmentation model will detect the ending frame of AP. All TCM patient was followed up in one year. Results: Fifteen TCM patients met the criteria (12/15 female). The AP in the TCM group was 3.17 +/- 0.53 seconds compared with 1.62 +/- 0.26 seconds in the control group (P<0.001). The TCM group had a mean EF 33.9 +/- 7.6 %, and all recovered to 58.8 +/- 12.6 % after two weeks. At one year follow-up, all patients had no chest pain and no re-admission, except for one case of non-cardiovascular mortality associated with septic shock from pneumonia 3 months after the index event. Conclusions: Chest pain in TCM was caused by slow flow (measured as prolonged arterial phase) which was detrimental to myocardial contraction. Their prognosis was benign because all patients recovered.

Abstract 17372: Cardiac Magnetic Resonance in Takotsubo Disease: Impact on Outcomes and Resource Utilization

Introduction: Takotsubo cardiomyopathy (CM), characterized by transient left ventricular dysfunction, presents diagnostic and management challenges. The utility of cardiac magnetic resonance (CMR) in Takotsubo CM is uncertain. We investigate CMR's impact on outcomes and resource utilization in Takotsubo CM. Methods: A retrospective analysis was conducted with TriNetX. Two cohorts with Takotsubo CM, with and without CMR within 1 month of diagnosis, were matched for lipidemias, hypertension, diabetes, sarcoidosis, and heart diseases (n=1,422 per cohort), Risks assessed 30-day, 1- and 5-year outcomes, resource utilization, and medication/procedure usage. Results: The CMR group had 3.9% (1.5% vs 5.4%, p=0.000) lower risk of mortality within 30 days and 2.6% (4.6% vs 7.2%, p=0.003) lower risk between 1 and 5 years. Hospitalization rates were similar, while complication risks (cardiomyopathy, heart failure) were higher in the CMR group at 1 and 5 years. The CMR group had higher utilization of GDMT, with similar usage for some treatments. Risk of pacemaker or implantable defibrillator usage were 4.9% higher within 30 days (5.8% vs 0.8%, p=0.000) and 5.8% higher within 1 year (8.2% vs 2.5% p=0.000) in the CMR group. Conclusions: Takotsubo patients undergoing CMR exhibited increased risk of concomitant diagnoses of CM/heart failure/pericarditis, received treatments earlier in the disease course, and experienced lower risk of mortality. These results support utilization of CMR as a routine diagnostic imaging modality in patients with suspected Takotsubo CM for comprehensive evaluation to guide treatment decisions and improve patient prognosis.

Takotsubo syndrome and stroke risk: A nationwide register-based study

AimsPrevious small-scale studies have indicated a short-term stroke incidence of 1.0–1.3% following Takotsubo (syndrome). In this nationwide register-based study, we investigated the 90-day risk of ischemic stroke (IS) or transient ischemia attack (TIA) and mortality of patients with Takotsubo. Methods and resultsPatients with incident Takotsubo between January 1st 2009 to September 30th 2018 were identified from Danish nationwide registries. Takotsubo patients were age- and sex-matched with background-, atrial fibrillation/flutter- (AF) and myocardial infarction (MI) cohorts. Cumulative incidences and Cox proportional-hazard regression models were used to analyze the following outcomes: 1) composite of IS/TIA and 2) all-cause mortality. A total of 890 patients with Takotsubo were followed for 90 days. The cumulative 90-day incidence of IS/TIA in the Takotsubo-, background-, AF- and MI cohort, was 2.1% (n = 19), 0.1% (n = 4), 1.1% (n = 47) and 1.5% (n = 66), respectively. The cumulative 90-day mortality in the Takotsubo-, background-, AF- and MI cohort was 5.1% (n = 45), 0.3% (n = 13), 1.7% (n = 75) and 5.6% (n = 230), respectively.The adjusted hazard ratio (HR) for 90-day IS/TIA was when compared to the background-, AF- and MI cohort, 26.43 (95% CI: 8.82–79.24), 1.91 (95% CI: 1.09–3.35) and 2.06 (95% CI: 1.12–3.79), respectively. The adjusted HR for 90-day mortality was when compared to the background-, AF- and MI cohort, 14.19 (95% CI: 7.43–27.09), 0.73 (95% CI: 0.52–1.02) and 1.96 (95% CI: 1.25–3.07), respectively. ConclusionPatients with Takotsubo had an increased 90-day hazard for IS/TIA when compared to age- and sex-matched background-, AF- and MI cohorts.

Hemostatic system in Takotsubo patients at long-term follow-up: A hidden activation?

BackgroundTakotsubo cardiomyopathy (TTS) has long been considered a benign condition, despite recurrent events and long-term adverse outcomes are often reported. Endothelial damage, blood hyperviscosity, and platelet activation described in acute phase persist in long-term follow-up; however, TTS pathophysiology is still not fully understood. Here, we explored the hemostatic system at a median of 3.1 years after TTS to uncover additional long-lasting changes in these patients. MethodsWe assessed hemostatic parameters in women with TTS (n = 23) or coronary artery disease (CAD; n = 31) and in control women (n = 26) age-matched, by thromboelastographic analysis, prothrombin time (PT) and partial thromboplastin time (aPTT) coagulation assays and microparticle exposing Tissue Factor (MP-TF). Functional fibrinogen and fibrin polymerization were analyzed by Clauss method and spectrophotometry, respectively. Platelet reactivity was evaluated by light transmission aggregometry, whereas plasminogen activator inhibitor-1 (PAI-1) and brain-derived neurotrophic factor (BDNF) were measured by ELISA kit. ResultsCompared with control subjects, TTS patients exhibit an accelerated clot formation, higher percentage of fibrin polymerization and higher PAI-1 levels. Compared with CAD, TTS patients showed sustained residual platelet activation but decreased functional fibrinogen, fibrin polymerization and MP-TF levels, prolonged aPTT and a marked BDNF increase. ConclusionsThe long-term activation of hemostatic system observed in TTS patients compared to control subjects suggests a persistent humoral abnormality that may be related to the propensity for TTS recurrence. The higher residual platelet activity observed in TTS than in CAD patients invites investigation on TTS-tailored antiplatelet therapy potentially needed to prevent TTS adverse outcomes.

Structural and Functional Brain Changes in Acute Takotsubo Syndrome

BackgroundTakotsubo syndrome mimics an acute myocardial infarction, typically in the aftermath of mental or physical stress. ObjectivesThe mechanism by which emotional processing in the context of stress leads to significant cardiac injury is poorly understood, so a full exploration of brain structure and function in takotsubo syndrome patients merits investigation. MethodsTwenty-five acute (<5 days) takotsubo patients and 25 control subjects were recruited into this observational cross-sectional study. Surface-based morphometry was carried out on magnetic resonance imaging (MRI) brain scans to extract cortical morphology based on volume, thickness, and surface area with the use of Freesurfer. Cortical morphology general linear models were corrected for age, sex, photoperiod, and total brain volume. Resting-state functional MRI and diffusion tensor tractography images were preprocessed and analyzed with the use of the Functional Magnetic Resonance Imaging of the Brain Diffusion Toolbox and Functional Connectivity Toolbox. ResultsThere was significantly smaller total white matter and subcortical gray matter volumes in takotsubo (P < 0.001), with smaller total brain surface area but increased total cortical thickness (both P < 0.001). Individual gray matter regions (hippocampus and others) were significantly smaller in takotsubo (P < 0.001); only thalamus and insula were larger (P < 0.001). There was significant hyperfunctional and hypofunctional connectivity in multiple areas, including thalamus-amygdala-insula and basal ganglia (P < 0.05). All structural tractography connections were increased in takotsubo (P < 0.05). ConclusionsThe authors showed smaller gray and white matter volumes driven by smaller cortical surface area, but increased cortical thickness and structural tractography connections with bidirectional changes in functional connectivity linked to emotion, language, reasoning, perception, and autonomic control. These are interventional targets in takotsubo patients’ rehabilitation.

Hemostatic System in Takotsubo Patients at Long-Term Follow-Up: A Hidden Activation?

Hemostatic System in Takotsubo Patients at Long-Term Follow-Up: A Hidden Activation?

Renin-angiotensin and endothelin systems in patients post takotsubo syndrome

Abstract Background We investigate if renin-angiotensin and endothelin-1 response pathways follow the same pattern of recovery as left ventricular ejection fraction in patients with takotsubo syndrome. Purpose To provide better insight into the pathophysiology underlying this condition. Methods Ninety takotsubo syndrome patients [n=30 in each of “acute”, “convalescent” (3–5 months) and “recovered” (&amp;gt;1 year) groups] who were on minimal or no medication and were free of any significant cardiac/metabolic co-morbidities, and 30 healthy controls were studied. Serum concentrations of renin, angiotensin converting enzyme, angiotensin II, big endothelin-1, endothelin-1 were measured using commercially available ELISA, and BNP was measured using an immunoassay. Results Left ventricular ejection fraction was 38±1.6% in acute, 63±2.0% in convalescent and 64±2.6% in recovered takotsubo syndrome patients. As shown in Figure 1, serum renin concentrations are persistently elevated after a takotsubo episode (p=0.03 vs controls). Angiotensin converting enzyme levels are significantly depressed during the acute phase compared to convalescent (p=0.004), recovered takotsubo (p=0.02) or controls (p=0.03). Angiotensin II is increased in takotsubo patients (p&amp;lt;0.001 vs controls) remaining persistently elevated long-term in the recovered group (p=0.03 vs controls). B-type natriuretic peptide concentrations remain elevated after a Takotsubo episode compared to controls (p=0.003). Big endothelin-1 levels are unchanged, but endothelin-1 is significantly lower after takotsubo syndrome compared to controls (p=0.03). Conclusions Despite “normalisation” of the left ventricular ejection fraction, there is long-term maladaptive activation of renin-angiotensin system in takotsubo syndrome patients. This suggests therapy aimed at modulating this pathway may be beneficial in the long-term. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): British Heart Foundation

Distinctive characteristics among MINOCA and Takotsubo patients and their prognostic value in a multicenter prospective cohort

Abstract Background/Introduction In the acute care setting, the working diagnosis of MINOCA exhibits increasing recognition and includes a broad spectrum of conditions, most of them yet not adequately understood. TakoTsubo syndrome (TTS) represents a significant proportion of such cases and despite its predominance on female gender as well as its imaging characteristics on the typical apical form it is not easily distinguishable from other MINOCA causes without the contribution of cardiac magnetic resonance (CMR). Purpose The aim of our study is to investigate for distinctive characteristics related to the index event among MINOCA cases from a multi-center prospective cohort with a mean follow up period of 18 months. Methods We divided our study population (n=74) into TTS (n=30) and non-TTS (n=44) according to multimodality imaging results. Information regarding the index event (Sep 2019-Feb 2021) were retracted from the medical notes. Results CMR results led to a post-discharge diagnosis reconsideration in 12 cases (16.2%). Female gender (n=29; 96.7% vs n=22; 50%, P&amp;lt;0.001), older age (mean age 66±11 vs 59±11, P=0.04) and history of hypertension (n=21; 70% vs n=19; 44.3%, p=0.035) were more frequent in TTS group. There was no statistically significant difference in body mass index, baseline renal function, history of dyslipidemia, diabetes and smoking between the two groups. During the index event, peak troponin levels 576 pg/ml (IQR: 184–9915) vs 767 pg/ml (IQR: 47–47000), P=0.005], were lower in the TTS group, whereas NSTEMI presentation was the commonest among all patients. Angina was the dominant symptom for both groups. However, severe angina expressed as more than 2 episodes within 24 hours was more frequent among the TTS population (n=19; 65.5% vs n=10; 22.7%, P=0.001). TTS probability assessed with the INTERTAK score was higher among the TTS group (68±10 vs 38±21, P&amp;lt;0.001). In hospital major cardiovascular events incidence was higher in the non-TTS group (n=2 vs n=11, P=0.06). Multivariate analysis revealed that the presence of severe angina (OR, 8.118, 95% CI: 1.173–56.157, P=0.038) is highly predictive of TTS in the acute care setting even independently of INTERTAK probability. Conclusions These preliminary results indicate that the presence of several anginal attacks may strengthen the predictive value of the INTERTAK score during MINOCA evaluation in the acute setting. Confirmation in a larger population is warranted. Funding Acknowledgement Type of funding sources: None.

Atypical Presentation of Takotsubo Cardiomyopathy in an Elderly Woman

We describe an 83-year-old woman who presented to the emergency department with extreme thirst. Diagnostic testing revealed Takotsubo cardiomyopathy. Following symptomatic improvement and discharge, she returned to the emergency department with exudative pericardial effusion and elevated intrapericardial pressures. This case illustrates the importance of close follow-up of Takotsubo patients in whom complications such as pericardial effusion may lead to cardiac tamponade and hemodynamic instability if not managed properly.

Psychological Characteristics of Patients with Takotsubo Syndrome and Patients with Acute Coronary Syndrome: An Explorative Study toward a Better Personalized Care.

During an acute cardiac event, Takotsubo Syndrome (TTS) and Acute Coronary Syndrome (ACS) apparently share very similar clinical characteristics. Since only a few inconsistent studies have evaluated the psychological features that characterize these different patients, the aim of the present explorative research was to investigate if post-recovery TTS and ACS patients present different psychological profiles. We also investigated whether the occurrence of acute psychological stressful episodes that had occurred prior to the cardiac event could be found in either syndrome. Twenty TTS and twenty ACS female patients were recruited. All patients completed self-report questionnaires about anxiety and depressive symptoms, perceived stress, type-D personality and post-traumatic symptoms. Results showed that only three subscales of health anxiety (i.e., Fear of Death/Diseases, Interference and Reassurance) significantly differed between the two groups, while no differences were found in the other psychological measurements. Moreover, personality traits seem to not be associated with the impact of the cardiac traumatic event. Finally, only TTS patients reported the presence of a significant emotional trigger preceding the acute cardiac event. In conclusion, post-recovery TTS patients differ from ACS patients in their level of concern about their health and in their need of reassurance and information only, probably as a result of the different clinical characteristics of the two illnesses.

A Pilot Study on the 1H-NMR Serum Metabolic Profile of Takotsubo Patients Reveals Systemic Response to Oxidative Stress

Takotsubo syndrome (TTS) presents as an acute coronary syndrome characterized by severe left ventricular (LV) dysfunction and non-obstructive coronary artery disease that typically shows spontaneous recovery within days or weeks. The mechanisms behind TTS are mainly related to beta-adrenergic overstimulation and acute endogenous catecholamine surge, both of which could increase oxidative status that may induce further deterioration of cardiac function. Although several studies reported evidence of inflammation and oxidative stress overload in myocardial tissue of TTS models, systemic biochemical evidence of augmented oxidant activity in patients with TTS is lacking. In this study, serum samples of ten TTS patients and ten controls have been analyzed using 1H-NMR spectroscopy. The results of this pilot study show a marked alteration in the systemic metabolic profile of TTS patients, mainly characterized by significant elevation of ketone bodies, 2-hydroxybutyrate, acetyl-L-carnitine, and glutamate levels, in contrast with a decrease of several amino acid levels. The overall metabolic fingerprint reflects a systemic response to oxidative stress caused by the stressor that triggered the syndrome’s onset.

Long-term outcome in patients with Takotsubo syndrome: a single-center study from a city in Austria

Abstract Background There is an increasing amount of evidence suggesting multiple fatal complications in Takotsubo Syndrome. However, findings on the long-term outcome are scarce and show inconsistent evidence. Methods This is a single-center study of long-term prognosis in Takotsubo patients admitted from September 2006 to August 2019. We investigated the clinical features, prognostic factors and outcome of patients with Takotsubo syndrome. Furthermore, survivors and non-survivors and patients with a different cause of death were compared. Results Overall, 147 patients were included in the study. The mean age was 70 years (±12,3), and 85% of the study population were women. Forty-nine Takotsubo patients (33,3%) died during the follow-up, with a median of 126 months. The most common cause of death was a non-cardiac cause (71,4% of all deaths), especially malignancies (26,5% of all deaths). Moreover, non-survivors were older and more often men with more comorbidities (chronic kidney disease, malignancy). Patients who died because of cardiovascular disease were older and more often women than patients who died due to non-cardiovascular cause. Age showed to be the only independent prognostic factor of cardiovascular mortality (HR=1,11, CI: 0,99–1,25, p=0,05). Female gender (HR=0,32, CI: 0,16–0,64, p&amp;lt;0,001), cancer (HR=2,35, CI: 1,15–4,8, p=0,019) and chronic kidney disease (HR=2,61, CI: 1,11–6,14, p=0,028) showed to be independent predictors of non-cardiovascular mortality. Conclusion Long-term prognosis of TTS patients is not favourable, mainly due to non-cardiac comorbidities. Hence, consequent outpatient care in relatively short time intervals after TTS event based on risk factor control and early detection of malignancies seems mandatory. Funding Acknowledgement Type of funding sources: None.

Atrial Strain by Feature-Tracking Cardiac Magnetic Resonance Imaging in Takotsubo Cardiomyopathy. Features, Feasibility, and Reproducibility.

The purpose of this study was to investigate whether there may be a bi-atrial dysfunction in Takotsubo syndrome (TS) during the transient course of the disease, using cardiac magnetic resonance imaging feature tracking (CMR-FT) in analyzing bi-atrial strain. Eighteen TS patients and 13 healthy controls were studied. Reservoir, conduit, and booster bi-atrial functions were analyzed by CMR-FT. The correlation between LA and RA strain parameters was assessed. Intra- and inter-observer reproducibility was evaluated for all strain and strain rate (SR) parameters using intraclass correlation coefficients (ICCs) and Bland-Altman analysis. Atrial strain were feasible in all patients and controls. Takotsubo patients showed an impaired LA Reservoir strain (∊s), LA Reservoir strain rate (SRs), LA and RA Conduit strain(∊e), LA and RA conduit strain rate (SRe) in comparison with controls (P < 0.001 for all of them), while no differences were found as to LA and RA booster deformation parameters (∊a and SRa). Analysis of correlation showed that LA ∊s, SRs, ∊e, and SRe were positively correlated with corresponding RA strain measurements (P < 0.001, r = 0.61 and P = 0,03, r = 0,54, respectively). Reproducibility was good to excellent for all atrial strain and strain rate parameters (ICCs ranging from 0,50 to 0,96). Atrial strain analysis using CMR-FT may be a useful tool to reveal new pathophysiological insights in Takotsubo cardiomyopathy. Additional studies, with a larger number of patients, are needed to confirm the possible role of these advanced CMR tools in characterizing TS patients.

The Value of Fetuin-A as a Predictor to Identify Takotsubo Patients at Risk of Cardiovascular Events.

Introduction: Takotsubo cardiomyopathy (TTC) remains a life-threatening disease with the risk of decompensated heart failure and arrhythmias. Valid markers for the prediction of outcome are unavailable. The novel biomarkers fetuin-A, matrix metalloproteinases-2 (MMP-2), myeloperoxidase (MPO), Syndecan-1 and CD40-L show promising results for risk stratification of cardiovascular patients. Nevertheless, clinical implementation has not been investigated in TTC patients. Methods: To investigate this issue, we evaluated clinical complications in 51 patients hospitalized for TTC and measured the serum levels of fetuin-A, MPO, MMP-2, Syndecan-1 and CD40-L within 24 h after admission. Results: Serum levels of Fetuin-A correlated inversely with the risk of cardiac decompensation and all cause complications within the acute phase of TTC. Fetuin-A levels over 190.1 µg/mL (AUC: 0.738, sensitivity 87.5%, specificity: 52.6%) indicate an acute phase of TTC without cardiac decompensation. Despite lower fetuin-A levels in patients with all cause complications, the combined endpoint remained slightly unmet (p = 0.058, AUC: 0.655). Patients with fetuin-A levels over 213.3 µg/mL are at risk of experiencing hemodynamic relevant rhythm disorders (AUC: 0.794; sensitivity: 75.0%, specificity: 79.1%). Other biomarkers failed to reveal a prognostic impact. Pro-BNP and hs troponin levels at admission did not predict adverse cardiac events. Conclusion: Fetuin-A is a promising marker in our study and could be of benefit for the prediction of short-term adverse cardiac events in TTC patients. Therefore, fetuin-A might be of value to evaluate an individual’s risk for complications within the acute phase of TTC and to individually choose the time of intensive care and hospitalization.

Short- and Long-Term Clinical Outcomes for Patients With Takotsubo Syndrome and Patients With Myocardial Infarction: A Report From the Swedish Coronary Angiography and Angioplasty Registry.

BackgroundTakotsubo syndrome (TS) is a potentially life‐threatening acute cardiac syndrome with a clinical presentation similar to myocardial infarction and for which the natural history, management, and outcome remain incompletely understood. Our aim was to assess the relative short‐term mortality risk of TS, ST‐segment–elevation myocardial infarction (STEMI), and non‐STEMI (NSTEMI) and to identify predictors of in‐hospital complications and poor prognosis in patients with TS.Methods and ResultsThis is an observational cohort study based on the data from the SCAAR (Swedish Coronary Angiography and Angioplasty Registry). We included all patients (n=117 720) who underwent coronary angiography in Sweden attributed to TS (N=2898 [2.5%]), STEMI (N=48 493 [41.2%]), or NSTEMI (N=66 329 [56.3%]) between January 2009 and February 2018. We compared patients with TS to those with NSTEMI or STEMI. The primary end point was all‐cause mortality at 30 days. Secondary outcomes were acute heart failure (Killip Class ≥2) and cardiogenic shock (Killip Class 4) at the time of angiography. Patients with TS were more often women compared with patients with STEMI or NSTEMI. TS was associated with unadjusted and adjusted 30‐day mortality risks lower than STEMI (adjusted hazard ratio [adjHR], 0.60; 95% CI, 0.48–0.76; P<0.001), but higher than NSTEMI (adjHR, 2.70; 95% CI, 2.14–3.41; P<0.001). Compared with STEMI, TS was associated with a similar risk of acute heart failure (adjHR, 1.26; 95% CI, 0.91–1.76; P=0.16) but a lower risk of cardiogenic shock (adjHR, 0.55; 95% CI, 0.34–0.89; P=0.02). The relative 30‐day mortality risk for TS versus STEMI and NSTEMI was higher for smokers than nonsmokers (adjusted P interaction STEMI=0.01 and P interaction NSTEMI=0.01).ConclusionsThe 30‐day mortality rate in TS was higher than in NSTEMI but lower than STEMI despite a similar risk of acute heart failure in TS and STEMI. Among patients with TS, smoking was an independent predictor of mortality.

Long-term outcome in patients with takotsubo syndrome : Asingle center study from Vienna.

There is an increasing amount of evidence suggesting multiple fatal complications in takotsubo syndrome; however, findings on the long-term outcome are scarce and show inconsistent evidence. This is asingle center study of long-term prognosis in takotsubo patients admitted to the Klinik Ottakring, Vienna, Austria, from September 2006 to August 2019. We investigated the clinical features, prognostic factors and outcome of patients with takotsubo syndrome. Furthermore, survivors and non-survivors and patients with adifferent cause of death were compared. Overall, 147 patients were included in the study and 49 takotsubo patients (33.3%) died during the follow-up, with amedian of 126 months. The most common cause of death was anon-cardiac cause (71.4% of all deaths), especially malignancies (26.5% of all deaths). Moreover, non-survivors were older and more often men with more comorbidities (chronic kidney disease, malignancy). Patients who died because of cardiovascular disease were older and more often women than patients who died due to non-cardiovascular cause. Adjusted analysis showed no feature of an independent predictor of cardiovascular mortality for takotsubo patients. Female gender (HR = 0.32, CI: 0.16-0.64, p < 0.001), cancer (HR = 2.35, CI: 1.15-4.8, p = 0.019) and chronic kidney disease (HR = 2.61, CI: 1.11-6.14, p = 0.028) showed to be independent predictors of non-cardiovascular mortality. Long-term prognosis of takotsubo patients is not favorable, mainly due to noncardiac comorbidities. Hence, consequent outpatient care in regular intervals after a takotsubo event based on risk factor control and early detection of malignancies seems justified.

Serum Metabolomic Analysis Suggests Impairment of Myocardial Energy Production in Takotsubo Syndrome.

Introduction: Takotsubo syndrome is a complex entity that, although it usually has a good prognosis, can be life threatening. While recent advances have improved the knowledge of takotsubo syndrome, many aspects of its etiology still remain uncertain. Metabolomics, a hypothesis generating approach, could provide novel pathophysiology information about this disease. Methods and Results: Serum samples were obtained from takotsubo (n = 19) and acute myocardial infarction patients (n = 8) at the cath lab and, in the case of takotsubo, again once the patient had recovered, 3 months after the main event. 1H NMR spectra of the serum were acquired at 9.4T using a CPMG pulse sequence (32 ms effective delay). Supervised and unsupervised pattern recognition approaches where applied to the data. Pattern recognition was able to differentiate between takotsubo and acute myocardial infarction during the acute phase with 95% accuracy. Myocardial infarction patients showed an increase in lipid signals, a known risk factor for the disease while takotsubo patients showed a relative increase in acetate that could suggest a reduced turnover of the Krebs cycle. When comparing acute and recovered phases, we could detect an increase in alanine and creatine once patients recovered. Conclusions: Our results demonstrate that takotsubo syndrome is metabolically different than AMI, showing limited myocardial energy production capacity during the acute phase. We achieved high classification success against AMI; however, this study should be considered as a proof of concept regarding clinical application of metabolic profiling in takotsubo cardiomyopathy.