Long term sequelae of takotsubo cardiomyopathy

Long term sequelae of takotsubo cardiomyopathy

Long term sequelae of takotsubo cardiomyopathy: Generally everyone thinks of takotsubo cardiomyopathy (stress cardiomyopathy or broken heart syndrome) as a cause of reversible left ventricular dysfunction in response to a major lifetime stress. Initial reports which caught attention were in elderly women who had lost their spouses and hence the term broken heart syndrome. As it involved the apical segments of the left ventricle, not conforming to any single vascular territory, another eponym was apical ballooning syndrome.

Recent work has questioned the complete reversal of cardiac pathology in this condition [1,2,3], though left ventricular ejection fraction rapidly returns to normal. They have noted long term mortality comparable to that of myocardial infarction. Hence Caroline Scally and colleagues [4] studied the long term functional and metabolic changes after stress cardiomyopathy. Thirty seven of their patients who had stress cardiomyopathy one year or more earlier completed the Minnesota Living with Heart Failure Questionnaire. They also underwent detailed clinical evaluation, biomarker estimation, echocardiography, cardiac magnetic resonance imaging and ³¹P magnetic resonance spectroscopy. They demonstrated long lasting symptomatic and functional impairment in cardiac status after takotsubo cardiomyopathy even though left ventricular ejection fraction improved. This would suggest persistent long term subclinical cardiac dysfunction.

Pelliccia F et al studied the predictors of long term prognosis in a meta analysis [5].  They included 54 studies with a total of 4,679 patients of which 4,077 were females and 602 were males. They found that older age, presence of a physical stressor, and atypical ballooning were the predictors of unfavorable long term outcome. There were 104 recurrences, indicating an annual recurrence rate of 1%. Annual mortality total rate was 3.5%. Of the 4567 patients who survived the index admission, 103 died of cardiac causes and 351 died of non cardiac causes, over a mean follow up period of 28 months. There were 112 deaths (2.4%) during admission. Prognosis was poorer in secondary takotsubo cardiomyopathy with a physical stressor compared to primary takotsubo cardiomyopathy with an emotional stressor.

References

1. Templin C, Ghadri JR, Diekmann J, Napp LC, Bataiosu DR, Jaguszewski M, Cammann VL, Sarcon A, Geyer V, Neumann CA, Seifert B, Hellermann J, Schwyzer M, Eisenhardt K, Jenewein J, Franke J, Katus HA, Burgdorf C, Schunkert H, Moeller C, Thiele H, Bauersachs J, Tschöpe C, Schultheiss HP, Laney CA, Rajan L, Michels G, Pfister R, Ukena C, Böhm M, Erbel R, Cuneo A, Kuck KH, Jacobshagen C, Hasenfuss G, Karakas M, Koenig W, Rottbauer W, Said SM, Braun-Dullaeus RC, Cuculi F, Banning A, Fischer TA, Vasankari T, Airaksinen KE, Fijalkowski M, Rynkiewicz A, Pawlak M, Opolski G, Dworakowski R, MacCarthy P, Kaiser C, Osswald S, Galiuto L, Crea F, Dichtl W, Franz WM, Empen K, Felix SB, Delmas C, Lairez O, Erne P, Bax JJ, Ford I, Ruschitzka F, Prasad A, Lüscher TF. Clinical features and outcomes of takotsubo (stress) cardiomyopathy. N Engl J Med. 2015;373:929–938.
2. Ghadri JR, Cammann VL, Napp LC, Jurisic S, Diekmann J, Bataiosu DR, Seifert B, Jaguszewski M, Sarcon A, Neumann CA, Geyer V, Prasad A, Bax JJ, Ruschitzka F, Lüscher TF, Templin C; International Takotsubo (InterTAK) Registry. Differences in the clinical profile and outcomes of typical and atypical takotsubo syndrome: data from the International Takotsubo Registry. JAMA Cardiol. 2016;1:335–340.
3. Tornvall P, Collste O, Ehrenborg E, Järnbert-Petterson H. A case-control study of risk markers and mortality in takotsubo stress cardiomyopathy. J Am Coll Cardiol. 2016;67:1931–1936.
4. Scally C, Rudd A, Mezincescu A, Wilson H, Srivanasan J, Horgan G, Broadhurst P, Newby DE, Henning A, Dawson DK. Persistent Long-Term Structural, Functional, and Metabolic Changes After Stress-Induced (Takotsubo) Cardiomyopathy. Circulation. 2018 Mar 6;137(10):1039-1048.
5. Francesco Pelliccia, Vincenzo Pasceri, Giuseppe Patti, Gaetano Tanzilli, Giulio Speciale, Carlo Gaudio, Paolo G Camici. Long-Term Prognosis and Outcome Predictors in Takotsubo Syndrome: A Systematic Review and Meta-Regression Study. JACC Heart Fail. 2019 Feb;7(2):143-154.