BACKGROUND The natural history, management, and outcome of takotsubo (stress) cardiomyopathy are incompletely understood. METHODS The International Takotsubo Registry, a consortium of 26 centers in Europe and the United States, was established to investigate clinical features, prognostic predictors, and outcome of takotsubo cardiomyopathy. Patients were compared with age-and sex-matched patients who had an acute coronary syndrome. RESULTS Of 1750 patients with takotsubo cardiomyopathy, 89.8% were women (mean age, 66.8 years). Emotional triggers were not as common as physical triggers (27.7% vs. 36.0%), and 28.5% of patients had no evident trigger. Among patients with takotsubo cardiomyopathy, as compared with an acute coronary syndrome, rates of neurologic or psychiatric disorders were higher (55.8% vs. 25.7%) and the mean left ventricular ejection fraction was markedly lower (40.7±11.2% vs. 51.5±12.3%) (P<0.001 for both comparisons). Rates of severe in-hospital complications including shock and death were similar in the two groups (P=0.93). Physical triggers, acute neurologic or psychiatric diseases, high troponin levels, and a low ejection fraction on admission were independent predictors for in-hospital complications. During long-term follow-up, the rate of major adverse cardiac and cerebrovascular events was 9.9% per patient-year, and the rate of death was 5.6% per patient-year. CONCLUSIONS Patients with takotsubo cardiomyopathy had a higher prevalence of neurologic or psychiatric disorders than did those with an acute coronary syndrome. This condition represents an acute heart failure syndrome with substantial morbidity and mortality. (Funded by the Mach-Gaensslen Foundation and others; ClinicalTrials.gov number, NCT01947621.).

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Table 2 Factors influencing prognosis Risk factors Subclinical Organ Damage Systolic and diastolic BP levels Electrocardiographic LVH (Sokolow-Lyon > 38 mm; Cornell > 2440 mm M ms) or: Levels of pulse pressure (in the elderly) Echocardiographic LVH8 (LVMI M ! 125 g/m 2 , W ! 110 g/m 2 ) Age (M > 55 years; W > 65 years) Carotid wall thickening (IMT > 0.9 mm) or plaque Smoking Carotid-femoral pulse wave velocity >12 m/s Dyslipidaemia Ankle/brachial BP index < 0.9 -TC > 5.0 mmol/l (190 mg/dl) or:Slight increase in plasma creatinine:-LDL-C > 3.0 mmol/l (115 mg/dl) or: M: 115-133 mmol/l (1.3-1.5 mg/dl); -HDL-C: M < 1.0 mmol/l (40 mg/dl), W < 1.2 mmol/l (46 mg/dl) or:Low estimated glomerular filtration rate y (< 60 ml/min/1.73 m 2 ) or creatinine clearance^(< 60 ml/min) -TG > 1.7 mmol/l (150 mg/dl) Fasting plasma glucose 5.6-6.9 mmol/L (102-125 mg/dl) Microalbuminuria 30-300 mg/24 h or albumin-creatinine ratio: ! 22 (M); or ! 31(W) mg/g creatinine Abnormal glucose tolerance test Abdominal obesity (Waist circumference > 102 cm (M), > 88 cm (W)) Family history of premature CV disease (M at age < 55 years; W at age < 65 years) Diabetes Mellitus Established CV or renal disease Fasting plasma glucose ! 7.0 mmol/l (126 mg/dl) on repeated measurements, or Cerebrovascular disease: ischaemic stroke; cerebral haemorrhage; transient ischaemic attack Postload plasma glucose > 11.0 mmol/l (198 mg/dl) Heart disease: myocardial infarction; angina; coronary revascularization; heart failure Renal disease: diabetic nephropathy; renal impairment (serum creatinine M > 133, W > 124 mmol/l); proteinuria (> 300 mg/24 h) Peripheral artery disease Advanced retinopathy: haemorrhages or exudates, papilloedema Note: the cluster of three out of 5 risk factors among abdominal obesity, altered fasting plasma glucose, BP > --130/85 mmHg, low HDL-cholesterol and high TG (as defined above) indicates the presence of metabolic syndrome M: men; W: women; CV: cardiovascular disease; IMT: intima-media thickness; BP: blood pressure; TG: triglycerides; C: cholesterol;^Cockroft Gault formula; y MDRD formula; 8Risk maximal for concentric LVH (left ventricular hypertrophy): increased LVMI (left ventricular mass index) with a wall thickness/radius ratio ! 0.42.

These practice guidelines on the management of arterial hypertension are a concise summary of the more extensive ones prepared by a Task Force jointly appointed by the European Society of Hypertension and the European Society of Cardiology.Stratification of CV risk in four categories of added risk. SBP = systolic blood pressure; DBP = diastolic blood pressure; CV = cardiovascular; HT = hypertension; OD = subclinical organ damage; MS = metabolic syndrome.Normal values for 24 hour average BP are lower than for office BP, i.e. < 125-130 mmHg systolic and < 80 mmHg diastolic. Normal values of daytime BP are < 130-135 mmHg systolic and < 85 mmHg diastolic.

BackgroundAtrial fibrillation is associated with higher mortality. Identification of causes of death and contemporary risk factors for all‐cause mortality may guide interventions.Methods and ResultsIn the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) study, patients with nonvalvular atrial fibrillation were randomized to rivaroxaban or dose‐adjusted warfarin. Cox proportional hazards regression with backward elimination identified factors at randomization that were independently associated with all‐cause mortality in the 14 171 participants in the intention‐to‐treat population. The median age was 73 years, and the mean CHADS 2 score was 3.5. Over 1.9 years of median follow‐up, 1214 (8.6%) patients died. Kaplan–Meier mortality rates were 4.2% at 1 year and 8.9% at 2 years. The majority of classified deaths (1081) were cardiovascular (72%), whereas only 6% were nonhemorrhagic stroke or systemic embolism. No significant difference in all‐cause mortality was observed between the rivaroxaban and warfarin arms (P=0.15). Heart failure (hazard ratio 1.51, 95% CI 1.33–1.70, P<0.0001) and age ≥75 years (hazard ratio 1.69, 95% CI 1.51–1.90, P<0.0001) were associated with higher all‐cause mortality. Multiple additional characteristics were independently associated with higher mortality, with decreasing creatinine clearance, chronic obstructive pulmonary disease, male sex, peripheral vascular disease, and diabetes being among the most strongly associated (model C‐index 0.677).ConclusionsIn a large population of patients anticoagulated for nonvalvular atrial fibrillation, ≈7 in 10 deaths were cardiovascular, whereas <1 in 10 deaths were caused by nonhemorrhagic stroke or systemic embolism. Optimal prevention and treatment of heart failure, renal impairment, chronic obstructive pulmonary disease, and diabetes may improve survival.Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00403767.