Antecedent cancer in Takotsubo syndrome predicts both cardiovascular and long-term mortality

Abstract

Background: Takotsubo syndrome (TTS), primarily an acute myocardial inflammatory condition engendered by catecholamine exposure, is associated with similar long-term mortality rates to those of patients with acute myocardial infarction. However, there is increasing evidence of a nexus between TTS and underlying malignancies:many patients have antecedent cancer (A/Ca), while incremental risk of late cancer-related death has also been reported. Purpose: To evaluate potential interactions between A/Ca among TTS patients and both early and late clinical course.Methods: Three hundred forty-six consecutive TTS patients [aged 69 ± 13 (SD) years, males: 8.2%] were prospectively followed up for a median duration of 4.1 (IQR 2.2-6.4) years. Associations between A/Ca and severity of acute attacks, in-hospital complications and long-term death rates were sought utilising univariate analyses followed by multiple logistic regression analysis. Results: A/Ca (present in 16.8% of patients) was associated with (i) greater elevation of hs-CRP and NT-proBNP concentrations (p = 0.01 and 0.04, respectively), (ii) more complicated in-hospital clinical course, with major adverse cardiac events (MACE) in 30.9% of patients, compared to 18.2% in non-A/Ca patients (p = 0.04). Long-term all-cause mortality rate was also greater [hazard ratio (HR) = 2.4, p = 0.0001] in A/Ca patients, with an excess cardiovascular (CVS) fatality rate (HR = 3.1, p = 0.001). On multivariate analysis, male gender, peak plasma concentrations of normetanephrine and hs-CRP, early arrhythmias and development of shock, but not A/Ca per se, were all independently associated with increased long-term mortality rate. Furthermore, patients discharged on β-adrenoceptor antagonists (βBl) or angiotensin converting enzyme inhibitors/ angiotensin receptor blockers (ACEi/ARB) had lower long-term mortality rates (β = − 0.2, p = 0.01; β = − 0.14, p = 0.05, respectively). Conclusions: (1) A/Ca is associated with greater clinical severity of initial TTS attacks and substantially greater longterm CVS-related as well as all-cause mortality.(2) Post-discharge therapy with either βBl or ACEi/ARB is associated with reductions in long-term mortality rates. Overall, the current data suggest operation of substantial interactions between neoplasia and TTS, both at the level of pathogenesis and of outcomes.

Evaluation and management of cancer patients presenting with acute cardiovascular disease: a Clinical Consensus Statement of the Acute CardioVascular Care Association (ACVC) and the ESC council of Cardio-Oncology—part 2: acute heart failure, acute myocardial diseases, acute venous thromboembolic diseases, and acute arrhythmias

“…In general, short-term mortality is comparable to patients without cancer. 25 Post-discharge mortality is lower with either betablockers or angiotensin converting enzyme inhibitors/angiotensin receptor blockers, 36 suggesting that cardioprotective therapies should not be withheld from TTS patients with cancer.…”

Shining a light on perioperative Takotsubo syndrome

“…10 Une autre publication australienne récente a rapporté une incidence similaire d'antécédent de cancer (16,8 %), et a en outre noté une association avec une gravité clinique initiale plus élevée et une mortalité à long terme, à la fois cardiovasculaire et toutes causes confondues, plus élevée. 11 Ong et coll. ont récemment passé en revue les progrès remarquables de nos connaissances concernant le syndrome de Takotsubo au cours de la dernière décennie.…”

“…10 Another recent publication from Australia reported a similar incidence of antecedent cancer (16.8%), and further found an association with higher initial clinical severity, and higher long-term mortality, both cardiovascular-related and all-cause mortality. 11 Ong et al recently reviewed the remarkable advances in our knowledge about TS from the past decade. 1 The authors conclude that the syndrome represents a spectrum of neurogenic stunned myocardium.…”

Takotsubo Syndrome: Finally Emerging From the Shadows?

“…Furthermore, it appears that a prior history of malignancy is an independent predictor of long-term mortality [49]. Recently published findings from our registry have demonstrated that TTS patients with antecedent malignancy (but not necessarily cancer chemotherapy) have more complicated in-hospital stays and a marked increase in late mortality rate, not only reflecting late risk associated with malignancy, but partially due to increased late cardiovascular mortality [50]. These findings therefore suggest some commonality of pathogenesis between TTS and malignancies.…”