Characteristics and Outcomes of Patients With Takotsubo Syndrome: Incremental Prognostic Value of Baseline Left Ventricular Systolic Function

Abstract

Background We sought to determine (1) long‐term outcomes in patients presenting with documented Takotsubo syndrome (TS), (2) whether left ventricular global longitudinal strain (LV‐GLS) provides incremental prognostic value, and (3) prognostic cutoffs of LV ejection fraction (LVEF) and LV‐GLS during an acute TS episode. Methods and Results We studied 650 patients with TS (aged 66±14 years, 88% women) who were diagnosed clinically and angiographically between 2006 and 2018. Baseline LVEF and LV‐GLS (using velocity vector imaging) were recorded. The primary end point was all‐cause mortality. TS triggers were unknown (34%), emotional (16%), physical (41%), and neurologic (10%). Mean LVEF and LV‐GLS were 36±10% and −11.6±0.4%; in addition, 94% patients had LVEF <52%, and 80% had apical ballooning. No patient had obstructive coronary artery disease. At a median of 2.2 years (interquartile range, 0.7–4.4), 175 (27%) had died (9% in‐hospital deaths). Multivariate Cox survival analysis revealed that higher age (hazard ratio [HR], 1.35), male sex (HR, 1.75), lower baseline LVEF (HR, 1.02), worse LV‐GLS (HR, 1.04), neurologic trigger (HR, 2.66), and physical trigger (HR, 2.64) were associated with mortality, whereas aspirin (HR, 0.70) and β‐blockers (HR, 0.73) improved survival (all P <0.049). The addition of LVEF and LV‐GLS to clinical markers (age, sex, cardiogenic shock at presentation, and peak troponin I) significantly increased log‐likelihood ratios: clinical (−521.48), clinical plus LVEF (−511.32, P <0.001), and clinical plus LVEF and LV‐GLS (−500.68, P <0.001). On penalized spline analysis, LVEF of 38% and LV‐GLS of −10% were cutoffs below which survival was significantly worse. Conclusions Patients with TS with a neurologic or physical trigger had significantly worse survival than those without such a trigger, with baseline LVEF and LV‐GLS providing incremental prognostic value.

Takotsubo Syndrome During the COVID-19 Pandemic: State-of-the-Art Review

“…One of the more sensitive modalities that was shown to detect early subtle myocardial contractility changes and predicts mortality in TTS is LV strain echocardiography (71). This modality may help to differentiate TTS from acute coronary syndrome (72).…”

Takotsubo Syndrome—Is There a Need for CMR?

“…In the first period, major adverse cardiac events (MACE) such as acute heart failure, arrhythmias and cardiogenic shock are in frequency and complexity comparable to ST-elevation myocardial infarction (STEMI) with mortality rates of 3.5–5% in hospital [ 12 , 25 , 26 ] and 10–12% per year [ 1 , 27 ]. In the clinical course, however, the characteristic myocardial functional limitations such as apical, midventricular or basal ballooning, the electrocardiographic abnormalities and the myocardial damage with increased biomarkers disappear completely within weeks in most of the cases [ 23 , 27 , 28 ].…”

Understanding the role of left and right ventricular strain assessment in patients hospitalized with COVID-19

“…Due to the nature of ROC analysis, this is expectedly less negative than the pooled normal value from a meta-analysis using healthy individuals which is reported to be −19.5% (95% CI −20.4 to −18.9%) [ 30 ], and less negative than the 5th percentile in a healthy general population (−18.4%) [ 31 ]. Our threshold ranges between the mean LV GLS of patients with acute pulmonary embolism (−16%) [ 32 ] and those with stress cardiomyopathy (−11.6%) [ 33 ], or acute decompensated heart failure (−9.8%) [ 34 ]. Based on our review of literature, this is the first report to provide a LV GLS cutoff value for presumed acute myocardial injury in the setting of COVID-19.…”