Clinical outcomes associated with catecholamine use in patients diagnosed with Takotsubo cardiomyopathy

Abstract

BackgroundRecent hypotheses have suggested the pathophysiological role of catecholamines in the evolution of the Takotsubo syndrome (TTS). The extent of cardiac and circulatory compromise dictates the use of some form of supportive therapy. This study was designed to investigate the clinical outcomes associated with catecholamine use in TTS patients.MethodsOur institutional database constituted a collective of 114 patients diagnosed with TTS between 2003 and 2015. The study-patients were subsequently classified into two groups based on the need for catecholamine support during hospital stay (catecholamine group n = 93; 81%, non-catecholamine group = 21; 19%). The primary end-point of our study was all-cause mortality.ResultsPatients receiving catecholamine support showed higher grades of circulatory and cardiac compromise (left ventricular ejection fraction (LVEF) 39.6% vs. 32.7%, p-value < 0.01) and the course of disease was often complicated by the occurrence of different TTS-associated complications. The in-hospital mortality (3.2% vs. 28.5%, p < 0.01), 30-day mortality (17.2% vs. 51.4%, p < 0.01) as well as long-term mortality (38.7% vs. 80.9%, p < 0.01) was significantly higher in the group of patients receiving catecholamine support. A multivariate Cox regression analysis attributed EF ≤ 35% (HR 3.6, 95% CI 1.6–8.1; p < 0.01) and use of positive inotropic agents (HR 2.2, 95% CI 1.0–4.8; p 0.04) as independent predictors of the adverse outcome.ConclusionRates of in-hospital events and short- as well as long-term mortality were significantly higher in TTS patients receiving catecholamine support as compared to the other study-patients. These results need further evaluation in pre-clinical and clinical trials to determine if external catecholamines contribute to an adverse clinical outcome already compromised by the initial insult.

A Review of Catecholamine Associated Cardiomyopathies and Channelopathies

“…The microvascular dysfunction caused by catecholamines has been proposed as part of the unifying mechanism of TC [4]. This fact is supported by the evidence that the administration of adenosine, a potent vasodilator, temporarily resolves perfusion and wall motion abnormalities in TC [8].…”

“…In cases of TC, the use of catecholamines for acute circulatory support may have deleterious effects and their use is associated with increased mortality [4,26]. Therefore, the need for circulatory support should be balanced with a potential causative role of catecholamines in TC.…”

“…Catecholamine-induced cardiomyopathy is a well-recognized and potentially life-threatening complication in pheochromocytoma and paragangliomas [2][3]. Indeed, catecholamines have been postulated to play a critical role in the pathogenesis of Takotsubo cardiomyopathy (TC) [4][5].…”

Management of Takotsubo Syndrome: A Comprehensive Review

“…A total of 4,313 articles were found of which 248 articles met the inclusion criteria. Based on predefined criteria, only 16 of these articles were included in this review ( Table 1) [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20].…”

“…Cardiogenic shock with LVOTO: In patients with cardiogenic shock with moderate to severe LVOTO, inotropic agents should not be used because they can increase the degree of obstruction [31,34]. In a study by Ansari et al, it was reported that inotropes such as epinephrine, norepinephrine, dobutamine, and dopamine should be avoided in TTS, and that catecholamine excess can increase 30-day and long-term mortality in TTS [9]. Only Marfella et al reported that alpha-adrenergic stimulation by alpha-lipoic therapy could increase sympathetic stimulation of the heart and show improvement of cardiac defects on 123Imetaiodobenzylguanidine myocardial scintigraphy at a 12-month follow-up in TTS patients [7].…”