Effects of pharmacological interventions on short- and long-term mortality in patients with takotsubo syndrome: a report from the SWEDEHEART registry

Abstract

Aim: Takotsubo cardiomyopathy (TS) is a heart condition mimicking acute myocardial infarction. TS is characterized by a sudden weakening of the heart muscle, usually triggered by physical or emotional stress. In this study, we aimed to investigate the effect of pharmacological interventions on short- and long-term mortality in patients with TS. Methods: We analyzed data from the SWEDEHEART (The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) registry, which included 1,724 patients with TS among 228,263 unique individuals who underwent coronary angiography between 2009 and 2016. The majority of patients were female (77.0%), and the average age was 66 ± 14 years. Results: Nearly half of the TS patients (49.4%) presented with non-ST-elevation acute coronary syndrome and a quarter (25.9%) presented as ST-elevation myocardial infarction. Most patients had non-obstructive coronary artery disease on angiography, while 11.7% had a single-vessel disease and 9.2% had multivessel disease. All patients received at least one pharmacological intervention, most used being beta-blockers or antiplatelet agents. All-cause mortality rates were 3.9% after 30-days and and 16.7% at long-term follow-up (median 877 days). Intravenous use of inotropes, diuretics, and orally administered digoxin were associated with increased mortality in TS, while ACE-I and statins were associated with decreased long-term mortality. Unfractionated and low-molecular-weight heparin (UH/LMWH) were associated with reduced 30-day mortality. However, medications such as ARBs, oral anticoagulants, P2Y12 antagonists, aspirin, and beta-blockers did not statistically correlate with mortality. Conclusion: Our findings suggest that some medications commonly used to treat TS are associated with higher mortality while others with lower mortality. These results could inform clinical decision-making and improve patient outcomes in TS. Further research is warranted to validate these findings and to identify optimal pharmacological interventions for patients with TS.

Diagnostic challenges between takotsubo cardiomyopathy and acute myocardial infarction—where is the emergency?: a literature review

“…Beta-blockers have the additional effect of antagonizing the excess of catecholamines and preventing LV-free wall rupture but should be cautiously used in patients with QTc > 500 ms [8,36]. ACEI has a cardioprotective effect due to renin angiotensin aldosterone system inhibition, central sympathetic system blocking, and bradykinin increase leading to vasodilation [37]. Statins may have a positive effect due to their anti-inflammatory effects, endothelial function improvement, and oxidative stress decrease and consequently have a favorable effect on mortality in patients with TC [37].…”

“…ACEI has a cardioprotective effect due to renin angiotensin aldosterone system inhibition, central sympathetic system blocking, and bradykinin increase leading to vasodilation [37]. Statins may have a positive effect due to their anti-inflammatory effects, endothelial function improvement, and oxidative stress decrease and consequently have a favorable effect on mortality in patients with TC [37]. Antiplatelet therapy has no proven utility in the absence of CAD.…”

“…The study conducted by Petursson et al using data from the SWEDEHEART Registry reviewed the effects of different drugs on mortality [37]. Therefore, in patients with TC, some drugs, such as inotropes, digoxin, and diuretics, were associated with increased mortality, while ACEI, statins, and anticoagulants (unfractionated heparin, low molecular weight heparin) lead to mortality decrease [37]. Other drugs-antiplatelets, beta-blockers, and ARBs did not influence the mortality [37].…”

“…Therefore, in patients with TC, some drugs, such as inotropes, digoxin, and diuretics, were associated with increased mortality, while ACEI, statins, and anticoagulants (unfractionated heparin, low molecular weight heparin) lead to mortality decrease [37]. Other drugs-antiplatelets, beta-blockers, and ARBs did not influence the mortality [37]. Inotropes, such as dobutamine or dopamine, may worsen heart failure in patients with TC because catecholamines play an important role in TC pathophysiology and are associated with the highest 30-day mortality of all drugs [37].…”

“…Other drugs-antiplatelets, beta-blockers, and ARBs did not influence the mortality [37]. Inotropes, such as dobutamine or dopamine, may worsen heart failure in patients with TC because catecholamines play an important role in TC pathophysiology and are associated with the highest 30-day mortality of all drugs [37]. In patients with TC who develop acute heart failure/pulmonary edema, intravenous diuretics and nitrates should be recommended, in the absence of LVOTO [2].…”