Frailty and cognitive impairment are predictive of takotsubo syndrome following pacemaker implantation

Abstract

BackgroundPacemaker (PM) implantation may cause acute emotional distress leading to takotsubo syndrome (TTS). Frailty and cognitive impairment are known to influence outcomes after surgical procedures. It is unclear whether they may also predispose to TTS following PM implantation.MethodsWe identified nine cases (81 ± 6 years) of TTS following PM implantation that took place between 2013 and 2017 in one high volume implantation center. TTS was diagnosed based on typical echocardiographic appearance with resolution over time and (in cases where deemed necessary) normal coronary angiography. The TTS cases were compared with 30 consecutive cases of PM implantation (75 ± 9 years), which were not complicated by TTS (control group). Frailty was assessed using retrospective Risk Analysis Index (RAI‐A). Pacing parameters were analyzed during PM implantation and after 1 month.ResultsCognitive impairment was more prevalent (67% vs 10%, P = .0005), and RAI‐A index was significantly higher in the TTS group compared to the control group (26 ± 13.7 vs 13.1 ± 9.8, P = .008). Perioperative right ventricular threshold was significantly higher in patients with TTS comparing to controls (0.99 ± 0.43 V vs 0.74 ± 0.20 V, P = .04). The magnitude of decrease in right ventricular threshold between implantation and 1 month follow‐up was greater in TTS patients compared to controls (−0.41 ± 0.29 V vs −0.15 ± 0.38 V, P = .049).ConclusionsTTS is a rare complication of PM implantation. Patients with cognitive impairment and frailty are at risk of TTS. Right ventricular pacing threshold is acutely affected by TTS and improves over time.

Takotsubo Syndrome after Pacemaker Implantation: A Systematic Review

“…In almost all the articles included in our review, the only echocardiographic feature reported was the left ventricular ejection fraction (LVEF). In the most case it was in the normal range with few cases that presented a mild reduced LVEF, among the cases where it was reported the mean value was approximately 62% (range 50–75%) [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ].…”

Takotsubo Syndrome After Pacemaker Implantation: A Case Report and Literature Review

“…In a retrospective analysis of a high-volume implantation center, Niewinski et al 7 identified nine cases of TTS following pacemaker implantation, with a prevalence of 0.54% on 1655 devices implanted between 2013–2017. In this study, female sex was not predictive of TTS, while cognitive decline and frailty syndrome were independently associated with the risk of TTS occurrence.…”

“…The Barcelona criteria were developed for patients with LBB block but have been successfully used in cases of AMI with an RV paced rhythm. 7 …”

“…Many questions regarding TTS after pacemaker implantation still remain open, including whether there are predicting factors to risk-stratify patients, but only a multicenter prospective study could provide answers to this and other issues. 2 , 7 , 8 Based on currently available knowledge, despite a benign clinical course in most cases, efforts should be focused on an early diagnosis, also considering a significant percentage of initially asymptomatic cases. An ECG combined with a simple fast echocardiogram before discharge could identify TTS signs, especially in patients deemed at a higher risk of this rare but fearsome complication.…”

Clinical implications of assessing frailty in elderly patients treated with permanent cardiac pacing

“…Notably, acute emotional distress leading to Takotsubo syndrome is a rare but potential complication of pacemaker implantation that appears associated with frailty and cognitive impairment. 14,15 In the presence of cognitive impairment and frailty, specific preventive measures may be appropriate, such as avoidance of temporary transvenous pacing 16 and shortening of hospital stay, as usually done in device replacements. 17 Additionally, as shown in Fig.…”