Cardiomyopathy
Predictors of Short- and Long-Term Outcomes of Takotsubo Cardiomyopathy

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Takotsubo cardiomyopathy (TC) is a reversible cardiomyopathy with a benign short-term prognosis but is associated with recurrence rate of 10%. Clinical variables that predict long-term mortality and recurrence are unknown; 56 consecutive patients presenting to a single urban medical center who fulfilled the Mayo Clinic criteria for the diagnosis of TC were included. Patients were followed with 100% completeness; >60 clinical factors were analyzed, including presentation, treatment, electrocardiogram, and echocardiographic, angiographic, and demographic variables. Survival analysis was performed using the Kaplan-Meier function and Cox proportional hazards regression models. There were 15 deaths during follow-up: 5 in-hospital, 4 before 90 days, and 6 after 90 days. Mean survival was 4.47 years (95% confidence interval 3.81 to 5.13). All short-term survivors had repeat ejection fraction evaluation demonstrating improvement; 45 of 56 patients were women and 96% were postmenopausal. The nonfatal recurrence rate was 1.8%. QTc interval at presentation was the factor most strongly predictive of overall outcome, after intubation. All patients with mortality had QTc intervals between 400 and 550 ms. In conclusion, this study demonstrates the prognostic significance of QTc prolongation at presentation in TC. Because the cause of TC involves intense catecholamine release and hyperadrenergic tone, the QTc may reflect the individual impact on myocardial repolarization and the balance between sympathetic innervation and parasympathetic compensation. In conclusion, in this series, TC was associated with an 8.9% in-hospital mortality, an additional 17.9% mortality after discharge, and a nonfatal recurrence rate of 1.8%. Moreover, the QTc on presentation with TC was predictive of outcome.

Section snippets

Methods

Fifty-six consecutive patients presenting to a single urban medical center with TC comprised the study group. The Institutional Review Board approved the study protocol and data analysis. No external funding was used for this study. The International Classification of Diseases, Ninth Revision (ICD code 429.83), was used to identify patients, aged ≥18 years, who were discharged with a diagnosis of TC. The charts of identified patients who presented from 2004 to 2014 were reviewed for the

Results

The clinical characteristics of the study patients are listed in Table 1. Intubation and mechanical ventilation occurred in 10.7% of subjects. Deep T-wave inversion was the most common abnormal finding on electrocardiography (57.1%). ST elevation was also noted in 7 patients (12.5%). Mean initial LVEF was 33.2 ± 7.9% and 57.6 ± 7.4% for repeat LVEF. Mean time to repeat echo was 21.6 ± 37.6 weeks. Mean troponin (6.47 ± 13.57) was elevated in all patients. Mean length of stay was 8.7 ± 8.1 days (

Discussion

This is the first clinical series demonstrating prognostic significance of QTc prolongation at presentation in TC. Because the cause of TC involves intense catecholamine release and hyperadrenergic tone, the QTc may reflect the individual impact on myocardial repolarization and sympathetic innervation, explaining its prognostic significance. In this series, TC was associated with an 8.9% in-hospital mortality, an additional 17.9% mortality after discharge (despite improvement in LV function),

Disclosures

The authors have no conflicts of interest to disclose.

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    The prevalence in our cohort was 61%, slightly higher than in previous studies, but a large variation among series has been observed.15,17,34 Prolongation of corrected QT interval is frequently present in TTS and predisposes to adverse events, characteristically malignant ventricular arrhythmia and sudden cardiac death.35-38 Previous work regarding prognostic factors of TTS has focused in clinical, echocardiographic, or hemodynamic factors, and less attention has been paid to electrocardiographic features.4,8,18

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    Murugiah et al. have shown that 1 in 10 patients was readmitted within 30 days, and our study shows that 1 in 4 patients will be readmitted within 90 days, which is similar to the study done by Shah et al. [14] and higher than readmissions after ACS [15]. Acute heart failure/recurrent takotsubo cardiomyopathy is the most common cardiac cause for readmission at 1.8% (n = 512), which is similar to the previously published studies [14,16]. The strongest predictors of readmission were found to be age, heart failure at baseline, chronic pulmonary disease, diabetes mellitus, peripheral vascular disease, and gender.

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