Clinical and echocardiographic course in takotsubo cardiomyopathy: Longterm followup from a multicenter study
Introduction
The suspicion, diagnosis and management of tako-tsubo cardiomyopathy (TC) have an evolving course. An acute phase with symptoms and ECG findings that, along with elevated biomarkers, generally lead to the examination of coronary arteries and ventriculography [1], [2]. Secondly, a subacute phase where ECG and echocardiographic monitoring gain importance [2]. In most TC cases, left ventricular (LV) systolic function impairment involves, in a supposedly reversible manner, the LV mid-cavity and apical regions [1], [3]. Furthermore, TC regional myocardial involvement is not circumscribed to ventricular segmentation determined by the distribution of coronary arteries [4]. These morphofunctional facets primarily detected by angiographic and echocardiographic examinations allow, together with a clinical presentation mimicking an acute coronary syndrome, for the suspicion and diagnosis of TC [1], [5]. Lastly, a chronic or out-of-hospital phase, with a wide range of between-center possible approaches, from long-term clinical follow-up through stop of outpatient evaluation.
A number of reasons might explain the physicians' variability in the approach to TC outpatient follow-up. Its etiology is not well defined [1]. Some cases have been reported in association with stress tests [6], [7], suggesting a sudden increase in catecholamine blood levels - induced by sympathetic nervous system overstimulation - as the underlying mechanism in TC cases with a stressful event as a trigger [2]. The fact that this catecholamine rise is limited in time may make some think that long-term follow-up is not necessary. Secondly, the concept of this condition's reversibility [2]. This general assumption, beyond myocardium detailed regional analysis or tissue characterization - i.e., by myocardial deformation techniques [8] or cardiovascular magnetic resonance [9] in acute and subacute phases -, does not help solve the issue of when and how these patients should be reevaluated after discharge.
Thus, it has largely been accepted that TC prognosis is generally benign. However, investigations on mortality and morbidity have regained interest in recent years as physicians have a broader knowledge of the disease. In-hospital mortality in TC has been reported to be lower (2.0–2.4%), as high (4.1%), or higher (8.6%) than that for acute coronary syndrome [10], [11], [12], [13]. On the other hand, there is even more controversy on long-term prognosis of TC, which may currently be considered in debate. Recent publications indicate, by retrospective analysis, that there appears to be a complete recovery of ventricular function in less than two thirds of TC cases, but with analysis of only the first months after the event [14]. There is a lack of studies including together clinical aspects, cardiovascular imaging reevaluation (i.e., LV global or regional wall motion) and prognostic outcomes at a long follow-up period after the TC event. The aim of this study was to jointly describe clinical characteristics, ECG and echocardiographic findings, and adverse cardiovascular events in patients diagnosed with TC in the long-term.
Section snippets
Study population
This was a longitudinal multicenter study including retrospective analysis of clinical and ECG data by medical chart review, and follow-up evaluation with clinical interview, electrocardiogram and echocardiogram. A search in the admission electronic registry (since January 1st 2006 through December 31st 2014) of the Cardiology Department at three tertiary care hospitals was performed. The search terms “tako-tsubo syndrome”, “apical ballooning syndrome”, “stress cardiomyopathy”, “tako-tsubo
Results
By the search in the admission electronic registry from the three participating centers 90 patients previously admitted with diagnosis of TC were identified (Fig. 1). All 90 patients met the diagnostic criteria for TC. None had significant valve disease or coronary artery disease at the time of the TC event. Hospital admission of all patients was due to TC with no other causes as concurrent comorbidities. Ten patients declined participation in the prospective electrocardiographic and
Discussion
Most of our knowledge about TC comes from the detailed analysis of this entity's acute and subacute phases, which usually stands for the in-hospital disease course. In this context, individual multiple forms of TC have been described with or without supposed triggers [14]. Besides, survival and complications during admission, as long as relatively short-term (i.e., one or two years) outcomes have been the subject of the majority of the patient follow-up investigations [18], [19]. Thus, the main
Funding sources/grant support
None to disclose.
Conflicts of interest
None to disclose.
Acknowledgements
None to disclose.
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