Elsevier

International Journal of Cardiology

Volume 228, 1 February 2017, Pages 97-102
International Journal of Cardiology

Clinical and echocardiographic course in tako­tsubo cardiomyopathy: Long­term follow­up from a multicenter study

https://doi.org/10.1016/j.ijcard.2016.11.256Get rights and content

Abstract

Objectives

To jointly describe clinical characteristics, ECG and echocardiographic findings, and adverse cardiovascular events in patients with tako-tsubo cardiomyopathy (TC) in the long-term.

Methods

Longitudinal multicenter study including retrospective analysis of clinical and ECG data, and follow-up evaluation with clinical interview, electrocardiogram and echocardiogram.

Results

Data from 66 cases of TC were available for analysis of clinical and adverse cardiovascular events, and 56 of them completed the follow-up visit including electrocardiogram and echocardiogram. Most patients (97%) were asymptomatic or oligosymptomatic (NYHA I [58%] or II [39%], respectively) at follow-up (median time: 3.7 [1.8–6.6] years). The vast majority of individual QRS complex and repolarization abnormalities had disappeared (87% with no ECG abnormalities at follow-up). On echocardiography, left ventricular ejection fraction was ≥ 50% in all patients (mean: 63 ± 6%). Wall motion abnormalities were observed in 4 patients (7%; 3 with apical wall motion abnormalities and 1 with mild global hypokinesia). Long-term outcomes were as follows: 4 deaths (6%), 2 cardiovascular and 2 non-cardiovascular; no atrial fibrillation development; no stroke events; 5 acute recurrence events of TC (8%). Globally, 57 patients (86%) had a clinical course free from adverse cardiovascular events.

Conclusions

After a long period following the admission event, patients discharged from TC remain asymptomatic or minimally symptomatic, and feature a low prevalence of both ECG and left ventricular wall motion abnormalities; moreover, the latter lead to a very mild impairment of ejection fraction. Among cardiovascular adverse events, recurrence of the TC event appears to play the most significant role.

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.

References (38)

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1

Contributed equally to this paper.

2

This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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