The Clinical Manifestations, Diagnosis and Management of Takotsubo Syndrome

The Takotsubo syndrome (TTS) is a transient cardiac dysfunction characterised by a variety of ventricular wall-motion abnormalities. Alternative nomenclatures for this disorder include stress-induced cardiomyopathy, apical ballooning syndrome and ‘broken heart syndrome’. TTS bears stark resemblance to an acute coronary syndrome, wherein patients present with acute chest pain and initial diagnostic workup correlates to abnormalities suggesting significant coronary stenosis. Interestingly, the distinguishing factor in TTS is the absence of an occlusive coronary vascular disease, which could correlate with these changes. The underlying pathophysiology explaining the evolution of TTS is still debatable; however, results from various recent studies and registers have shed more light on this obscure clinical entity. The detailed description of a criterion which demonstrably includes most patients with probable TTS has helped tune management strategies in ensuring necessary supportive care and early therapeutic interventions of complications, which could arise in course of the disease

Interventional Left Atrial Appendage Closure: Focus on Practical Implications

Catheter-based left atrial appendage closure is an evolving therapy for the prophylaxis of thromboembolic complications in nonvalvular atrial fibrillation patients, which are ineligible for long-term oral anticoagulation. For this indication, it is recommended by the current European guidelines. This review of the existing literature should facilitate the understanding of the therapy’s practical implications. It presents a clinical approach toward a correct patient selection, gives an overview of the different devices and the procedural aspects, reflects differences and benefits between several postprocedural regimens for device surveillance as well as antithrombotic medication and rounds off with a summary of the relevant studies concerning efficacy and safety outcome measures

Comparison and Outcome Analysis of Patients with Takotsubo Cardiomyopathy Triggered by Emotional Stress or Physical Stress

Background: Previous studies revealed that takotsubo cardiomyopathy (TTC) is triggered by physical and emotional stresses. This study was performed to determine the short- and long-term prognostic impact of emotional- and physical stress associated with TTC.Methods and results: Our institutional database constituted a collective of 84 patients diagnosed with TTC between 2003 and 2015. The patients were divided into two groups as per the presence of emotional stress (n = 24, 21%) or physical stress (n = 60, 52.6%). The endpoint was a composite of in-hospital events (thromboembolic events and life-threatening arrhythmias), myocardial infarction, all-cause of mortality, re-hospitalization due to heart failure, stroke, and recurrence of TTC. A Kaplan–Meier analysis indicated a significantly lower event-free survival rate over a mean follow-up of 5 years in the emotional group than the physical stress group (log-rank, p < 0.01). Multivariate Cox regression analysis revealed only emotional stress (HR 0.4, 95% CI: 0.2–0.9, p < 0.05) as a negative independent predictor of the primary endpoint.Conclusion: Rates of in-hospital events and short- as well as long-term events were significantly lower in TTC patients suffering from emotional stress as compared to patients with physical stress

Statin therapy and outcome in Takotsubo syndrome patients: Results from the multicenter international GEIST registry

Endothelial dysfunction; Statin; Takotsubo syndromeDisfunció endotelial; Estatina; Síndrome de TakotsuboDisfunción endotelial; Estatina; Síndrome de TakotsuboBackground and aims Several studies have shown that endothelial dysfunction plays a role in the pathogenesis of Takotsubo syndrome (TTS). Given the potential benefit of statin therapy on endothelial dysfunction, we hypothesized that such treatment could improve outcome. Aim of our study was to evaluate clinical characteristics and outcome of TTS patients treated with statin therapy. Methods Patients were enrolled in the international multicenter GEIST (GErman Italian Spanish Takotsubo) registry. Demographic data, clinical features and drug therapy at discharge were recorded. Primary study outcome was the occurrence of all-cause death at follow-up. Results Study population included 2429 consecutive TTS patients: 1293 (53.2%) discharged on statin and 1136 (46.8%) without statin. Patients with statin were older (age 72 ± 11 vs 69 ± 13 years, p < 0.001), with higher prevalence of hypertension (74.3% vs 60.3%, p < 0.001), diabetes (21.1% vs 14.7%, p < 0.001), dyslipidemia (56.1% vs 23.3%, p < 0.001), history of coronary artery disease (13.3% vs 6.3%, p < 0.001) and lower rates of in-hospital complications (14.7% vs 19.3%, p = 0.003). Survival analysis showed similar mortality rates between groups (log rank p = 0.803). At univariable analysis, statin therapy at discharge was not associated with lower mortality (HR: 0.97, 95% CI 0.74–1.26, p = 0.803). At multivariable analysis age (HR: 1.06 95% CI 1.04–1.08, p < 0.001), male sex (HR: 1.83, 95% CI 1.20–2.80, p = 0.005), diabetes (HR: 2.55, 95% CI 1.83–3.54 p < 0.001), malignancies (HR: 2.41, 95% CI 1.68–3.44, p < 0.001) and physical trigger (HR: 2.24, 95% CI 1.62–3.10, p < 0.001) were associated with increased mortality. Conclusions Statin therapy after a TTS event was not associated with better prognosis at follow-up

Clinical outcomes associated with catecholamine use in patients diagnosed with Takotsubo cardiomyopathy

Background: Recent hypotheses have suggested the pathophysiological role of catecholamines in the evolution of the Takotsubo syndrome (TTS). The extent of cardiac and circulatory compromise dictates the use of some form of supportive therapy. This study was designed to investigate the clinical outcomes associated with catecholamine use in TTS patients. Methods: Our institutional database constituted a collective of 114 patients diagnosed with TTS between 2003 and 2015. The study-patients were subsequently classified into two groups based on the need for catecholamine support during hospital stay (catecholamine group n = 93; 81%, non-catecholamine group = 21; 19%). The primary end-point of our study was all-cause mortality. Results: Patients receiving catecholamine support showed higher grades of circulatory and cardiac compromise (left ventricular ejection fraction (LVEF) 39.6% vs. 32.7%, p-value &lt; 0.01) and the course of disease was often complicated by the occurrence of different TTS-associated complications. The in-hospital mortality (3.2% vs. 28.5%, p &lt; 0.01), 30-day mortality (17.2% vs. 51.4%, p &lt; 0.01) as well as long-term mortality (38.7% vs. 80.9%, p &lt; 0.01) was significantly higher in the group of patients receiving catecholamine support. A multivariate Cox regression analysis attributed EF ≤ 35% (HR 3.6, 95% CI 1.6–8.1; p &lt; 0.01) and use of positive inotropic agents (HR 2.2, 95% CI 1.0–4.8; p 0.04) as independent predictors of the adverse outcome. Conclusion: Rates of in-hospital events and short- as well as long-term mortality were significantly higher in TTS patients receiving catecholamine support as compared to the other study-patients. These results need further evaluation in pre-clinical and clinical trials to determine if external catecholamines contribute to an adverse clinical outcome already compromised by the initial insult

Age‐Related Differences in Takotsubo Syndrome: Results From the Multicenter GEIST Registry

Age variation; Takotsubo syndromeVariación de edad; Síndrome de takotsuboVariació d'edat; Síndrome de takotsuboBackground The role of age in the short‐ and long‐term prognosis of takotsubo syndrome (TTS) is controversial. The aim of the present study was to evaluate age‐related differences and prognostic implications among patients with TTS. Methods and Results In total, 2492 consecutive patients with TTS enrolled in an international registry were stratified into 4 groups (<45, 45–64, 65–74, and ≥75 years). The median long‐term follow‐up was 480 days (interquartile range, 83–1510 days). The primary outcome was all‐cause mortality (in‐hospital and out‐of‐hospital mortality). The secondary end point was TTS‐related in‐hospital complications. Among the 2479 patients, 58 (2.3%) were aged <45 years, 625 (25.1%) were aged 45 to 64 years, 733 (29.4%) were aged 65 to 74 years, and 1063 (42.6%) were aged ≥75 years. Young patients (<45 years) had a higher prevalence of men (from youngest to oldest, 24.1% versus 12.6% versus 9.7% versus 11.4%; P<0.01), physical triggers (46.6% versus 27.5%, 33.9%, and 38.4%; P<0.01), and non‐apical forms of TTS (25.9% versus 23.7%, 12.7%, and 9%; P<0.01) than those aged 45 to 64, 65 to 74, and ≥75 years. During hospitalization, young patients experienced a higher rate of in‐hospital complications (32.8% versus 23.4%, 27.4%, and 31.9%; P=0.01), but in‐hospital mortality was higher in the older group (0%, 1.6%, 2.9%, and 5%; P=0.001). Long‐term all‐cause mortality was significantly higher in the older cohort (5.6%, 6.4%, 11.3%, and 22.3%; log‐rank P<0.001), as was long‐term cardiovascular mortality (0%, 0.9%, 1.9%, and 3.2%; log‐rank P=0.01). Conclusions Young patients with TTS have a typical phenotype characterized by a higher prevalence of male sex, non‐apical ballooning patterns, and in‐hospital complications. However, in‐hospital and long‐term mortality are significantly lower in young patients with TTS. Registration URL: https://classic.clinicaltrials.gov/ct2/show/NCT04361994. Unique identifier: NCT04361994

- LAA Occluder View for post-implantation Evaluation (LOVE) - standardized imaging proposal evaluating implanted left atrial appendage occlusion devices by cardiac computed tomography

Background: A standardized imaging proposal evaluating implanted left atrial appendage (LAA) occlusion devices by cardiac computed tomography angiography (cCTA) has never been investigated. Methods: cCTA datasets were acquired on a 3rd generation dual-source CT system and reconstructed with a slice thickness of 0.5 mm. An interdisciplinary evaluation was performed by two interventional cardiologists and one radiologist on a 3D multi-planar workstation. A standardized multi-planar reconstruction algorithm was developed in order to assess relevant clinical aspects of implanted LAA occlusion devices being outlined within a pictorial essay. Results: The following clinical aspects of implanted LAA occlusion devices were evaluated within the most appropriate cCTA multi-planar reconstruction: (1) topography to neighboring structures, (2) peri-device leaks, (3) coverage of LAA lobes, (4) indirect signs of neo-endothelialization. These are illustrated within concise CT imaging examples emphasizing the potential value of the proposed cCTA imaging algorithm: Starting from anatomical cCTA planes and stepwise angulation planes perpendicular to the base of the LAA devices generates an optimal LAA Occluder View for post-implantation Evaluation (LOVE). Aligned true axial, sagittal and coronal LOVE planes offer a standardized and detailed evaluation of LAA occlusion devices after percutaneous implantation. Conclusions: This pictorial essay presents a standardized imaging proposal by cCTA using multi-planar reconstructions that enables systematical follow-up and comparison of patients after LAA occlusion device implantation

Trigger‐Associated Clinical Implications and Outcomes in Takotsubo Syndrome: Results From the Multicenter GEIST Registry

Stress‐induced cardiomyopathy; Takotsubo syndromeMiocardiopatía inducida por estrés; Síndrome de takotsuboMiocardiopatia induïda per l'estrès; Síndrome de takotsuboBackground Takotsubo syndrome is usually triggered by a stressful event. The type of trigger seems to influence the outcome and should therefore be considered separately. Methods and Results Patients included in the GEIST (German‐Italian‐Spanish Takotsubo) registry were categorized according to physical trigger (PT), emotional trigger (ET), and no trigger (NT) of Takotsubo syndrome. Clinical characteristics as well as outcome predictors were analyzed. Overall, 2482 patients were included. ET was detected in 910 patients (36.7%), PT in 885 patients (34.4%), and NT was observed in 717 patients (28.9%). Compared with patients with PT or NT, patients with ET were younger, less frequently men, and had a lower prevalence of comorbidities. Adverse in‐hospital events (NT: 18.8% versus PT: 27.1% versus ET: 12.1%, P<0.001) and long‐term mortality rates (NT: 14.4% versus PT: 21.6% versus ET: 8.5%, P<0.001) were significantly lower in patients with ET. Increasing age (P<0.001), male sex (P=0.007), diabetes (P<0.001), malignancy (P=0.002), and a neurological disorder (P<0.001) were associated with a higher risk of long‐term mortality, while chest pain (P=0.035) and treatment with angiotensin‐converting enzyme inhibitor/angiotensin receptor blocker (P=0.027) were confirmed as independent predictors for a lower risk of long‐term mortality. Conclusions Patients with ET have better clinical conditions and a lower mortality rate. Increasing age, male sex, malignancy, a neurological disorder, chest pain, angiotensin‐converting enzyme inhibitor/angiotensin receptor blocker, and diabetes were confirmed as predictors of long‐term mortality

Follow-up of iatrogenic aorto-coronary "Dunning" dissections by cardiac computed tomography imaging

Background: Iatrogenic aorto-coronary dissections following percutaneous coronary interventions (PCI) represent a rare but potentially life threatening complication. This restrospective and observational study aims to describe our in-house experience for timely diagnostics and therapy including cardiovascular imaging to follow-up securely high-risk patients with Dunning dissections. Methods: Dunning dissections (DD) occurred during clinical routine PCIs, which were indicated according to current ESC guidelines. Diagnostic assessment, treatment and follow-up were based on coronary angiography with PCI or conservative treatment and cardiac computed tomography (cCTA) imaging. Results: A total of eight patients with iatrogenic DD were included. Median age was 69 years (IQR 65.8–74.5). Patients revealed a coronary multi-vessel-disease in 75% with a median SYNTAX-II-score of 35.3 (IQR 30.2–41.2). The most common type of DD was type III (50%), followed by type I (38%) and type II (13%). In most patients (88%) the DD involved the right coronary arterial ostium. 63% were treated by PCI, the remaining patients were treated conservatively. 88% of patients received at least one cCTA within 2 days, 50% were additionally followed-up by cCTA within a median of 6 months (range: 4–8 months) without any residual. Conclusion: Independently of the type of DD (I-III) it was demonstrated that cCTA represents a valuable imaging modality for detection and follow-up of patients with DDs