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Takotsubo Cardiomyopathy and Elderly Adults: Still a Benign Condition?

2015; Wiley; Volume: 63; Issue: 2 Linguagem: Inglês

10.1111/jgs.13276

1532-5415

Iván J. Núñez‐Gil, Alessandro Sionís, Mireia Andrés, Manuel Almendro Delia, Ana Martín‐Garcia, Álvaro Lozano, Juan Gabriel Córdoba Soriano, José Antonio Linares Vicente, Sílvia González Sucarrats, Alejandro Sánchez Grande Flecha, Hernán Mejía‐Rentería, Corina Biagioni, Gisela Feltes, Jose A. Barrabés,

Cardiac Health and Mental Health

To the Editor: Takotsubo syndrome (TKS)1 mimics an acute coronary syndrome2-10 and has been deemed to be related to stressful situations. The prognosis is usually good,2, 3 but data concerning TKS in elderly adults are limited and mainly based on case reports and small case series. The aim of the current study was to examine TKS in elderly adults and to compare their baseline features, clinical presentation, natural history, and long-term prognosis with those of a cohort of contemporary younger adults with TKS as a control group. A prospective database2 of individuals with TKS (Mayo modified criteria)6 between January 2003 and April 2014 and the National Spanish Registry of TKS were reviewed.8 Three hundred forty-three individuals were analyzed, 235 of whom were classified as elderly (≥65) and the remaining 107 as younger (<65). Mean follow-up was 17.3 months. Recurrence (development of a new TKS episode or similar symptoms, mainly chest discomfort), readmission to cardiology for cardiovascular causes, and death from any cause were recorded as main endpoints. A combined event of recurrence, readmission, and death was also analyzed. Patients were mostly female (89.8%), with a mean age of 69.8. A psychological trigger was identified in 46.4%. Elderly adults (mean 76.7 vs 54.6 years) were more likely to have cardiovascular risk factors, with a family history of ischemic cardiomyopathy, except smoking, which was more frequent in younger people. The older cohort had worse functional class (more advanced symptoms of heart failure) before admission. There were no statistically significant differences in length of hospital stay (median 7 days), admission left ventricular ejection fraction (48.8% vs 44.8%), and maximum creatine kinase level (183 vs 212 IU/L). Regarding treatment before admission, elderly adults were more likely to be taking aspirin (19.1% vs 8.4%, P = .01), anticoagulants (13.6% vs 2.8%, P = .002), diuretics (26.0% vs 21.5%, P < .001), beta-blockers (11.5% vs 5.6%, P = .08), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (6.0% vs 2.8%, P = .009), and anxiolytics (26.0% vs 15.0%, P = .02). The only difference found during admission was more intensive diuretic use in the older group. No differences in the use of inotropics, mechanic ventilation, intubation, intra-aortic balloon pump, antidepressants, insulin, or other drugs were found. After discharge, the older adults were more likely to be taking anticoagulants (22.2% vs 7.5%, P = .001), diuretics, and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. There were 14 deaths in the older group (cardiovascular causes, n = 3, including two sudden deaths; sepsis, n = 4; neurological, n = 2; digestive, n = 3; respiratory, n = 2; neoplasia, n = 1) and two deaths in the younger group (one each cardiogenic shock and stroke). Half of the deaths in the older group and both in the control group happened during the hospital stay. During follow-up, the elder cohort had a higher percentage of complications (Figure 1). Readmission rates (30.2% vs 22.4%) and chest pain recurrence (23.8 vs 19.6) were higher in the senior group, also. This is the first study specifically addressing an elder subpopulation with TKS. Studies in individuals of all ages (not just older adults) have generally reported a good long-term prognosis with low mortality.2-10 The current results agree with that. Nevertheless, when one considers a complex patient, such as an elderly adult, this figure could change dramatically even if the left ventricle recovers completely. During admission, elderly adults had worse Killip degrees. The different clinical profile could explain, in part, why the prognosis of the elder cohort was not as good as that of controls after discharge. Thus, there were more deaths, more recurrences, and more readmissions in the older group. Hence, although TKS is supposed to be a transient cardiomyopathy and usually displays normal left ventricular function after a while, there can be serious complications during admission and after discharge. At this point, there is no evidence to dictate specific treatment guidelines.2-9 Nevertheless, double antiplatelet therapy does not seem necessary, and treating cardiovascular risk factors,10 mainly hypertension, and avoiding potential stressors may be advisable.2 Older adults with TKS could have a worse long-term prognosis than previously reported for the overall population with this condition, which warrants thorough surveillance during the hospital stay and after discharge. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: IJN designed the registry. All the other authors participated in acquisition, analysis, and interpretation of data. IJG prepared the manuscript. Sponsor's Role: None. Jaume Figueras (Servicio de Cardiología, Hospital Vall d'Hebron, Barcelona), Oscar Fabregat Andrés y Francisco Ridocci-Soriano (Servicio de Cardiología, Consorcio Hospital General Universitario de Valencia, Valencia), Hernán D. Mejía, Gisela I. Feltes Guzmán y Corina Biagioni (Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid), Alberto Duran Cambra (Servicio de Cardiología, Hospital Sant Pau, Barcelona), José Ramón Ruiz Arroyo (Servicio de Cardiología, Hospital Clínico Lozano Blesa, Zaragoza), Teresa Bastante (Servicio de Cardiología, Hospital de la Princesa, Madrid), Martín Jesús García González (Servicio de Cardiología, Hospital Universitario de Canarias, Sta. Cruz de Tenerife), Beatriz Pérez y Manuel de Mora Martín (Servicio de Cardiología, Hospital Carlos Haya, Málaga), Juan María Escudier Villa (Servicio de Cardiología, Hospital Puerta de Hierro, Majadahonda, Madrid), Roberto Martin Reyes, Álvaro Aceña y Hans Paul Gaebelt (Servicio de Cardiología, Hospital Fundación Jiménez Díaz, Madrid), Alberto Pérez Castellanos (Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid), Ferrán Rueda Sobella y Irene Santos Pardo (Servicio de Cardiología, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona), Cristina Cambeiro, José María García Acuña y Milagros Pedreira Pérez (Servicio de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña), Jesús Piqueras Flores, Andrea Moreno Arcinegas, Jaime Benítez Peyrat, Álvaro-León Moreno Reig y Luis Ruiz Valdepeas Herrero (Servicio de Cardiología, Hospital General Universitario de Ciudad Real, Ciudad Real), Rafael Vidal Perez (Servicio de Cardiología, Hospital Da Costa, Burela, Lugo), Vicente Bodí y Ernesto Valero Picher (Servicio de Cardiología, Hospital Clínico de Valencia, Valencia), Bernardo García de la Villa Redondo y Germán Alberto Madoz Peruzzo (Servicio de Cardiología, Hospital de Manacor, Mallorca), Miguel Corbí Pascual (Servicio de Cardiología, Complejo Hospitalario Universitario de Albacete, Albacete), Mario Sutil Vega (Servicio de Cardiología. Hospital de Sant Pau, Barcelona), Pedro Luis Sánchez y Javier Jiménez Candil (Servicio de Cardiología, Hospital Universitario de Salamanca, Salamanca), Ramón Bascompte y Fernando Worner (Servicio de Cardiología, Hospital Universitario Arnau de Vilanova, Lérida), María del Carmen Manzano Nieto (Servicio de Cardiología, Hospital Severo Ochoa, Leganés, Madrid), Javier García (Servicio de Cardiología, Hospital Príncipe de Asturias, Alcalá de Henares, Madrid), Juan Carlos García Rubira (Servicio de Cardiología, Hospital Virgen de la Macarena, Sevilla).