Outcomes Associated With Cardiogenic Shock in Takotsubo Syndrome
2019; Lippincott Williams & Wilkins; Volume: 139; Issue: 3 Linguagem: Inglês
10.1161/circulationaha.118.036164
ISSN1524-4539
AutoresDavide Di Vece, Rodolfo Citro, Victoria L. Cammann, Ken Kato, Sebastiano Gili, Konrad A. Szawan, Jozef Micek, Stjepan Jurisic, Katharina J. Ding, Beatrice Bacchi, Moritz Schwyzer, Alessandro Candreva, Eduardo Bossone, Fabrizio D’Ascenzo, Annahita Sarcon, Jennifer Franke, L. Christian Napp, Miłosz Jaguszewski, Michel Noutsias, Thomas Münzel, Maike Knorr, Susanne Heiner, Hugo A. Katus, Christof Burgdorf, Heribert Schunkert, Hölger Thiele, Johann Bauersachs, Carsten Tschöpe, Burkert Pieske, Lawrence Rajan, Guido Michels, Roman Pfister, Alessandro Cuneo, Claudius Jacobshagen, Gerd Hasenfuβ, Mahir Karakas, Wolfgang Köenig, Wolfgang Rottbauer, Samir M. Said, Ruediger C. Braun‐Dullaeus, Adrian Banning, Florim Cuculi, Richard Kobza, Thomas Fischer, Tuija Vasankari, Juhani Airaksinen, Grzegorz Opolski, Rafał Dworakowski, Philip MacCarthy, Christoph Kaiser, Stefan Osswald, Leonarda Galiuto, Filippo Crea, Wolfgang Dichtl, Klaus Empen, Stephan B. Felix, Clément Delmas, Olivier Lairez, Ibrahim El‐Battrawy, İbrahim Akın, Martin Borggrefe, Ekaterina Gilyarova, Alexandra Shilova, Mikhail Gilyarov, John D. Horowitz, Martin Kozel, Petr Toušek, Petr Widimský, David E. Winchester, Christian Ukena, Carlo Di Mario, Abhiram Prasad, Michael Böhm, Jeroen J. Bax, Thomas F. Lüscher, Frank Ruschitzka, Jelena R. Ghadri, Christian Templin,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoHomeCirculationVol. 139, No. 3Outcomes Associated With Cardiogenic Shock in Takotsubo Syndrome Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBOutcomes Associated With Cardiogenic Shock in Takotsubo SyndromeResults From the International Takotsubo Registry Davide Di Vece, MD, Rodolfo Citro, MD, PhD, Victoria L. Cammann, Ken Kato, MD, PhD, Sebastiano Gili, MD, Konrad A. Szawan, Jozef Micek, Stjepan Jurisic, MD, Katharina J. Ding, Beatrice Bacchi, MD, Moritz Schwyzer, MD, Alessandro Candreva, MD, Eduardo Bossone, MD, PhD, Fabrizio D’Ascenzo, MD, PhD, Annahita Sarcon, MD, Jennifer Franke, MD, L. Christian Napp, MD, Milosz Jaguszewski, MD, PhD, Michel Noutsias, MD, Thomas Münzel, MD, Maike Knorr, MD, Susanne Heiner, MD, Hugo A. Katus, MD, Christof Burgdorf, MD, Heribert Schunkert, MD, Holger Thiele, MD, Johann Bauersachs, MD, Carsten Tschöpe, MD, Burkert M. Pieske, MD, Lawrence Rajan, MD, Guido Michels, MD, Roman Pfister, MD, Alessandro Cuneo, MD, Claudius Jacobshagen, MD, Gerd Hasenfuβ, MD, Mahir Karakas, MD, Wolfgang Koenig, MD, Wolfgang Rottbauer, MD, Samir M. Said, MD, Ruediger C. Braun-Dullaeus, MD, Adrian Banning, MD, Florim Cuculi, MD, Richard Kobza, MD, Thomas A. Fischer, MD, Tuija Vasankari, MD, K.E. Juhani Airaksinen, MD, Grzegorz Opolski, MD, PhD, Rafal Dworakowski, MD, Philip MacCarthy, MD, PhD, Christoph Kaiser, MD, Stefan Osswald, MD, Leonarda Galiuto, MD, PhD, Filippo Crea, MD, Wolfgang Dichtl, MD, PhD, Klaus Empen, MD, Stephan B. Felix, MD, Clément Delmas, MD, Olivier Lairez, MD, PhD, Ibrahim El-Battrawy, MD, Ibrahim Akin, MD, Martin Borggrefe, MD, Ekaterina Gilyarova, MD, Alexandra Shilova, MD, PhD, Mikhail Gilyarov, MD, PhD, John Horowitz, MBBS, PhD, Martin Kozel, MD, Petr Tousek, MD, PhD, Petr Widimský, MD, PhD, David E. Winchester, MD, Christian Ukena, MD, Carlo Di Mario, MD, PhD, Abhiram Prasad, MD, Michael Böhm, MD, Jeroen J. Bax, MD, PhD, Thomas F. Lüscher, MD, Frank Ruschitzka, MD, Jelena R. Ghadri, MD and Christian Templin, MD, PhD Davide Di VeceDavide Di Vece Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland (D.D.V., V.L.C., K.K., S.G., K.A.S., J.M., S.J., K.J.D., B.B., M.S., A.C., F.R., J.R.G., C.T.). *Drs Di Vece and Citro contributed equally. Search for more papers by this author , Rodolfo CitroRodolfo Citro Heart Department, University Hospital San Giovanni di Dio e Ruggi d’Aragona, Salerno, Italy (R.C., E.B.). *Drs Di Vece and Citro contributed equally. Search for more papers by this author , Victoria L. CammannVictoria L. Cammann Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland (D.D.V., V.L.C., K.K., S.G., K.A.S., J.M., S.J., K.J.D., B.B., M.S., A.C., F.R., J.R.G., C.T.). Search for more papers by this author , Ken KatoKen Kato Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland (D.D.V., V.L.C., K.K., S.G., K.A.S., J.M., S.J., K.J.D., B.B., M.S., A.C., F.R., J.R.G., C.T.). Search for more papers by this author , Sebastiano GiliSebastiano Gili Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland (D.D.V., V.L.C., K.K., S.G., K.A.S., J.M., S.J., K.J.D., B.B., M.S., A.C., F.R., J.R.G., C.T.). Search for more papers by this author , Konrad A. SzawanKonrad A. Szawan Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland (D.D.V., V.L.C., K.K., S.G., K.A.S., J.M., S.J., K.J.D., B.B., M.S., A.C., F.R., J.R.G., C.T.). Search for more papers by this author , Jozef MicekJozef Micek Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland (D.D.V., V.L.C., K.K., S.G., K.A.S., J.M., S.J., K.J.D., B.B., M.S., A.C., F.R., J.R.G., C.T.). Search for more papers by this author , Stjepan JurisicStjepan Jurisic Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland (D.D.V., V.L.C., K.K., S.G., K.A.S., J.M., S.J., K.J.D., B.B., M.S., A.C., F.R., J.R.G., C.T.). Search for more papers by this author , Katharina J. DingKatharina J. Ding Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland (D.D.V., V.L.C., K.K., S.G., K.A.S., J.M., S.J., K.J.D., B.B., M.S., A.C., F.R., J.R.G., C.T.). Search for more papers by this author , Beatrice BacchiBeatrice Bacchi Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland (D.D.V., V.L.C., K.K., S.G., K.A.S., J.M., S.J., K.J.D., B.B., M.S., A.C., F.R., J.R.G., C.T.). Search for more papers by this author , Moritz SchwyzerMoritz Schwyzer Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland (D.D.V., V.L.C., K.K., S.G., K.A.S., J.M., S.J., K.J.D., B.B., M.S., A.C., F.R., J.R.G., C.T.). Search for more papers by this author , Alessandro CandrevaAlessandro Candreva Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland (D.D.V., V.L.C., K.K., S.G., K.A.S., J.M., S.J., K.J.D., B.B., M.S., A.C., F.R., J.R.G., C.T.). Search for more papers by this author , Eduardo BossoneEduardo Bossone Heart Department, University Hospital San Giovanni di Dio e Ruggi d’Aragona, Salerno, Italy (R.C., E.B.). Search for more papers by this author , Fabrizio D’AscenzoFabrizio D’Ascenzo Department of Medical Sciences, Division of Cardiology, AOU Città della Salute e della Scienza, University of Turin, Italy (F.D.A.). Search for more papers by this author , Annahita SarconAnnahita Sarcon Keck School of Medicine, University of Southern California, Los Angeles (A.S.). Search for more papers by this author , Jennifer FrankeJennifer Franke Department of Cardiology, Heidelberg University Hospital, Germany (J.F., H.A.K.) Search for more papers by this author , L. Christian NappL. Christian Napp Department of Cardiology and Angiology, Hannover Medical School, Germany (L.C.N., J.B.). Search for more papers by this author , Milosz JaguszewskiMilosz Jaguszewski First Department of Cardiology, Medical University of Gdansk, Poland (M.J.). Search for more papers by this author , Michel NoutsiasMichel Noutsias Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Germany (M.N.). Search for more papers by this author , Thomas MünzelThomas Münzel Center for Cardiology, Cardiology 1, University Medical Center Mainz, Germany (T.M., M.K., S.H.). Search for more papers by this author , Maike KnorrMaike Knorr Center for Cardiology, Cardiology 1, University Medical Center Mainz, Germany (T.M., M.K., S.H.). Search for more papers by this author , Susanne HeinerSusanne Heiner Center for Cardiology, Cardiology 1, University Medical Center Mainz, Germany (T.M., M.K., S.H.). Search for more papers by this author , Hugo A. KatusHugo A. Katus Department of Cardiology, Heidelberg University Hospital, Germany (J.F., H.A.K.) Search for more papers by this author , Christof BurgdorfChristof Burgdorf Heart and Vascular Centre Bad Bevensen, Germany (C.B.). Search for more papers by this author , Heribert SchunkertHeribert Schunkert Deutsches Herzzentrum München, Technische Universität München, Germany (H.S., W.K.). German Centre for Cardiovascular Research, Munich Heart Alliance, Germany (H.S., W.K.). Search for more papers by this author , Holger ThieleHolger Thiele Department of Internal Medicine/Cardiology, Heart Center Leipzig, University Hospital, Germany (H.T.). Search for more papers by this author , Johann BauersachsJohann Bauersachs Department of Cardiology and Angiology, Hannover Medical School, Germany (L.C.N., J.B.). Search for more papers by this author , Carsten TschöpeCarsten Tschöpe Department of Cardiology, Charité, Campus Rudolf Virchow, Berlin, Germany (C.T., B.M.P.). Search for more papers by this author , Burkert M. PieskeBurkert M. Pieske Department of Cardiology, Charité, Campus Rudolf Virchow, Berlin, Germany (C.T., B.M.P.). Search for more papers by this author , Lawrence RajanLawrence Rajan TJ Health Partners Heart and Vascular, Glasgow, Kentucky (L.R.). Search for more papers by this author , Guido MichelsGuido Michels Department of Internal Medicine III, Heart Center University of Cologne, Germany (G.M., R.P.). Search for more papers by this author , Roman PfisterRoman Pfister Department of Internal Medicine III, Heart Center University of Cologne, Germany (G.M., R.P.). Search for more papers by this author , Alessandro CuneoAlessandro Cuneo Krankenhaus “Maria Hilf” Medizinsche Klinik, Stadtlohn, Germany (A.C.). Search for more papers by this author , Claudius JacobshagenClaudius Jacobshagen Clinic for Cardiology and Pneumology, Georg August University Goettingen, Goettingen, Germany (C.J., G.H.). Search for more papers by this author , Gerd HasenfuβGerd Hasenfuβ Clinic for Cardiology and Pneumology, Georg August University Goettingen, Goettingen, Germany (C.J., G.H.). Search for more papers by this author , Mahir KarakasMahir Karakas Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (M.K.). Search for more papers by this author , Wolfgang KoenigWolfgang Koenig Deutsches Herzzentrum München, Technische Universität München, Germany (H.S., W.K.). German Centre for Cardiovascular Research, Munich Heart Alliance, Germany (H.S., W.K.). Search for more papers by this author , Wolfgang RottbauerWolfgang Rottbauer Department of Internal Medicine II–Cardiology, University of Ulm, Medical Center, Germany (W.R.). Search for more papers by this author , Samir M. SaidSamir M. Said Department of Cardiac Electrophysiology, Helios St Marienberg, Hospital Helmstedt, Germany (S.M.S.). Search for more papers by this author , Ruediger C. Braun-DullaeusRuediger C. Braun-Dullaeus Internal Medicine/Cardiology, Angiology, and Pneumology, Magdeburg University, Germany (R.C., B.D.). Search for more papers by this author , Adrian BanningAdrian Banning Department of Cardiology, John Radcliffe Hospital, Oxford University Hospitals, United Kingdom (A.B.). Search for more papers by this author , Florim CuculiFlorim Cuculi Department of Cardiology, Kantonsspital Lucerne, Switzerland (F.C., R.K.). Search for more papers by this author , Richard KobzaRichard Kobza Department of Cardiology, Kantonsspital Lucerne, Switzerland (F.C., R.K.). Search for more papers by this author , Thomas A. FischerThomas A. Fischer Department of Cardiology, Kantonsspital Winterthur, Switzerland (T.A.F.). Search for more papers by this author , Tuija VasankariTuija Vasankari Heart Center, Turku University Hospital and University of Turku, Finland (T.V., K.E.J.A.). Search for more papers by this author , K.E. Juhani AiraksinenK.E. Juhani Airaksinen Heart Center, Turku University Hospital and University of Turku, Finland (T.V., K.E.J.A.). Search for more papers by this author , Grzegorz OpolskiGrzegorz Opolski Department of Cardiology, Medical University of Warsaw, Poland (G.O.). Search for more papers by this author , Rafal DworakowskiRafal Dworakowski Department of Cardiology, Kings College Hospital, Kings Health Partners, London, United Kingdom (R.D., P.M.). Search for more papers by this author , Philip MacCarthyPhilip MacCarthy Department of Cardiology, Kings College Hospital, Kings Health Partners, London, United Kingdom (R.D., P.M.). Search for more papers by this author , Christoph KaiserChristoph Kaiser Department of Cardiology, University Hospital Basel, Switzerland (C.K., S.O.). Search for more papers by this author , Stefan OsswaldStefan Osswald Department of Cardiology, University Hospital Basel, Switzerland (C.K., S.O.). Search for more papers by this author , Leonarda GaliutoLeonarda Galiuto Department of Cardiovascular Sciences, Catholic University of the Sacred Heart Rome, Italy (L.G., F.C.). Search for more papers by this author , Filippo CreaFilippo Crea Department of Cardiovascular Sciences, Catholic University of the Sacred Heart Rome, Italy (L.G., F.C.). Search for more papers by this author , Wolfgang DichtlWolfgang Dichtl University Hospital for Internal Medicine III, Cardiology and Angiology, Medical University Innsbruck, Austria (W.D.). Search for more papers by this author , Klaus EmpenKlaus Empen Department of Internal Medicine, Kreiskrankenhaus Wolgast, Germany (K.E.). Search for more papers by this author , Stephan B. FelixStephan B. Felix Department of Internal Medicine B, University Medicine Greifswald, Germany (S.B.F.). German Centre for Cardiovascular Research, Greifswald, Germany (S.B.F.). Search for more papers by this author , Clément DelmasClément Delmas Department of Cardiology and Cardiac Imaging Center, University Hospital of Rangueil, Toulouse, France (C.D., O.L.). Search for more papers by this author , Olivier LairezOlivier Lairez Department of Cardiology and Cardiac Imaging Center, University Hospital of Rangueil, Toulouse, France (C.D., O.L.). Search for more papers by this author , Ibrahim El-BattrawyIbrahim El-Battrawy First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany (I.E, I.A., M.B). German Center for Cardiovascular Research, Heidelberg-Mannheim, Germany (I.E, I.A., M.B.). Search for more papers by this author , Ibrahim AkinIbrahim Akin First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany (I.E, I.A., M.B). German Center for Cardiovascular Research, Heidelberg-Mannheim, Germany (I.E, I.A., M.B.). Search for more papers by this author , Martin BorggrefeMartin Borggrefe First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany (I.E, I.A., M.B). German Center for Cardiovascular Research, Heidelberg-Mannheim, Germany (I.E, I.A., M.B.). Search for more papers by this author , Ekaterina GilyarovaEkaterina Gilyarova Intensive Coronary Care Unit, Moscow City Hospital, Russia (E.G., A.S., M.G.). Search for more papers by this author , Alexandra ShilovaAlexandra Shilova Intensive Coronary Care Unit, Moscow City Hospital, Russia (E.G., A.S., M.G.). Search for more papers by this author , Mikhail GilyarovMikhail Gilyarov Intensive Coronary Care Unit, Moscow City Hospital, Russia (E.G., A.S., M.G.). Search for more papers by this author , John HorowitzJohn Horowitz Department of Cardiology, Basil Hetzel Institute, Queen Elizabeth Hospital, University of Adelaide, Australia (J.H.). Search for more papers by this author , Martin KozelMartin Kozel German Centre for Cardiovascular Research, Hamburg/Kiel/Luebeck, Germany (M.K.). Charles University, University Hospital Kralovske Vinohrady, Czech Republic (M.K., P.T., P.W.). Search for more papers by this author , Petr TousekPetr Tousek Charles University, University Hospital Kralovske Vinohrady, Czech Republic (M.K., P.T., P.W.). Search for more papers by this author , Petr WidimskýPetr Widimský Charles University, University Hospital Kralovske Vinohrady, Czech Republic (M.K., P.T., P.W.). Search for more papers by this author , David E. WinchesterDavid E. Winchester Department of Medicine, College of Medicine, University of Florida, Gainesville (D.E.W.). Search for more papers by this author , Christian UkenaChristian Ukena Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany (C.U., M.B.). Search for more papers by this author , Carlo Di MarioCarlo Di Mario Structural Interventional Cardiology, University Hospital Careggi, Florence, Italy (C.D.M.). Search for more papers by this author , Abhiram PrasadAbhiram Prasad Division of Cardiovascular Diseases, Mayo Clinic, Rochester MN (A.P.). Search for more papers by this author , Michael BöhmMichael Böhm Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany (C.U., M.B.). Search for more papers by this author , Jeroen J. BaxJeroen J. Bax Department of Cardiology, Leiden University Medical Centre, The Netherlands (J.J.B.). Search for more papers by this author , Thomas F. LüscherThomas F. Lüscher Center for Molecular Cardiology, Schlieren Campus, University of Zurich, Switzerland (T.F.L.). Royal Brompton and Harefield Hospitals Trust and Imperial College, London, United Kingdom (T.F.L). Search for more papers by this author , Frank RuschitzkaFrank Ruschitzka Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland (D.D.V., V.L.C., K.K., S.G., K.A.S., J.M., S.J., K.J.D., B.B., M.S., A.C., F.R., J.R.G., C.T.). Search for more papers by this author , Jelena R. GhadriJelena R. Ghadri Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland (D.D.V., V.L.C., K.K., S.G., K.A.S., J.M., S.J., K.J.D., B.B., M.S., A.C., F.R., J.R.G., C.T.). Search for more papers by this author and Christian TemplinChristian Templin Christian Templin, MD, PhD, Department of Cardiology, Acute Cardiac Care, Andreas Grüntzig Heart Catheterization Laboratories, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091 Zurich, Switzerland. Email E-mail Address: [email protected] Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland (D.D.V., V.L.C., K.K., S.G., K.A.S., J.M., S.J., K.J.D., B.B., M.S., A.C., F.R., J.R.G., C.T.). Search for more papers by this author Originally published10 Nov 2018https://doi.org/10.1161/CIRCULATIONAHA.118.036164Circulation. 2019;139:413–415Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: November 10, 2018: Ahead of Print The clinical course of takotsubo syndrome (TTS) can be complicated by several life-threatening conditions.1 In particular, cardiogenic shock (CS) represents one of the leading causes of mortality in the acute phase and occurs in a considerable number of patients with TTS, with an incidence of ≈10%.2,3 At present, no established guidelines are available to support specific treatment recommendations, and the conventional therapy for CS leads to uncertain results in TTS cases.4 The International Takotsubo Registry (www.takotsubo-registry.com) is an observational, prospective, and retrospective registry established at the University Hospital Zurich in 2011, with the largest TTS database worldwide. Patients were included in the registry between 2011 and 2017 based on modified Mayo Clinic Diagnostic criteria.1,5 Hospitalization data were recorded through standardized forms on admission or during revision of clinical charts; follow-up data were obtained from medical records, telephone follow-up, or clinical visits.1 The study population was categorized into 2 groups: patients with TTS with and without CS. The study protocol was reviewed by the respective local ethics committees or investigational review boards at each collaboration site. Where informed consent was required, formal written consent was obtained from patients.Overall, 2078 patients were included in the present analysis. Of these patients, 198 (9.5%) experienced CS. Of 170 patients with sufficient information regarding CS timing, 119 (70%) presented signs of CS on admission, whereas 51 (30%) developed CS during hospitalization. Patients with TTS with CS were younger (63.4±14.9 years versus 67.2±12.6 years, P<0.001) and more frequently males (14.1% versus 9.3%, P=0.027) than those without CS. Compared with patients without CS, patients with CS more often experienced physical triggers (66.7% versus 33.0%, P<0.001), in contrast to a lower prevalence of emotional triggers (10.6% versus 31.7%, P<0.001). Furthermore, apical TTS occurred more often in patients with CS (80.3% versus 70.2%, P<0.001). Atrial fibrillation on admission ECG (13.1% versus 5.7%, P<0.001) as well as lower left ventricular ejection fraction (32.7±11.5% versus 41.6±11.3%, P<0.001) were detected more frequently in patients with CS. It is important to note that patients with CS had a higher prevalence of major cardiovascular risk factors such as diabetes mellitus (21.0% versus 14.8%, P=0.023) and smoking (27.4% versus 19.3%, P=0.010). Furthermore, neurologic disorders were more prevalent among patients with TTS and CS (31.7% versus 23.4%, P=0.013). On admission, patients with CS were taking less frequently angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers (30.3% versus 39.1%, P=0.038) and statins (13.2% versus 20.7%, P=0.033) than those without CS. Multivariable logistic regression demonstrated that apical TTS (odds ratio [OR], 1.68; 95% CI, 1.15–2.46; P=0.007), physical stress (OR, 2.84; 95% CI, 1.96–4.12; P<0.001), left ventricular ejection fraction <45% (OR, 2.49; 95% CI, 1.63–3.80; P 70 years (OR, 0.62; 95% CI, 0.44–0.87; P=0.005) and emotional stress (OR, 0.53; 95% CI, 0.31–0.91; P=0.021) were negatively associated with risk of developing CS (Figure, A). Patients with CS had a significantly higher rate of in-hospital (23.5% versus 2.3%, P<0.001) and 60-day (P<0.001) (Figure, B) mortality compared with patients without CS. Furthermore, patients with CS who received cardiac mechanical support (n=39), including intraaortic balloon pump (n=39), Impella (n=1), and/or extracorporeal membrane oxygenation (n=1), had a lower in-hospital mortality rate than those without cardiac mechanical support (5 of 39 [12.8%] versus 45 of 159 [28.3%], P=0.046). This result was also confirmed by propensity score analysis computed with cardiac mechanical support as a dependent variable and clinical parameters such as age, sex, physical trigger, left ventricular ejection fraction, heart rate as potential confounding variables (OR, 0.34; 95% CI, 0.12–0.95; P=0.04). A landmark survival analysis demonstrated a high mortality rate for patients with CS at 60 days as well as at 5-year follow-up (P<0.001) (Figure, B).Download figureDownload PowerPointFigure. Factors associated with cardiogenic shock in takotsubo syndrome and landmark survival analysis.A, Multivariable logistic regression showed that apical type, physical stress, left ventricular ejection fraction (LVEF) <45%, atrial fibrillation, and diabetes mellitus were independently associated with the development of cardiogenic shock in takotsubo syndrome (TTS). Errors bars represent 95% CI. Black rhombi indicate statistical significance, grey rhombi not statistical significance. B, Landmark survival analysis demonstrated a worse outcome within the first 60 days after admission (P<0.001) as well as at 5-year follow-up (P<0.001). ACE indicates angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; and OR, odds ratio.CS complicates the in-hospital mortality course of ≈10% of patients with TTS. The high rate of in-hospital mortality and the controversies regarding medical therapy emphasize the need for early identification of patients with TTS with initial signs of CS or at high risk of developing hemodynamic instability during hospitalization. Therefore, this study suggests that parameters easily detectable on admission, such as apical TTS, physical stress, lower left ventricular ejection fraction, diabetes mellitus, and atrial fibrillation, might enable primary risk stratification for the identification of patients more prone to develop CS, hence requiring closer clinical and echocardiographic monitoring. Cardiac mechanical support might be valuable as a bridge-to-recovery therapy, aiming to reduce TTS mortality in the acute stage. It is surprising that patients with CS experienced worse outcomes not only during the acute phase but also at 5-year follow-up. It is conceivable that the higher prevalence of physical triggers and certain comorbidities might impact the short- and long-term prognoses of patients with CS. Further studies are needed to investigate the appropriate treatment of patients with TTS and CS in both the acute phase and at long-term follow-up.Sources of FundingJ.R.G. has received a “Filling the Gap” grant from the University of Zurich. C.T. has been supported by the H.H. Sheikh Khalifa bin Hamad Al-Thani Research Programme.DisclosuresNone.Footnotes*Drs Di Vece and Citro contributed equally.https://www.ahajournals.org/journal/circData sharing: The data, analytic methods, and study materials will not be made available to other researchers for purposes of reproducing the results or replicating the procedure.Christian Templin, MD, PhD, Department of Cardiology, Acute Cardiac Care, Andreas Grüntzig Heart Catheterization Laboratories, University Hospital Zurich, University Heart Center, Raemistrasse 100, 8091 Zurich, Switzerland. Email christian.[email protected]chReferences1. 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Tehrani B, Epps K and Sherwood M (2022) Unloading a Broken Heart: Impella Support for Takotsubo Syndrome Complicated by Cardiogenic Shock, Cardiovascular Revascularization Medicine, 10.1016/j.carrev.2022.04.020, 40, (120-122), Online publication date: 1-Jul-2022. Napp L, Westenfeld R, Møller J, Pappalardo F, Ibrahim K, Bonello L, Wilkins C, Pershad A, Mannino S, Schreiber T, Hall P, Medjamia A, Haurand J, Sieweke J, Schäfer A, Grines C, Burkhoff D, Moses J, Ohman E, O'Neill W, Kapur N and Bauersachs J (2022) Impella Mechanical Circulatory Support for Takotsubo Syndrome With Shock: A Retrospective Multicenter Analysis, Cardiovascular Revascularization Medicine, 10.1016/j.carrev.2021.11.018, 40, (113-119), Online publication date: 1-Jul-2022. Silverio A, Bellino M, Galasso G, Bossone E and Citro R (2022) Response to: Correspondence on ‘Beta-blockers are associated with better long-term survival in patients with Takotsubo syndrome’ by Chang et al , Heart, 10.1136/heartjnl-2022-321263, (heartjnl-2022-321263) Singh T, Khan H, Gamble D, Scally C, Newby D and Dawson D (2022) Takotsubo Syndrome: Pathophysiology, Emerging Concepts, and Clinical Implications, Circulation, 145:13, (1002-1019), Online publication date: 29-Mar-2022. Benak A, Sramko M, Janek B, Zelizko M and Kautzner J Successful Treatment of Cardiogenic Shock Due to Takotsubo Cardiomyopathy With Left Ventricular Outflow Tract Obstruction and Acute Mitral Regurgitation by Impella CP, Cureus, 10.7759/cureus.23168 Terasaki S, Kanaoka K, Nakai M, Sumita Y, Onoue K, Soeda T, Watanabe M, Miyamoto Y and Saito Y (2022) Outcomes of catecholamine and/or mechanical support in Takotsubo syndrome, Heart, 10.1136/heartjnl-2021-319904, (heartjnl-2021-319904) Vincent L, Grant J, Ebner B, Maning J, Montana P, Olorunfemi O, Olarte N, de Marchena E, Munagala M and Colombo R (2022) Effect of Gender on Prognosis in Patients With Takotsubo Syndrome (from a Nationwide Perspective), The Ame
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