Prevalence and prognostic relevance of atrial fibrillation in patients with Takotsubo syndrome.

Takotsubo syndrome (TTS) is associated with a considerable risk of complications during the acute phase and substantial long-term mortality rates. Concomitant atrial fibrillation may have an impact on outcome in these patients. Aim of this study was to assess the prevalence and prognostic relevance of atrial fibrillation in TTS. We performed an international, multicenter study including 387 TTS patients consecutively enrolled at 3 centers. Atrial fibrillation was defined as known history before admission or documented episodes during hospital stay. Long-term mortality was evaluated in median 2.9years after the acute event. Atrial fibrillation was found in 97 TTS patients (25.1%) and was associated with older age (p<0.01), less emotional triggers (p=0.03), higher incidence of cardiogenic shock (p<0.01), lower left ventricular ejection fraction (p<0.01), and a prolonged hospital stay (p<0.01). Determinants of atrial fibrillation at admission (n=34 patients; 9.0%) in multivariate logistic regression analysis were age (p=0.001) and cardiogenic shock (p=0.013). Long-term mortality was significantly higher in TTS patients with as compared to patients without atrial fibrillation (35.2% versus 15.3%; hazard ratio 3.02, 95% confidence interval 1.90-4.78; p<0.001). In multivariate Cox regression analysis atrial fibrillation was identified as an independent determinant of outcome even after adjustment for clinical variables, left ventricular functional parameters (ballooning pattern, ejection fraction), and cardiogenic shock. In TTS patients, atrial fibrillation is frequent and associated with increased long-term mortality rates. Furthermore, our study identifies atrial fibrillation as an independent predictor of outcome and a potential tool for risk stratification in TTS.

Stiermaier T ，Santoro F ，Eitel C ，Graf T ，Möller C ，Tarantino N ，Guastafierro F ，Di Biase M ，Thiele H ，Brunetti ND ，Eitel I ... -  《-》

Impact of Atrial Fibrillation on Outcome in Takotsubo Syndrome: Data From the International Takotsubo Registry.

El-Battrawy I ，Cammann VL ，Kato K ，Szawan KA ，Di Vece D ，Rossi A ，Wischnewsky M ，Hermes-Laufer J ，Gili S ，Citro R ，Bossone E ，Neuhaus M ，Franke J ，Meder B ，Jaguszewski M ，Noutsias M ，Knorr M ，Heiner S ，D'Ascenzo F ，Dichtl W ，Burgdorf C ，Kherad B ，Tschöpe C ，Sarcon A ，Shinbane J ，Rajan L ，Michels G ，Pfister R ，Cuneo A ，Jacobshagen C ，Karakas M ，Koenig W ，Pott A ，Meyer P ，David Arroja J ，Banning A ，Cuculi F ，Kobza R ，Fischer TA ，Vasankari T ，Airaksinen KEJ ，Napp LC ，Budnik M ，Dworakowski R ，MacCarthy P ，Kaiser C ，Osswald S ，Galiuto L ，Chan C ，Bridgman P ，Beug D ，Delmas C ，Lairez O ，Gilyarova E ，Shilova A ，Gilyarov M ，Kozel M ，Tousek P ，Winchester DE ，Galuszka J ，Ukena C ，Poglajen G ，Carrilho-Ferreira P ，Hauck C ，Paolini C ，Bilato C ，Kobayashi Y ，Prasad A ，Rihal CS ，Liu K ，Schulze PC ，Bianco M ，Jörg L ，Rickli H ，Pestana G ，Nguyen TH ，Böhm M ，Maier LS ，Pinto FJ ，Widimský P ，Felix SB ，Opolski G ，Braun-Dullaeus RC ，Rottbauer W ，Hasenfuß G ，Pieske BM ，Schunkert H ，Thiele H ，Bauersachs J ，Katus HA ，Horowitz JD ，Di Mario C ，Münzel T ，Crea F ，Bax JJ ，Lüscher TF ，Ruschitzka F ，Duru F ，Borggrefe M ，Ghadri JR ，Akin I ，Templin C ... -  《-》

Short- and Long-Term Prognostic Relevance of Cardiogenic Shock in Takotsubo Syndrome: Results From the RETAKO Registry.

This study sought to describe the incidence, determinants, and prognostic impact of cardiogenic shock (CS) in takotsubo syndrome (TTS). TTS can be associated with severe hemodynamic instability. The prognostic implication of CS has not been well characterized in large studies of TTS. We analyzed patients with a definitive TTS diagnosis (modified Mayo criteria) who were recruited for the National RETAKO (Registry on Takotsubo Syndrome) trial from 2003 to 2016. Cox and competing risk regression models were used to identify factors associated with mortality and recurrences. A total of 711 patients were included, 81 (11.4%) of whom developed CS. Male sex, QTc interval prolongation, lower left ventricular ejection fraction at admission, physical triggers, and presence of "a significant" left intraventricular pressure gradient, were associated with CS (C index = 0.85). In-hospital complication rates, including mortality, were significantly higher in patients with CS. Over a median follow-up of 284 days (interquartile range: 94 to 929 days), CS was the strongest independent predictor of long-term, all-cause mortality (hazard ratio [HR]: 5.38; 95% confidence interval [CI]: 2.60 to 8.38); cardiovascular (CV) death (sub-HR: 4.29; 95% CI: 2.40 to 21.2), and non-CV death (sub-HR: 3.34; 95% CI: 1.70 to 6.53), whereas no significant difference in the recurrence rate was observed between groups (sub-HR: 0.76; 95% CI: 0.10 to 5.95). Among patients with CS, those who received beta-blockers at hospital discharge experienced lower 1-year mortality compared with those who did not receive a beta-blocker (HR: 0.52; 95% CI: 0.44 to 0.79; pinteraction = 0.043). CS is not uncommon and is associated with worse short- and long-term prognosis in TTS. CS complicating TTS may constitute a marker of underlying disease severity and could identify a masked heart failure phenotype with increased vulnerability to catecholamine-mediated myocardial stunning.

Almendro-Delia M ，Núñez-Gil IJ ，Lobo M ，Andrés M ，Vedia O ，Sionis A ，Martin-García A ，Cruz Aguilera M ，Pereyra E ，Martín de Miguel I ，Linares Vicente JA ，Corbí-Pascual M ，Bosch X ，Fabregat Andrés O ，Sánchez Grande Flecha A ，Pérez-Castellanos A ，Pais JL ，De Mora Martín M ，Escudier Villa JM ，Martín Asenjo R ，Guillen Marzo M ，Rueda Sobella F ，Aceña Á ，García Acuña JM ，García-Rubira JC ，RETAKO Investigators ... -  《-》

Prevalence and Prognostic Impact of Diabetes in Takotsubo Syndrome: Insights From the International, Multicenter GEIST Registry.

In view of low prevalence rates, diabetes is discussed as a protective factor for the occurrence of Takotsubo syndrome (TTS). Furthermore, it was associated with improved outcome in a small single-center analysis. Therefore, this study assessed the prevalence and prognostic relevance of concomitant diabetes in TTS. A total of 826 patients with TTS were enrolled in an international, multicenter, registry-based study (eight centers in Italy and Germany). All-cause mortality was compared between patients with diabetes and patients without diabetes, and the independent predictive value of diabetes was evaluated in multivariate regression analysis. The prevalence of diabetes was 21.1% (n = 174). TTS patients with diabetes were older (P < 0.001), were more frequently male (P = 0.003), had a higher prevalence of hypertension (P < 0.001), physical triggers (P = 0.041), and typical apical ballooning (P = 0.010), had a lower left ventricular ejection fraction (P = 0.008), had a higher rate of pulmonary edema (P = 0.032), and had a longer hospital stay (P = 0.009). However, 28-day all-cause mortality did not differ between patients with diabetes and patients without diabetes (6.4% vs. 5.7%; hazard ratio [HR] 1.11 [95% CI 0.55-2.25]; P = 0.772). Longer-term follow-up after a median of 2.5 years revealed a significantly higher mortality among TTS patients with diabetes (31.4% vs. 16.5%; P < 0.001), and multivariate regression analysis identified diabetes as an independent predictor of adverse outcome (HR 1.66 [95% CI 1.16-2.39]; P = 0.006). Diabetes is not uncommon in patients with TTS, is associated with increased longer-term mortality rates, and is an independent predictor of adverse outcome irrespective of additional risk factors.

Stiermaier T ，Santoro F ，El-Battrawy I ，Möller C ，Graf T ，Novo G ，Santangelo A ，Mariano E ，Romeo F ，Caldarola P ，Fanelli M ，Thiele H ，Brunetti ND ，Akin I ，Eitel I ... -  《-》

Impact of persistent ST elevation on outcome in patients with Takotsubo syndrome. Results from the GErman Italian STress Cardiomyopathy (GEIST) registry.

Potential predictors of clinical complications of Takotsubo syndrome (TTS) are poorly known. Persistent ST-segment elevation (PSTE) may have an impact on outcome similar as previously reported in acute coronary syndrome. The aim of this study was to assess the prevalence and prognostic relevance of PSTE in patients with TTS. Two-hundred-sixty-nine consecutive patients were enrolled in an international multicenter registry. PSTE was defined as the documentation of ST-elevation at least for the first 48h of hospitalization. Long-term mortality was evaluated in median 1.9years after the acute event. PSTE was found in 52 TTS patients (19%). Patients with PSTE were characterized by higher admission levels of troponin-I (23±12 vs 8±49ng/L, p<0.001), experienced a longer hospitalization (10±5 vs 8±3days, p=0.02) and a higher rate of in-hospital complications (31% vs 17% p=0.03). At multivariate analysis including PSTE, age, male sex, admission ejection fraction, PSTE (odds ratio [OR] 4.2; 95% confidence interval [CI] 1.4-13; p=0.01), age (OR 1.05; 95%CI 1.00-1.10; p=0.03) and admission ejection fraction (OR 0.93; 95%CI 0.87-0.99; p=0.02) were independent predictors of in-hospital complications. At long-term follow-up no significant differences in terms of mortality were observed between patients with and without PSTE (19% vs 15%; p=0.5). However, PSTE was a predictor of major cardiac adverse events (MACE) at follow-up (HR 2.32, 95% CI 1.02-5.31, p 0.045). In TTS patients, PSTE is a common finding, represents an independent predictor of in-hospital complications and could be associated with MACE at follow-up.

Santoro F ，Stiermaier T ，Tarantino N ，Guastafierro F ，Graf T ，Möller C ，Di Martino LFM ，Thiele H ，Di Biase M ，Eitel I ，Brunetti ND ... -  《-》