Expert Consensus on Takotsubo Syndrome, Part II

Authors:
Ghadri JR, Wittstein IS, Prasad A, et al.
Citation:
International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management. Eur Heart J 2018;May 29:[Epub ahead of print].

The following are key points to remember from part II of this International Expert Consensus Document on Takotsubo Syndrome (TTS):

  1. Patients presenting with ST-segment elevation should undergo urgent coronary angiography with left ventriculography to exclude acute myocardial infarction (AMI). In patients with non–ST-segment elevation, the InterTAK Diagnostic Score can be considered. Patients with a low probability (InterTAK Score ≤70 points) should undergo coronary angiography with left ventriculography, while in patients with a high score (score ≥70), transthoracic echocardiography should be considered.
  2. The InterTAK Diagnostic Score comprises seven parameters (female sex, emotional trigger, physical trigger, absence of ST-segment depression [except in lead aVR], psychiatric disorders, neurologic disorders, and QT prolongation) ranked by their diagnostic importance with a maximum attainable score of 100 points.
  3. Recently, specific cardiac magnetic resonance criteria for TTS diagnosis at the time of acute presentation were established, which include the combination of typical regional wall motion abnormalities, edema, and the absence of evidence of irreversible tissue injury (late gadolinium enhancement [LGE]).
  4. Although TTS has generally been considered a benign disease, contemporary observations show that rates of cardiogenic shock and death are comparable to acute coronary syndrome (ACS) patients treated according to current guidelines.
  5. Guidelines regarding TTS management are lacking, as no prospective randomized clinical trials have been performed in this patient population. Therapeutic strategies are therefore based on clinical experience and expert consensus.
  6. As TTS is clinically difficult to distinguish from ACS, upon first presentation, patients should be transferred to a cardiology unit with imaging capabilities and a cardiac catheterization laboratory and receive guideline-based treatment of ACS, in particular aspirin, heparin, and if required, morphine and oxygen. Patients with cardiogenic shock or post-cardiac arrest require intensive care.
  7. As catecholamine levels are elevated in TTS, beta-blockers seem to be reasonable until full recovery of left ventricular ejection fraction, but trials supporting this hypothesis are lacking. Furthermore, due to the potential risk of pause-dependent torsades de pointes, beta-blockers should be used cautiously, especially in patients with bradycardia and QTc >500 ms.
  8. The use of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers was associated with improved survival at 1-year follow-up even after propensity matching. In contrast, there was no evidence of any survival benefit for the use of beta-blockers.
  9. Psychiatric disorders (e.g., depression, anxiety) are common in TTS patients, and those might benefit from a combined psychocardiologic rehabilitation.
  10. TTS is more than a cardiac disease, and it requires a new and interdisciplinary approach to increase awareness among not only cardiologists, but physicians at large. To establish evidence-based strategies for effective TTS treatment, randomized prospective trials will be necessary, utilizing a large number of patients from multicenter international consortia.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Anticoagulation Management and ACS, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Interventions and ACS, Interventions and Imaging, Angiography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Adrenergic beta-Antagonists, Arrhythmias, Cardiac, Aspirin, Bradycardia, Catecholamines, Coronary Angiography, Depression, Diagnostic Imaging, Echocardiography, Edema, Gadolinium, Heart Arrest, Heart Failure, Heparin, Magnetic Resonance Spectroscopy, Mental Disorders, Nervous System Diseases, Shock, Cardiogenic, Stroke Volume, Takotsubo Cardiomyopathy, Torsades de Pointes


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