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Cardiogenic Shock and Takotsubo Syndrome
Study Questions:
What is the incidence, determinants, and prognostic impact of cardiogenic shock (CS) in takotsubo syndrome (TTS)?
Methods:
The investigators analyzed 711 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. The National Multicenter RETAKO trial, sponsored by the Ischemic Heart Disease and Acute Cardiovascular Care Section of the Spanish Society of Cardiology, is a partially retrospective and prospective (from January 1, 2012, onwards) voluntary observational study that enrolled TTS patients from 23 centers in Spain. Cox and competing risk regression models were used to identify factors associated with mortality and recurrences. In addition, a 30-day landmark analysis was performed to evaluate short-term mortality.
Results:
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, 94-929 days), CS was the strongest independent predictor of long-term, all-cause mortality (hazard ratio [HR], 5.38; 95% confidence interval [CI], 2.60-8.38); cardiovascular (CV) death (sub-HR, 4.29; 95% CI, 2.40-21.2), and non-CV death (sub-HR, 3.34; 95% CI, 1.70-6.53), whereas no significant difference in the recurrence rate was observed between groups (sub-HR, 0.76; 95% CI, 0.10-5.95). 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, 0.44-0.79; p for interaction = 0.043).
Conclusions:
The authors concluded that CS is not uncommon and is associated with worse short- and long-term prognosis in TTS.
Perspective:
This study reports that CS was not an uncommon clinical complication of TTS and male sex, left ventricular outflow tract gradient, stressful physical triggers, longer QTc intervals, and lower left ventricular ejection fractions at admission were related to CS. Overall, non-CV mortality, due to underlying comorbidities, was the leading cause of death in patients with TTS, regardless of the CS diagnosis. Furthermore, the independent association of CS with an increased mortality risk in TTS was not restricted to the acute phase and persisted for the long-term even for CV mortality, and patients who were discharged on beta-blockers experienced lower 1-year all-cause mortality compared with those not on beta-blockers. Given potential confounding factors due to observational study design, additional studies are indicated to confirm the potential protective role of beta-blockers in TTS and elucidate the underlying mechanisms.
Clinical Topics: Heart Failure and Cardiomyopathies, Prevention, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure
Keywords: Adrenergic beta-Antagonists, Coronary Artery Disease, Heart Failure, Myocardial Ischemia, Secondary Prevention, Shock, Cardiogenic, Stroke Volume, Takotsubo Cardiomyopathy, Ventricular Pressure
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