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Cardiogenic shock confers worse outcomes in takotsubo cardiomyopathy
Among patients with takotsubo cardiomyopathy, cardiogenic shock was linked to worse short- and long-term outcomes, according to a study published in JACC: Heart Failure.
Manuel Almendro-Delia, MD, PhD, an acute care cardiologist at Hospital Virgen Macarena in Sevilla, Spain, and colleagues analyzed data from 711 patients (mean age, 70 years; 13% men) from the RETAKO trial with a definitive takotsubo cardiomyopathy diagnosis between 2003 and 2016. A dedicated electronic case report form was used to collect information on baseline patient characteristics, in-hospital course, triggering factors, short- and long-term outcomes, and pharmacological treatment by the attending physician.
Follow-up after hospital discharge consisted of structured telephone interviews or outpatient clinical visits. Outcomes of interest were first nonfatal takotsubo cardiomyopathy recurrence and/or all-cause mortality.
During a median follow-up of 284 days, 11.4% of patients developed cardiogenic shock. Factors associated with cardiogenic shock included corrected QT interval prolongation (OR = 1.95; 95% CI, 1.17-3.24), male sex (OR = 2.52; 95% CI, 1.15-6.32), physical triggers (OR = 2.45; 95% CI, 1.05-5.68), lower left ventricular ejection fraction at admission (OR per 10% increase = 0.29; 95% CI, 0.18-0.47) and the presence of a significant left intraventricular pressure gradient (OR = 4.62; 95% CI, 1.46-14.62).
Patients with cardiogenic shock were more likely to have in-hospital complications, including infections (50%), death (13.6%), ventricular arrhythmias (12%), acute kidney failure (36%) and new-onset atrial fibrillation (30%).
During follow-up, cardiogenic shock was the strongest independent predictor of CV death (sub-HR = 4.29; 95% CI, 2.4-21.2), non-CV death (sub-HR = 3.34; 95% CI, 1.7-6.53) and all-cause mortality (HR = 5.38; 95% CI, 2.6-8.38).
Patients with cardiogenic shock who received beta-blockers when they were discharged from the hospital had a lower rate of mortality at 1 year vs. those who did not receive a beta-blocker (HR = 0.52; 95% CI, 0.44-0.79; P for interaction = .043).
“[Cardiogenic shock] complicating [takotsubo cardiomyopathy] 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 and colleagues wrote. – by Darlene Dobkowski
Disclosures: The authors report no relevant financial disclosures.
Perspective
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In this report from the Registry on Takotsubo Syndrome, cardiogenic shock occurred in 11% of takotsubo patients and predicted both in-hospital mortality and long-term all-cause mortality, mostly driven by non-cardiovascular causes. Cardiogenic shock was associated with male sex and physical triggers, as well as low ejection fraction at admission, prolonged QTc interval, and resting left ventricular outflow tract gradient > 25 mmHg. Cardiogenic shock was not significantly associated with takotsubo recurrence rate, which was approximately 1% per patient-year. Patients with cardiogenic shock who were discharged on beta-blockers had significantly lower 1-year all-cause mortality compared to those who did not receive beta-blockers.
Since elevated left ventricular outflow tract gradient was an independent predictor of shock, early identification using echocardiography may be important to optimize therapy in the acute setting of patients with takotsubo syndrome. In addition, this study was the first to identify a potential prognostic impact of beta-blockers in takotsubo patients with cardiogenic shock, although this observational study is unable to inform clinicians regarding optimal timing or duration of beta-blocker therapy.
Despite improved understanding of risk factors for the development of cardiogenic shock in patients with takotsubo syndrome as well as predictors of mortality, underlying pathophysiological mechanisms contributing to the heterogenous phenotypes of takotsubo syndrome are still unknown. While men with takotsubo due to a physical trigger may have the highest risk for cardiogenic shock and subsequent mortality, patients with takotsubo are still predominantly female, and those with emotional triggers are still at risk for cardiogenic shock. Research is needed to understand which patients are susceptible to takotsubo syndrome, to guide clinical management and prevent cardiogenic shock and recurrent events.