Clinical Characteristics, Sex Hormones, and Long‐Term Follow‐Up in Swiss Postmenopausal Women Presenting With Takotsubo Cardiomyopathy

Abstract

Background:The overwhelming majority of patients with stress cardiomyopathy (SC) are postmenopausal women, suggesting an important pathophysiologic role of the female sex hormones. Preliminary data suggest that myocardial stunning might be provoked by estrogen deficiency. Hypothesis: We hypothesized that, compared with age-and gender-matched patients with myocardial infarction (MI) or patients with normal coronary arteries, patients with SC would exhibit altered levels of sex hormones. Furthermore, we aimed to describe the clinical course and the pattern of sex hormones of the SC patients during long-term follow-up. Methods: Blood samples obtained on hospital admission were analyzed for estradiol (E2), progesterone (P), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) in women with SC (n = 17), age-matched women with acute MI (n = 16), and women with normal coronary arteries (n = 15). Six years after the initial event, SC patients underwent a clinical and echocardiographic follow-up and reassessment of sex hormones. Results: Estrogen concentrations at hospital admission were significantly higher in the SC group compared with the MI and the control groups, with no difference in P, FSH, and LH concentrations. Follow-up E2 after 6 years in SC patients was lower than during the acute SC episode. Follow-up P in these patients was lower than P in the MI and control groups during the acute event, with a similar trend for E2. After a median follow-up of 6.4 years, 1 sudden cardiac death occurred and 2 patients suffered from SC recurrence. Conclusions: During the acute event, E2 concentrations are elevated in postmenopausal SC patients compared with women with acute MI or with normal coronary arteries. The higher E2 concentrations might have exerted atheroprotective effects and thus diverted the stress response to SC rather than MI. Recurrence and/or sudden cardiac death remains a potential risk of SC.

Editorial: Another Reason For Women to Avoid Estrogen?

“…This may be of importance since spontaneous coronary dissection (and perhaps other unusual mechanisms of MI), may occur during times of widely fluctuation estrogen levels. 12,13 Similar to this current report, prior studies have shown that high thrombus burden, low initial flow, larger baseline infarct size, low ejection fraction, anterior MI, prior MI, C-reactive protein, elevated blood counts, high SYNTAX score, and delay in reperfusion were predictive of no-reflow after primary PCI. [14][15][16] The potential mechanism of no-reflow is multifactorial, and may include platelet and leukocyte plugging, distal embolization, myocardial edema, and/ or reperfusion injury.…”

“…Whereas estrone is primarily generated by adipose tissue, the estradiol may be generated from adipose or from residual ovarian function. This may be of importance since spontaneous coronary dissection (and perhaps other unusual mechanisms of MI), may occur during times of widely fluctuation estrogen levels …”

Lack of Efficacy of Drug Therapy in Preventing Takotsubo Cardiomyopathy Recurrence: A Meta‐analysis

“…Seven studies on the effects of β‐blockers on the prevention of TTC recurrence were evaluated in a pooled analysis . In aggregate, the pooled studies included 471 subjects.…”

“…The remaining 165 records were screened, and 140 of them were excluded because the median follow‐up was shorter than 3 months. Twenty‐five full‐text articles were assessed for eligibility, but only 8 studies met all the inclusion criteria (Table ) …”

Cardiomyopathies: Evolution of pathogenesis concepts and potential for new therapies

“…Estrogen deficiency in the postmenopausal state may play a role [47] . Of particular interest, in other conditions with elevated catecholamine levels like subarachnoid hemorrhage, segmental wall motion abnormality is also predominantly seen in women.…”