Coronary slow flow is associated with a worse clinical outcome in patients with Takotsubo syndrome

Abstract

ObjectivePatients with Takotsubo syndrome (TTS) present an acute microvascular dysfunction that leads to an impaired myocardial perfusion and, in more severe forms, an impaired epicardial flow. However, clinical relevance of a delayed coronary flow, the coronary slow flow (CSF), has never been investigated. We studied the prognostic value of CSF occurring in the acute phase of TTS.MethodsThis cohort study prospectively evaluated patients with a diagnosis of TTS. CSF was defined as angiographically non-obstructive coronary arteries with thrombolysis in myocardial infarction-2 flow. The incidence of overall mortality and major adverse cardiovascular events (MACEs), defined as the composite of TTS recurrence, cardiac rehospitalisation, cerebrovascular events and mortality, was assessed at follow-up.ResultsWe enrolled 101 patients (mean age 71.0±11.1 years, 86 (85.1%) female); CSF occurred in 18 (17.8%) patients. At admission, patients with CSF presented more frequently with Killip class III/IV, moderate-to-severe left ventricle systolic dysfunction and right ventricle dysfunction. During the index admission, patients with CSF had a higher rate of intrahospital complications (12 (66.7%) vs 28 (33.7%), p=0.01). At long-term follow-up, patients with CSF had a significantly higher occurrence of overall mortality (9 (50%) vs 19 (22.9%), p=0.011), mainly due to non-cardiac causes (89.3%), and a higher rate of MACE (10 (55.5%) vs 27 (32.5%), p=0.06). At multivariable Cox regression, CSF was independently associated with death from any causes.ConclusionsPatients with TTS presenting with CSF have a worse clinical presentation with a higher rate of intrahospital complications and a poor long-term clinical outcome.

Takotsubo syndrome: between evidence, myths, and misunderstandings

“…A very characteristic angiographic finding in TS is coronary slow-flow, especially in the LAD in patients with apical TS [74]. This might be attributed to microvascular dysfunction [75,76], and its extent potentially correlates with adverse prognosis [77].…”

Primary and secondary takotsubo syndrome: Pathophysiological determinant and prognosis

“…Lastly, when including in the study population patients with takotsubo syndrome secondary to severe end-stage disease neurological, oncological or traumatic diseases, overall mortality goes as high as 27.7%, mostly driven by non-cardiac causes. 18 In conclusion, based on current literature, we propose a novel classification of takotsubo syndrome into primary and secondary based on the absence or presence of preexisting organic disease, on the severity and reversibility of LV dysfunction and on the favourable or unfavourable outcome. We hypothesize that the two forms are sustained by different pathophysiological mechanisms, being primary takotsubo syndrome, mainly due to reversible microvascular dysfunction, and secondary takotsubo syndrome, due to direct myocardial damage.…”

“…Lastly, when including in the study population patients with takotsubo syndrome secondary to severe end-stage disease neurological, oncological or traumatic diseases, overall mortality goes as high as 27.7%, mostly driven by non-cardiac causes. 18…”

Myocardial and Microvascular Injury Due to Coronavirus Disease 2019

“…Studies Comparing Clinical Characteristics and Outcomes of Patients with or without It is also well known that acute coronary microvascular dysfunction can contribute to the onset of takotsubo syndrome (TTS) 11,12. At present, a few cases of TTS have been registered among COVID-19 patients; therefore, the prevalence and the prognostic impact of this syndrome in this particular patient population is still unknown.…”