Prognostic implications of pre-existing medical comorbidity in Takotsubo cardiomyopathy

Abstract

Takotsubo cardiomyopathy (TC) is associated with significant short-term morbidity and mortality. Several risk factors for poor outcomes have been identified; however, the prognostic implications of pre-existing comorbidity in TC are poorly delineated. We sought to assess the association of aggregate pre-existing comorbidity with short-term outcomes in TC. We performed a retrospective observational study of adult subjects diagnosed with TC at two academic tertiary care hospitals between 2005 and 2018. Overall burden of medical comorbidity was estimated using the Charlson comorbidity index (CCI). Multivariable logistic regression was used to test for independent association of CCI with 30-day mortality and severe shock at index presentation. Multivariable poisson regression was performed to assess the association of CCI with duration of hospitalization. Five-hundred and thirty-eight subjects were diagnosed with TC during the study period. The median CCI score of all subjects was 2 (IQR 1-4). Among subjects with physical triggers of TC, the median CCI score was 2 (IQR 1-4) compared to a median CCI score of 1 (IQR 0-1) in subjects with non-physical triggers of TC (P < 0.001). Seventy-six (14%) subjects died within 30 days of index diagnosis and 185 (34%) subjects experienced severe shock. The median duration of hospitalization was 7 days (IQR 3-14 days). In multivariable logistic regression, CCI was not associated with 30-day mortality or severe shock. In multivariable Poisson regression, CCI (IRR 1.17, 95% CI 1.16-1.18, P < 0.001) was associated with duration of hospitalization. Increased burden of pre-existing medical comorbidity was not independently associated with 30-day mortality or severe shock at index presentation, but was associated with increased duration of hospitalization after diagnosis of TC.

Outcomes of catecholamine and/or mechanical support in Takotsubo syndrome

“…The Charlson score is an indicator of the degree of comorbidity at the time of admission. A study reported that TTS due to physical stress was associated with a higher Charlson score 20. We showed that the Charlson score might be useful in predicting TTS severity.…”

Prognostic factors of Takotsubo cardiomyopathy: a systematic review

“…28 Other studies suggest that age is not associated with shortterm mortality in TCM patients (Table 2). 18,19,23,27,38,63,69,70 After a multivariable logistic regression analysis, Cammann et al found no significant difference among different age groups in in-hospital mortality (age 51-74 years old as reference, ≤50 years old, P = 0.14; ≥75 years old, P = 0.75) or 60 day mortality (P = 0.16). 27 In a univariate meta-regression analysis of 54 studies with 4679 TCM patients, in-hospital mortality in each study was not associated with age (P = 0.67, coefficient: 0.002, 95% CI 0.000-0.004), although the in-hospital mortality rate had wide heterogeneity (I 2 = 78%).…”

“…A prospective study of 1750 TCM patients in the International Takotsubo Registry noted that about 36% of TCM cases were triggered by specific physical activities, 27.7% was triggered by emotion, 2.8% were triggered by both physical and emotional activities, and 28.5% of cases had no identifiable trigger. 8 Many studies show that physical triggers are associated with poor short-term 8,70,80,84,85 42 A study of 939 TCM patients from the Spanish National Registry on Takotsubo Syndrome used multiple Cox regression to show that patients with physical triggers (HR 3.073, 95% CI 1.758-4.302) and those with no identifiable trigger (HR 1.913, 95% CI 1.003-3.649) had a higher 5 year mortality rate than patients with emotional triggers group. 55 Emotional triggers, on the other hand, predict better shortterm 8,27 and long-term 44,47,56 TCM outcomes (Table 4).…”

“…Other studies suggest that age is not associated with short‐term mortality in TCM patients ( Table 2 ). 18 , 19 , 23 , 27 , 38 , 63 , 69 , 70 After a multivariable logistic regression analysis, Cammann et al . found no significant difference among different age groups in in‐hospital mortality (age 51–74 years old as reference, ≤50 years old, P = 0.14; ≥75 years old, P = 0.75) or 60 day mortality ( P = 0.16).…”

“…Many studies show that physical triggers are associated with poor short‐term 8 , 70 , 80 , 84 , 85 and long‐term 41 , 42 , 49 , 55 , 62 , 75 , 86 , 87 outcomes in TCM ( Table 4 ). One study divided TCM patients into three classes according to their triggers: emotional triggers as Class I (485 patients), physical triggers as Class II (532 patients with physical activities, medical conditions, or procedures as Class IIa, 98 patients with neurologic disorders as Class IIb), and no identifiable trigger as Class III (498 patients).…”