Stress cardiomyopathy in hospitalized patients with cancer: machine learning analysis by primary malignancy type

Abstract

Aims Previous studies have shown that patients with stress (Takotsubo) cardiomyopathy (SC) and cancer have higher in‐hospital mortality than patients with SC alone. No studies have examined outcomes in patients with active cancer and SC compared to patients with active cancer without SC. We aimed to assess the potential association between primary malignancy type and SC and their shared interaction with inpatient mortality. Methods and results We analysed SC by primary malignancy type with propensity score adjusted multivariable regression and machine learning analysis using the 2016 United States National Inpatient Sample. Of 30 195 722 adult hospitalized patients, 4 719 591 had active cancer, of whom 568 239 had SC. The mean age of patients with cancer and SC was 69.1, of which 74.7% were women. Among patients with cancer, those with SC were more likely to be female and have white race, Medicare insurance, hypertension, heart failure with reduced ejection fraction, obesity, cerebrovascular disease, anaemia, and chronic obstructive pulmonary disease (P < 0.003 for all). In machine learning‐augmented, propensity score multivariable regression adjusted for age, race, and income, only lung cancer [OR 1.25; 95% CI: 1.08–1.46; P = 0.003] and breast cancer [OR 1.81; 95% CI: 1.62–2.02; P < 0.001] were associated with a significantly increased likelihood of SC. Neither SC alone nor having both SC and cancer was significantly associated with in‐hospital mortality. The presence of concomitant SC and breast cancer was significantly associated with reduced mortality (OR 0.48; 95% CI: 0.25–0.94; P = 0.032). Conclusions This analysis demonstrates that primary malignancy type influences the likelihood of developing SC. Further studies will be necessary to delineate characteristics in patients with lung cancer and breast cancer which contribute to development of SC. Additional investigation should confirm lower mortality in patients with SC and breast cancer and determine possible explanations and protective factors.

Beta-blockers are associated with better long-term survival in patients with Takotsubo syndrome

“…Likewise, the influence of beta-blocking agents on non-cardiac mortality is not yet well understood 28. As emerged from recent research, it might be hypothesised an impact on complex and multifactorial mechanisms involving neuroendocrine axis, immune response and cell proliferation whose modulation results in positive effects in conditions commonly associated with patients with TTS such as neurological and cancer diseases 29 30…”

Cancer and Takotsubo syndrome: from rarity to clinical practice

“…13 The InterTAK Registry reported that the most common malignancy associated with TTS is breast cancer, followed by tumors of gastrointestinal system and then respiratory track, and so forth. 6 Javaid and colleagues 14 report the results of a large cohort study, based on a US national inpatient sample, having included 4.7 million patients hospitalized with active cancer. 14 The authors found a significant prevalence of TTS in these patients of 12%, while they further investigated the association between primary tumor type and the risk for TTS using propensity-score adjustment and machine learning.…”

“…6 Javaid and colleagues 14 report the results of a large cohort study, based on a US national inpatient sample, having included 4.7 million patients hospitalized with active cancer. 14 The authors found a significant prevalence of TTS in these patients of 12%, while they further investigated the association between primary tumor type and the risk for TTS using propensity-score adjustment and machine learning. According to their findings, only breast and lung cancer were associated with a significantly increased likelihood of TTS.…”

“…Javaid et al and previous investigators have identified a series of risk factors including female sex, age older than 45 years, and cardiovascular and non-cardiovascular comorbidities, such as hypertension, dyslipidaemia, anaemia, lung and neurologic disease. 6,14,15,17 The median time of TTS onset is 2 days (1-150) after the beginning of therapy. 15 The typical clinical presentation of TTS is that of chest pain or dyspnea during or after treatment, but in 26.8% of patients, cardiogenic shock may be the first manifestation being potentially lethal.…”

“…Interestingly, Javaid and colleagues found that TTS was associated with reduced mortal-ity only in combination with breast cancer and not other tumor types. 14 The diagnosis of TTS may be missed in cancer patients given the increasing frequency and wide range of cardiotoxic effects of systemic antineoplastic treatments, such as left ventricular dysfunction, heart failure, myocarditis, and acute myocardial infarction. High suspicion is essential for early diagnosis and improved outcomes with lower mortality rates and healthcare costs.…”