Trigger‐Associated Clinical Implications and Outcomes in Takotsubo Syndrome: Results From the Multicenter GEIST Registry

Abstract

Background Takotsubo syndrome is usually triggered by a stressful event. The type of trigger seems to influence the outcome and should therefore be considered separately. Methods and Results Patients included in the GEIST (German‐Italian‐Spanish Takotsubo) registry were categorized according to physical trigger (PT), emotional trigger (ET), and no trigger (NT) of Takotsubo syndrome. Clinical characteristics as well as outcome predictors were analyzed. Overall, 2482 patients were included. ET was detected in 910 patients (36.7%), PT in 885 patients (34.4%), and NT was observed in 717 patients (28.9%). Compared with patients with PT or NT, patients with ET were younger, less frequently men, and had a lower prevalence of comorbidities. Adverse in‐hospital events (NT: 18.8% versus PT: 27.1% versus ET: 12.1%, P <0.001) and long‐term mortality rates (NT: 14.4% versus PT: 21.6% versus ET: 8.5%, P <0.001) were significantly lower in patients with ET. Increasing age ( P <0.001), male sex ( P =0.007), diabetes ( P <0.001), malignancy ( P =0.002), and a neurological disorder ( P <0.001) were associated with a higher risk of long‐term mortality, while chest pain ( P =0.035) and treatment with angiotensin‐converting enzyme inhibitor/angiotensin receptor blocker ( P =0.027) were confirmed as independent predictors for a lower risk of long‐term mortality. Conclusions Patients with ET have better clinical conditions and a lower mortality rate. Increasing age, male sex, malignancy, a neurological disorder, chest pain, angiotensin‐converting enzyme inhibitor/angiotensin receptor blocker, and diabetes were confirmed as predictors of long‐term mortality.

Long-Term Functional Limitations on Cardiopulmonary Exercise Testing in Emotion-Triggered Takotsubo Syndrome

“…Long-term effects directly attributable to a TTS attack remain controversial due to the paucity of available data and concomitant presence of comorbidities, acute diseases and other confounding factors that can impact the outcomes within this heterogeneous population. Accordingly, multiple studies showed that patients with events triggered by emotional stress had better short and long-term outcomes compared with TTS secondary to physical triggers [7,10,16]. Scally et al [4] showed a reduction in peak VO 2 and VO 2 pulse and an increase in VE/VCO 2 slope at 20 (13-39) months from the index event in a heterogeneous population of 20 patients with previous TTS compared with matched control subjects.…”

“…Baseline demographics and clinical data were collected, including ECG and echocardiographic presentation. Preceding trigger, if present, was recorded by the physician in charge at the time of hospital admission and reported as emotional, physical or absent as previously described [16]. Clinical, ECG and echocardiographic follow-up protocols in TTS patients at our Institution have been previously described [17].…”

Smoking influence in Takotsubo syndrome: insights from an international cohort

“…TTS secondary forms, as previously defined ( 10 ), were considered when a physical trigger or emotional plus physical triggers were present. Primary forms were those without triggers or with an isolated identifiable emotional trigger ( 10 , 11 ). Right ventricular involvement was considered as such when any abnormality was demonstrated in the echocardiogram at that level and included in the clinical report.…”

A contemporary update on cancer and takotsubo syndrome

“…These are not only “contributors” of the clinical picture of vulnerable HF patients typical of TTS, but, most importantly, are prognostic factors ( 8 , 12 , 14 , 16 ). Accordingly, TTS secondary to an emotional trigger has a relatively good prognosis, while physically triggered TTS has higher prevalence of non-CV comorbidities ( 17 ) and therefore is associated with worse outcomes ( 11 , 17 ).…”

“…Similar frequencies were found in subsequent meta-analyses ( 18 , 26 , 27 ). In the three largest international TTS registries, cancer prevalence ranges from about 12% to 17% ( 17 , 28 , 29 ). Overall, cancer in TTS appears more common as compared to the general population, as well as to patients with AMI and HF ( 27 , 30 – 33 ).…”