P817Shall takotsubo syndrome be tear apart from the working diagnosis of myocardial infarction with non-obstructive coronary arteries?
Authors: Lopez Pais J , Izquierdo Coronel B , Galan Gil D , Alcon Duran B , Espinosa Pascual M J , Alvarez Rodriguez L , Nunez Rodriguez A , Martinez Peredo C G , Awamleh Garcia P , Moreno Vinues C , Gorriz Magana J , Nunez Gil I J , Oteo Dominguez J F , Gonzalez Juanatey J R , Alonso Martin J J 
Published: October 2019

Abstract

Background
There is controversy to whether Takotsubo Syndrome (TTS) should be classified as a Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA). The aim of this study is to compare the clinical profile and prognosis of TTS with non-TTS MINOCA patients.

Methods
Analytical and observational study developed in a University Hospital, which covers 220.000 individual. We analyzed the clinical data of all consecutive MINOCA patients admitted to our center during a 3 years period (2016–2018). We used the definitions and the clinical management of 2016 ESC Working Group Position Paper on MINOCA, which considers TTS as a MINOCA. Follow up analysis included death from any cause and major adverse cardiovascular events (MACE). Survival analysis is based on Cox regression. Median follow-up was 17 months.

Results
Twenty-six out of 109 patients (24%) classified as MINOCA where TTS. Patients with TTS were older (72.2±11.5 vs 62.3±14.9, p<0.01) and the female proportion was higher (72.0 vs 43.9%, p 0.01) than in the non-TTS MINOCA group. Regarding cardiovascular risk factors, there were no significant differences: Hypertension (56.0 vs 63.4%), Dyslipidemia (48.9 vs 45.7%), smoking rate (41.7 vs 41.8%) and diabetes (32.0 vs 22.0%,). The antecedent of atrial fibrillation tended to be higher in TTS group (4.0 vs 18.3%, p 0.08).
TTS patients at admission referred angina as the main symptom in fewer cases (56.0 vs 78.0%, p 0.03), but they had an electrocardiogram suggesting ischemia more frequently (87.5 vs 53.7%, p<0.01). TTS presented more frequently with Killip class worse than II (24.9 vs 1.2%, p<0.01) and with more systolic dysfunction (92.0 vs 15.9%m p<0.01) than non-TTS MINOCA. There was no significant difference in the peak of troponin (5.7±9.7 vs 5.6±8.8). Levels of hemoglobin at the admission were lower in the TTS group (12.4±2.2 vs 13.8±2.0, p<0.01).
The proportion of in-hospital complications (recovered cardiac arrest, shock, pulmonary edema, ictus, re-infarction) were higher in the TTS group (40.0 vs 6.1%, p<0.01). TTS was an intercurrent complication during admission for a non-cardiovascular pathology in more occasions than non-TTS MINOCA (16 vs 4.9%, p 0.06).
During follow-up, TTS showed worse prognosis, with higher all-cause mortality: 16.0 vs 4.0%, Hazard Ratio (HR) 4.49 (Confidence Interval [CI] 1.01–20.10, p<0.05); a tendency to more cardiovascular mortality: 8.0 vs 1.2%, p 0.07, HR 6.7 (CI 0.61–74.35, p 0.12) and to an excess of MACE: 20.0 vs 8.0%, p 0.1, HR 3.1 (CI 0.92–9.98, p 0.07).

Conclusion
There are differences in the clinical profile and prognosis of TTS patients compared to the rest of non-TTS MINOCA, being TTS a more aggressive entity. We think these data are in line with the recently released 4th Universal Definition of Myocardial Infarction, where TTS should be considered apart from the rest causes of “myocardial injury” or “myocardial infarction”, being an entity with its own characteristics and prognosis.