Coexistence and outcome of coronary artery disease in Takotsubo syndrome
Authors: Napp L Christian , Cammann Victoria L , Jaguszewski Milosz , Szawan Konrad A , Wischnewsky Manfred , Gili Sebastiano , Knorr Maike , Heiner Susanne , Citro Rodolfo , Bossone Eduardo , D’Ascenzo Fabrizio , Neuhaus Michael , Franke Jennifer , Sorici-Barb Ioana , Noutsias Michel , Burgdorf Christof , Koenig Wolfgang , Kherad Behrouz , Sarcon Annahita , Rajan Lawrence , Michels Guido , Pfister Roman , Cuneo Alessandro , Jacobshagen Claudius , Karakas Mahir , Pott Alexander , Meyer Philippe , Arroja Jose D , Banning Adrian , Cuculi Florim , Kobza Richard , Fischer Thomas A , Vasankari Tuija , Airaksinen K E Juhani , Hauck Christian , Paolini Carla , Bilato Claudio , Imori Yoichi , Kato Ken , Kobayashi Yoshio , Opolski Grzegorz , Budnik Monika , Dworakowski Rafal , MacCarthy Philip , Kaiser Christoph , Osswald Stefan , Galiuto Leonarda , Dichtl Wolfgang , Chan Christina , Bridgman Paul , Beug Daniel , Delmas Clément , Lairez Olivier , El-Battrawy Ibrahim , Akin Ibrahim , Gilyarova Ekaterina , Shilova Alexandra , Gilyarov Mikhail , Horowitz John D , Polednikova Karolina , Tousek Petr , Widimský Petr , Winchester David E , Galuszka Jan , Ukena Christian , Poglajen Gregor , Carrilho-Ferreira Pedro , Di Mario Carlo , Prasad Abhiram , Rihal Charanjit S , Schulze P Christian , Bianco Matteo , Crea Filippo , Borggrefe Martin , Maier Lars S , Pinto Fausto J , Braun-Dullaeus Ruediger C , Rottbauer Wolfgang , Katus Hugo A , Hasenfuß Gerd , Tschöpe Carsten , Pieske Burkert M , Thiele Holger , Schunkert Heribert , Böhm Michael , Felix Stephan B , Münzel Thomas , Bax Jeroen J , Bauersachs Johann , Braunwald Eugene , Lüscher Thomas F , Ruschitzka Frank , Ghadri Jelena R , Templin Christian 
Published: March 2020

Abstract

Aims
Takotsubo syndrome (TTS) is an acute heart failure syndrome, which shares many features with acute coronary syndrome (ACS). Although TTS was initially described with angiographically normal coronary arteries, smaller studies recently indicated a potential coexistence of coronary artery disease (CAD) in TTS patients. This study aimed to determine the coexistence, features, and prognostic role of CAD in a large cohort of patients with TTS.

Methods and results
Coronary anatomy and CAD were studied in patients diagnosed with TTS. Inclusion criteria were compliance with the International Takotsubo Diagnostic Criteria for TTS, and availability of original coronary angiographies with ventriculography performed during the acute phase. Exclusion criteria were missing views, poor quality of angiography loops, and angiography without ventriculography. A total of 1016 TTS patients were studied. Of those, 23.0% had obstructive CAD, 41.2% had non-obstructive CAD, and 35.7% had angiographically normal coronary arteries. A total of 47 patients (4.6%) underwent percutaneous coronary intervention, and 3 patients had acute and 8 had chronic coronary artery occlusion concomitant with TTS, respectively. The presence of CAD was associated with increased incidence of shock, ventilation, and death from any cause. After adjusting for confounders, the presence of obstructive CAD was associated with mortality at 30 days. Takotsubo syndrome patients with obstructive CAD were at comparable risk for shock and death and nearly at twice the risk for ventilation compared to an age- and sex-matched ACS cohort.

Conclusions
Coronary artery disease frequently coexists in TTS patients, presents with the whole spectrum of coronary pathology including acute coronary occlusion, and is associated with adverse outcome.

Trial registration
ClinicalTrials.gov number: NCT01947621.