Ethnic comparison in takotsubo syndrome: novel insights from the International Takotsubo Registry
Authors: Imori Yoichi , Kato Ken , Cammann Victoria L. , Szawan Konrad A. , Wischnewsky Manfred , Dreiding Sara , Würdinger Michael , Schönberger Maximilian , Petkova Vanya , Niederseer David , Levinson Rena A. , Di Vece Davide , Gili Sebastiano , Seifert Burkhardt , Wakita Masaki , Suzuki Noriko , Citro Rodolfo , Bossone Eduardo , Heiner Susanne , Knorr Maike , Jansen Thomas , Münzel Thomas , D’Ascenzo Fabrizio , Franke Jennifer , Sorici-Barb Ioana , Katus Hugo A. , Sarcon Annahita , Shinbane Jerold , Napp L. Christian , Bauersachs Johann , Jaguszewski Milosz , Shiomura Reiko , Nakamura Shunichi , Takano Hitoshi , Noutsias Michel , Burgdorf Christof , Ishibashi Iwao , Himi Toshiharu , Koenig Wolfgang , Schunkert Heribert , Thiele Holger , Kherad Behrouz , Tschöpe Carsten , Pieske Burkert M. , Rajan Lawrence , Michels Guido , Pfister Roman , Mizuno Shingo , Cuneo Alessandro , Jacobshagen Claudius , Hasenfuß Gerd , Karakas Mahir , Mochizuki Hiroki , Pott Alexander , Rottbauer Wolfgang , Said Samir M. , Braun-Dullaeus Ruediger C. , Banning Adrian , Isogai Toshiaki , Kimura Akihisa , Cuculi Florim , Kobza Richard , Fischer Thomas A. , Vasankari Tuija , Airaksinen K. E. Juhani , Tomita Yasuhiro , Budnik Monika , Opolski Grzegorz , Dworakowski Rafal , MacCarthy Philip , Kaiser Christoph , Osswald Stefan , Galiuto Leonarda , Crea Filippo , Dichtl Wolfgang , Murakami Tsutomu , Ikari Yuji , Empen Klaus , Beug Daniel , Felix Stephan B. , Delmas Clément , Lairez Olivier , Yamaguchi Tetsuo , El-Battrawy Ibrahim , Akin Ibrahim , Borggrefe Martin , Horowitz John D. , Kozel Martin , Tousek Petr , Widimský Petr , Gilyarova Ekaterina , Shilova Alexandra , Gilyarov Mikhail , Neuhaus Michael , Meyer Philippe , Arroja Jose David , Chan Christina , Bridgman Paul , Galuszka Jan , Poglajen Gregor , Carrilho-Ferreira Pedro , Pinto Fausto J. , Hauck Christian , Maier Lars S. , Liu Kan , Di Mario Carlo , Paolini Carla , Bilato Claudio , Bianco Matteo , Jörg Lucas , Rickli Hans , Winchester David E. , Ukena Christian , Böhm Michael , Bax Jeroen J. , Prasad Abhiram , Rihal Charanjit S. , Saito Shigeru , Kobayashi Yoshio , Lüscher Thomas F. , Ruschitzka Frank , Shimizu Wataru , Ghadri Jelena R. , Templin Christian 
Published: May 2021

Abstract
Background
Ethnic disparities have been reported in cardiovascular disease. However, ethnic disparities in takotsubo syndrome (TTS) remain elusive. This study assessed differences in clinical characteristics between Japanese and European TTS patients and determined the impact of ethnicity on in-hospital outcomes.

Methods
TTS patients in Japan were enrolled from 10 hospitals and TTS patients in Europe were enrolled from 32 hospitals participating in the International Takotsubo Registry. Clinical characteristics and in-hospital outcomes were compared between Japanese and European patients.

Results
A total of 503 Japanese and 1670 European patients were included. Japanese patients were older (72.6 ± 11.4 years vs. 68.0 ± 12.0 years; p < 0.001) and more likely to be male (18.5 vs. 8.4%; p < 0.001) than European TTS patients. Physical triggering factors were more common (45.5 vs. 32.0%; p < 0.001), and emotional triggers less common (17.5 vs. 31.5%; p < 0.001), in Japanese patients than in European patients. Japanese patients were more likely to experience cardiogenic shock during the acute phase (15.5 vs. 9.0%; p < 0.001) and had a higher in-hospital mortality (8.2 vs. 3.2%; p < 0.001). However, ethnicity itself did not appear to have an impact on in-hospital mortality. Machine learning approach revealed that the presence of physical stressors was the most important prognostic factor in both Japanese and European TTS patients.

Conclusion
Differences in clinical characteristics and in-hospital outcomes between Japanese and European TTS patients exist. Ethnicity does not impact the outcome in TTS patients. The worse in-hospital outcome in Japanese patients, is mainly driven by the higher prevalence of physical triggers.

Trial Registration
URL: https://www.clinicaltrials.gov; Unique Identifier: NCT01947621.