In hospital outcomes of patients with Takotsubo cardiomyopathy and coronary artery vasospasm, insights from a 9 year US retrospective analysis
Authors: Inestroza K , Severdija R , Kopecky S , Colombo R , Prasad A 
Published: June 2024

Abstract

Background
Physical or emotional stress is the most common cause of Takotsubo cardiomyopathy (TS). The exact mechanism of TS remains unclear, and some possible mechanism include myocardial edema and inflammation, coronary vasospasm, microcirculatory dysfunction, catecholamine surge, and sympathetic overdrive. Recently, and consistent with the availability of coronary spasm provocative studies, data suggests that coronary artery vasospasm (CAVS) plays an essential role in the pathogenesis of TS. However, whether CAVS is a consequence or a primary cause of TS is still unclear. The clinical implications of concomitant TS and CAVS have not been studied.

Purpose
Describe differences in baseline characteristics, comorbidities, cardiovascular risk factors, in-hospital mortality, and outcomes of patients with TS and documented CAVS.

Methods
The US National Inpatient Database was queried from 2011 to 2019 for relevant ICD-9 and -10 diagnostic and procedural codes. We identified patients admitted with TS who had a coronary angiogram. We then excluded those who underwent coronary percutaneous coronary intervention (PCI), coronary artery bypass graft (CAGB) or had a diagnosis of myocarditis. We compared baseline characteristics and in-hospital outcomes of patients with TS with vs. without documented CAVS.

Results
We identified 136,732 patients admitted with TS, of which 1,112 (0.8%) had CAVS. We found that those patients with TS and CAVS were younger and less likely to have hypertension, diabetes, atrial fibrillation, hyperlipidemia, coronary artery disease, peripheral artery disease, chronic kidney disease, chronic obstructive pulmonary disease, a prior cancer diagnosis, and smoking history than those without CAVS. Conversely, they were more likely to be obese, have substance abuse disorder, a history of polycystic ovary syndrome, post-traumatic stress disorder, anxiety, history of migraines, and have had a prior myocardial infarction (MI).
Regarding in-hospital outcomes, we did not find a significant difference in mortality between groups. Those with TS and CAVS were more likely to have a cardiac arrest, 2nd-degree AV block, ventricular fibrillation, ventricular tachycardia, and more likely to require ICD placement compared to those patients without CAVS.

Conclusions
Patients with TS and coronary vasospasm were younger, had fewer cardiovascular risk factors but were more likely to have had a prior MI than those without CAVS. We report no significant difference in mortality between groups. However, those with TS and CAVS were more likely to have hospitalizations complicated by cardiac arrest and significant arrhythmias like ventricular fibrillation, ventricular tachycardia, and 2nd-degree AV Block, which led to a higher need for ICD implantation. This large US nationwide retrospective study can provide hypotheses generating ideas for more extensive prospective studies to determine the frequency and role of CAVS in patients with TS.