Five-year follow-up and outcomes of takotsubo/stress cardiomyopathy in a single centre- an irish perspective
Authors: O Dea G , Traynor B , Mc Adam B 
Published: February 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Takotsubo Cardiomyopathy (TC) is an acute cardiac presentation characterised by acute myocardial injury and transient left ventricular systolic dysfunction, in the absence of obstructive coronary disease(1). Postulated causes include catecholamine excess, microvascular dysfunction, and multi-vessel coronary artery spasm. Predominantly seen in post-menopausal women, frequently triggered by emotional or physical stressor with in-hospital mortality rate reported at 2-5%(2). We present a single centre experience of TC with five-year follow-up.

Methods
We performed a retrospective descriptive study of patients with a diagnosis of TC coded by Hospital In-Patient Enquiry data from a tertiary level Irish hospital between 2010 and 2016. Data collection was electronic patient records/chart review. 21 cases were confirmed by modified Mayo Clinic criteria(3). Three patients were lost to follow up, two patients died during the follow-up period and one patient was excluded due to a focal area of transmural infarction on follow-up cardiac magnetic-resonance imaging (CMRI). Follow up data was obtained on sixteen patients up to 01/08/2021. Statistical analysis using SPSS v. 27, expressed as mean +- SD in %.

Results
Mean age at event was 64 +/- 12 years, 95% were female. Triggers identified in 55% of cases; emotional stressors in 35%, physical stressors in 25%. All had raised Troponin I (peak 3.13 ± 2.42ng/ml) and electrocardiograph (ECG) changes. Coronary angiography performed in all with no or mild CAD in seventeen and moderate CAD in two cases. CMRI was performed in 60% (n = 12) at on average 14.8 months post discharge. Average left ventricular ejection fraction (LVEF) was 31+/- 8% and 62+/-7% at diagnosis and follow up respectively, improving in all cases with mean improvement of 30.8 +/-11% (p &lt; 0.001). Three patients had a further TC event. Two of the cases underwent angiography at the time of second presentation with normal coronary arteries and follow-up imaging showed full LVEF recovery in both cases. The third patient is awaiting follow-up CMRI. Of the recurrent cases two occurred despite best medical therapy. Two of the cases showed full recovery of LVEF between events and one showed minimal LVEF improvement prior to recurrence but full recovery after the second event. All patients who remained in Ireland had initial follow up (n = 15), 46% attend Cardiology outpatients in 2021.

Conclusions
Our demographic data is similar to previous studies with the majority of cases occurring in postmenopausal women(4). Our mortality rate was 9.5%, current published prognostic data in TC are limited and conflicting(2). The recurrence rate among our small cohort was 16.6% (n = 3) despite cardio-protective medications in two of the three cases, higher than previous reviews(5). The time to clinical and imaging follow up was discordant but all patients in our follow up group regained a normal LVEF which is very reassuring and in-keeping with prior studies. Abstract Figure. TTE apical 4-chamber view Abstract Figure. CMRI 4-chamber view end systole