Long-term excess mortality in Takotsubo syndrome: is it justified to charge Takotsubo for the excess long-term mortality?: Reply

We thank Dr Y‐Hassan for his interest in our work regarding the prognosis of patients with Takotsubo cardiomyopathy (TTC).1 Apart from our investigation, two other study groups have published long‐term outcome data in large TTC populations recently.2, 3 A Swedish registry study compared long‐term mortality between 302 TTC patients and a control group of patients with acute myocardial infarction and found a similar risk of death.2 Furthermore, long‐term follow‐up in the large International Takotsubo (InterTAK) Registry which comprises 1750 patients revealed a rate of major adverse cardiac and cerebrovascular events (MACCE) of 9.9% per patient‐year and a rate of death from any cause of 5.6% per patient‐year.3 In accordance with the 24.7% long‐term mortality in our bicentric study in 286 TTC patients, these data suggest a substantial mortality and complication rate beyond the acute and subacute phase of the disease.1-3 Therefore, patients with TTC seem to represent a patient population with an increased risk of complications in both the short and long term. However, we agree with Dr Y‐Hassan that the causes of death vary between different phases of the disease and that underlying non‐cardiovascular co‐morbidities probably contribute significantly to long‐term mortality. In our population, 56% of deaths during the first year after initial presentation (19/34 patients) were definitely attributable to cardiovascular causes, while non‐cardiovascular reasons were predominant in patients dying >1 year after the acute stage (17/33 patients, 52%). Nevertheless, we think that the risk of delayed cardiovascular events should not be neglected given the considerable MACCE rate during a follow‐up period of 10 years in the InterTAK Registry.3 In view of the substantial long‐term mortality in patients with TTC, the question of the optimal management strategy arises. Close monitoring regarding heart failure symptoms or arrhythmias is mandatory until complete recovery of LV function. Thereafter, continuous medical care with particular attention to diagnosis and treatment of co‐morbidities with a long‐term prognostic impact (e.g. cancer) seems reasonable. However, the risk of delayed cardiovascular events or recurrence of the disease should be considered as well. Unfortunately we did not systematically assess the exact incidence of TTC recurrences in the current study. Future research efforts should be directed to improve treatment approaches for both cardiovascular and non‐cardiovascular complications to prevent adverse events in the high‐risk cohort of patients with TTC.