Prognosis in Patients With Takotsubo Cardiomyopathy

Recently, increasing research efforts have been directed to the prognosis of patients with Takotsubo cardiomyopathy (TTC). Several study groups have published outcome data during the last year. A Swedish registry study found a 30-day mortality of 4.1% in 302 patients with TTC (1). The large International Takotsubo Registry included 1,750 patients, and it reported 5.9% mortality after 30 days (2). The rate of death during long-term follow-up was 5.6% per patient-year. Furthermore, our bicentric study in 286 prospectively identified TTC patients revealed 28-day, 1-year, and long-term mortality rates of 5.5%, 12.5%, and 24.7%, respectively (3). Of note, all these trials compared mortality in TTC with matched cohorts of patients with acute myocardial infarction or acute coronary syndrome, and found a similar risk of death 1, 2, 3. Long-term mortality in TTC even exceeded that of patients presenting with ST-segment elevation myocardial infarction in 1 study (3). These findings challenge the initial opinion of a favorable prognosis in TTC patients due to complete recovery of left ventricular dysfunction within days to weeks. Murugiah et al. (4) examined the United States Medicare database and reported 30-day and 1-year mortality rates of 2.5% and 6.9% for patients with principal TTC and 4.7% and 11.4% for patients with secondary TTC, respectively. These results illustrate the indisputable prognostic difference between principal and secondary TTC, which has also been demonstrated previously (5). However, the observed mortality in the overall TTC population is comparable to the aforementioned trials in unselected TTC patients, albeit at the lower end of the reported rates.

Considering these novel insights, we think that the prognosis of TTC should no longer be referred to as favorable for patients with principal TTC. During the acute and subacute phases of the disease, patients are prone to severe complications, including heart failure, cardiogenic shock, or life-threatening arrhythmias. Therefore, we suggest close monitoring in coronary care units, in a similar fashion as recommended for patients with acute coronary syndrome. Recovery of left ventricular function and electrocardiographic changes should be documented during regular follow-up visits after hospital discharge. Future research efforts should be directed to determining the detailed causes of death, and particularly, the impact of underlying noncardiovascular diseases in patients with secondary TTC. Furthermore, the development of evidence-based treatment approaches is desirable. It is necessary to enhance the awareness of the substantial mortality rates in TTC and to avoid trivializing the disease to ensure adequate management strategies and to achieve scientific progress.