Out-of-hospital versus in-hospital Takotsubo cardiomyopathy: Analysis of 3719 patients in the Diagnosis Procedure Combination database in Japan

International Journal of Cardiology (Impact Factor: 4.04). 08/2014; 176(2). DOI: 10.1016/j.ijcard.2014.07.110
Source: PubMed

ABSTRACT Background:
Although Takotsubo cardiomyopathy (TC) generally occurs after a stressful event out-of-hospital, it occasionally occurs secondary to acute medical illness after hospital admission. No study has examined and compared patient backgrounds and in-hospital outcomes between patients with out-of-hospital TC and those with in-hospital TC.

Methods and results:
Using the Diagnosis Procedure Combination inpatient database in Japan, we identified 3719 eligible patients with a diagnosis of TC who underwent coronary angiography without any revascularization procedure between 2010 and 2013, including 419 patients with in-hospital TC and 3300 patients with out-of-hospital TC. There was no significant difference in age between those with in-hospital TC and those with out-of-hospital TC (74.2 ± 10.9 years versus 73.4 ± 11.3 years, p=0.211). Patients with in-hospital TC had a higher proportion of males than out-of-hospital TC patients (31.3% versus 21.3%, p<0.001). Patients with in-hospital TC had significantly higher proportions of several chronic comorbidities and acute medical illnesses. In-hospital mortality was significantly higher in patients with in-hospital TC than in patients with out-of-hospital TC (17.9% versus 5.4%, p<0.001). In the multivariable logistic regression analysis, in-hospital TC was significantly associated with higher in-hospital mortality (adjusted odds ratio 2.02; 95% confidence interval, 1.43 to 2.85; p<0.001), even after adjustment for patient backgrounds. Malignancy, chronic liver disease, rheumatic disease, sepsis, pneumonia, cerebrovascular diseases, acute renal failure, and acute gastrointestinal diseases were also significantly associated with higher in-hospital mortality.

In-hospital TC was associated with more severe clinical background and poorer short-term prognosis than out-of-hospital TC.

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    ABSTRACT: Takotsubo syndrome is an acute cardiac syndrome first described in 1990 and characterized by transient left ventricular dysfunction affecting more than one coronary artery territory, often in a circumferential apical, mid-ventricular, or basal distribution. Several pathophysiological explanations have been proposed for this syndrome and its intriguing appearance, and awareness is growing that these explanations might not be mutually exclusive. The reversible apical myocardial dysfunction observed might result from more than one pathophysiological phenomenon. The pathophysiology of Takotsubo syndrome is complex and integrates neuroendocrine physiology, potentially involving the cognitive centres of the brain, and including the hypothalamic–pituitary–adrenal axis. Cardiovascular responses are caused by the sudden sympathetic activation and surge in concentrations of circulating catecholamines. The multiple morphological changes seen in the myocardium match those seen after catecholamine-induced cardiotoxicity. The acute prognosis and recurrence rate are now known to be worse than initially thought, and much still needs to be learned about the epidemiology and the underlying pathophysiology of this fascinating condition in order to improve diagnostic and treatment pathways.
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