We thank Dr. Madias for highlighting the low rate of diabetes in patients with Takotsubo syndrome (TTS) in our cohort, as has been reported in other cohorts of patients with TTS .

If a protective link between diabetes and TTS does exist, it may indeed be mediated via autonomic neuropathy. TTS would thus affect fewer patients with long-term diabetes, as well as those with clinical neuropathy from other causes. Unfortunately, despite our best efforts to gather information about the severity, duration, etc. of diabetes in our patients, we were not successful.

In the entire cohort, an identifiable psychological event as the likely cause of TTS was present in 74/117 patients; roughly two thirds of these events were mental stresses and one-third were physical stresses. The proportion of such events was not different in the group of 13 diabetic patients (10 patients with psychological events: seven mental stresses and three physical stresses). As in the entire cohort, for some diabetic patients, the stress was severe (e.g. brother’s death, son’s car crash or best friend’s funeral), while for others it was more banal (e.g. dental care, vomiting, verbal fight with a neighbour or a fall).

From our small cohort, which included only 13 patients with diabetes, it is not possible to assume a protective link between diabetes and TTS. A case-control study may be a viable option to address this issue.