Summary
Background
Takotsubo cardiomyopathy (TTC) is a rare condition characterized by a sudden temporary weakening of the heart. TTC can mimic acute myocardial infarction and is associated with a minimal release of myocardial biomarkers in the absence of obstructive coronary artery disease.
Aims
To provide an extensive description of patients admitted to hospital for TTC throughout France and to study the management and outcomes of these patients.
Methods
In 14 non-academic hospitals, we collected clinical, electrocardiographic, biological, psychological and therapeutic data in patients with a diagnosis of TTC according to the Mayo Clinic criteria.
Results
Of 117 patients, 91.5% were women, mean ± SD age was 71.4 ± 12.1 years and the prevalence of risk factors was high (hypertension: 57.9%, dyslipidaemia: 33.0%, diabetes: 11.5%, obesity: 11.5%). The most common initial symptoms were chest pain (80.5%) and dyspnoea (24.1%). A triggering psychological event was detected in 64.3% of patients. ST-segment elevation was found in 41.7% of patients and T-wave inversion in 71.6%. Anterior leads were most frequently associated with ST-segment elevation, whereas T-wave inversion was more commonly associated with lateral leads, and Q-waves with septal leads. The ratio of peak B-type natriuretic peptide (BNP) or N-terminal prohormone BNP (NT-proBNP) level to peak troponin level was 1.01. No deaths occurred during the hospital phase. After 1 year of follow-up, 3 of 109 (2.8%) patients with available data died, including one cardiovascular death. Rehospitalizations occurred in 17.4% of patients: 2.8% due to acute heart failure and 14.7% due to non-cardiovascular causes. There was no recurrence of TTC.
Conclusions
This observational study of TTC included primarily women with atherosclerotic risk factors and mental stress. T-wave inversion was more common than ST-segment elevation. There were few adverse cardiovascular outcomes in these patients after 1-year follow-up.
Résumé
Contexte
Le syndrome de Takotsubo est une affection rare caractérisée par un affaiblissement temporaire soudain du cœur. Le syndrome de Takotsubo peut simuler un infarctus du myocarde aigu et est associé à une élévation minime des biomarqueurs de nécrose myocardique en l’absence de maladie coronaire obstructive.
Buts
Fournir une description extensive d’une population de patients admis pour un syndrome de Takotsubo sur le territoire français et d’étudier la prise en charge et l’évolution de ces patients.
Méthodes
Nous avons rassemblé les données cliniques, électrocardiographiques, biologiques, psychologiques et thérapeutiques chez des patients admis pour un syndrome de Takotsubo sur les critères diagnostiques de la Mayo Clinic, dans 14 hôpitaux non universitaires de France.
Résultats
Cent dix-sept patients ont été inclus. Les patients étaient en majorité des femmes (91,5 %) d’âge moyen 71,4 ± 12,1 ans, présentant fréquemment des facteurs de risque cardiovasculaire (hypertension : 57,9 %, dyslipidémie : 33,0 %, diabète : 11,5 %, obésité : 11,5 %). Les principaux symptômes à l’admission étaient la douleur thoracique (80,5 %) et la dyspnée (24,1 %). Un événement psychologique déclenchant était identifié chez 64,3 % des patients. Le sus-décalage du segment ST était retrouvé chez 41,7 % des patients et une inversion de l’onde T dans 71,6 % des cas. Les dérivations antérieures étaient les plus souvent concernées en cas de sus-décalage du ST, les dérivations latérales en cas d’inversion de l’onde T et les dérivations septales en cas d’onde Q. Le rapport BNP ou NT-proBNP/troponine était de 1,01. Il n’y avait aucun décès hospitalier. Après un an de suivi, trois patients (2,8 %) étaient décédés dont un décès de cause cardiovasculaire. Des réhospitalisations ont été observées chez 2,8 % des patients pour insuffisance cardiaque aiguë, et pour raisons non cardiovasculaires chez 14,7 % de ceux-ci. Il n’y a pas eu de récidive de syndrome de Takotsubo.
Conclusions
Cet observatoire du syndrome de Takotsubo a inclus des femmes ayant de nombreux facteurs de risque cardiovasculaire et un facteur aigu de stress mental. L’électrocardiogramme montrait dans moins de la moitié des cas un sus-décalage ST et plus fréquemment une inversion de l’onde T. Il y avait peu de complications cardiovasculaires après un suivi d’un an.
Introduction
Takotsubo cardiomyopathy (TTC) is a cardiac syndrome characterized by transient left ventricular dysfunction, electrocardiographic changes that can mimic acute myocardial infarction, and a minimal release of myocardial biomarkers in the absence of obstructive coronary artery disease . Observational data from cohorts of patients presenting with acute TTC provide the opportunity to improve the knowledge of this syndrome. While data from some observational studies have been particularly helpful , others suffer from a relative lack of representativeness or are highly representative but did not collect extensive clinical data . Mansencal et al. provided epidemiological data on TTC in the Paris area ; however, there are no nationwide data on the management of this disease.
The Observational French SyndromEs of TakoTsubo (OFSETT) was designed to collect extensive nationwide data from patients hospitalized for TTC with a follow-up of 1 year. A distinctive feature of OFSETT is the comprehensive data collected in terms of clinical, electrocardiographic, biological and psychological aspects, and the treatment of these patients. The aims of OFSETT were to provide detailed description of the population of patients admitted for TTC throughout France.
Methods
Study design
OFSETT was a multicentre observational study of TTC diagnosed in French non-academic hospitals ( Appendix A ). The study prospectively included consecutive patients with TTC from December 2010 to December 2011. To increase the number of patients included, the study also collected data retrospectively from the hospital records of patients admitted with this syndrome from November 2005 to November 2010 in the same centres.
The cardiologists who participated in the study were not supposed to modify their therapeutic approach for these patients in any way. Patients provided written informed consent to participate. The study was conducted in accordance with good clinical practice, French law and the French data protection law. The data recorded and the way they were handled and stored were reviewed and approved by the Comité consultatif sur le traitement de l’information en matière de recherche dans le domaine de la santé (No. CCTIRS: 10.067) and the Commission nationale informatique et liberté (No. CNIL: 910131).
Patients and centres
Eligible patients were ≥18 years of age and met the Mayo Clinic diagnostic criteria for TTC , namely: transient hypokinesis, akinesis or dyskinesis of the left ventricular mid-segments with or without apical involvement; regional wall motion abnormalities extend beyond a single epicardial vascular distribution; a stressful trigger is often, but not always, present; the absence of obstructive coronary disease or angiographic evidence of acute plaque rupture; appearance of new electrocardiographic (ECG) abnormalities (ST-segment elevation and/or T-wave inversion) or a modest elevation in cardiac troponin; and the absence of pheochromocytoma or myocarditis. No exclusion criteria were applied. All patients underwent coronary angiography on admission.
Centres selected to participate were required to have a cardiac intensive care unit and a catheterization laboratory available 24/7 and to perform >1000 percutaneous coronary interventions per year. Of 83 non-academic hospitals with interventional cardiology facilities in France, 30 fulfilled these criteria and 14 agreed to participate.
Data collection
A computerized case record form was completed for each eligible patient, based on hospital records and additional specific questionnaires. The following data were collected: medical history and presenting characteristics (clinical characteristics including psychological assessment, electrocardiographic, echocardiographic and angiographic characteristics); cardiac biomarkers (troponin and B-type natriuretic peptide [BNP] or N-terminal prohormone BNP [NT-proBNP]); and treatment at admission and at discharge. Patients were followed up for 1 year. The outcomes were in-hospital complications, all-cause death, cardiac rehospitalization (including recurrence of TTC and heart failure) and non-cardiac rehospitalization at 1 year.
Definitions
Peak cardiac troponin and peak BNP or NT-proBNP levels are expressed as multiples of the upper limit of normal (ULN) – defined as the 99th percentile – in each biological laboratory because the ULN of these tests can differ by laboratory and type of reagent used. The ratio of peak BNP or NT-proBNP increase (multiple of the ULN) to peak troponin increase (multiple of the ULN) was calculated for each patient with available data.
The triggering stressor event was assessed in each patient. Physical stress was defined as the force applied to a given area of biological tissue, and included surgical procedures such as cholecystectomy, colonoscopy, difficult urinary catheterization, pacemaker implantation and electrical cardioversion . Mental stress (emotionally induced stress) included the death, severe illness or injury of a loved one; the receipt of bad news; a severe argument; an assault; public speaking; financial loss; a car accident; and natural disasters .
Statistical analysis
Categorical variables are expressed as counts and percentages and comparisons were made using the Chi-square test or Fisher’s exact test. Continuous variables are expressed as means and standard deviations (SDs) or medians and interquartile ranges (IQRs) and comparisons were made with Student’s t test or the Mann-Whitney U test. For all tests, statistical significance was set at P < 0.05. The data were analysed using Stata SE 10 (Stata Statistical Software: Release 10 [2007]; StataCorp LP, College Station, Texas, USA).
Results
The study population comprised 117 patients, 56 of whom were enrolled prospectively and 61 retrospectively. Most of the patients were women (91.5%), the mean ± SD age was 71.4 ± 12.1 years and the prevalence of risk factors was high ( Table 1 ). The only significant difference between the retrospective and prospective groups was more frequent prevalence of diabetes mellitus in the prospective group ( P = 0.03). The most common initial symptoms were chest pain (80.5%) and dyspnoea (24.1%). A triggering event was detected in 64.3% of patients. Among patients for whom a triggering event was detected, mental stress was found in 70.4% and physical stress in 26.1%.
| Characteristics | All OFSETT ( n = 117) | Prospective group ( n = 56) | Retrospective group ( n = 61) |
|---|---|---|---|
| Women | 107/117 (91.5) | 51/56 (91.1) | 56/61 (91.8) |
| Age (years) | 71.4 ± 12.1 | 70.5 ± 12.5 | 72.3 ± 11.8 |
| Admission mode | |||
| Mobile intensive care unit | 56/114 (49.1) | 31/54 (57.4) | 25/60 (41.7) |
| Emergency department | 34/114 (29.8) | 14/54 (25.9) | 20/60 (33.3) |
| Cardiovascular risk factors | |||
| Hypertension | 66/114 (57.9) | 29/55 (52.7) | 37/59 (62.7) |
| Diabetes mellitus | 13/113 (11.5) | 10/55 (18.2) | 3/58 (5.2) a |
| Active smokers | 6/111 (5.4) | 5/54 (9.3) | 1/59 (1.7) |
| Obesity (BMI ≥30 kg/m 2 ) | 11/96 (11.5) | 7/47 (14.9) | 4/49 (8.2) |
| Dyslipidaemia | 37/112 (33.0) | 20/54 (37.0) | 17/58 (29.3) |
| Psychiatric history | 11/110 (10.0) | 6/54 (11.1) | 5/56 (8.9) |
| Medical history | |||
| Previous stroke/TIA | 7/113 (6.2) | 4/54 (7.4) | 3/59 (5.1) |
| Previous coronary heart disease | 8/113 (7.1) | 6/54 (11.1) | 2/59 (3.4) |
| Peripheral artery disease | 7/111 (6.3) | 1/53 (1.9) | 6/58 (10.3) |
| COPD | 6/111 (5.4) | 3/53 (5.7) | 3/59 (5.1) |
| Chronic kidney disease | 1/91 (1.1) | 0/32 (0.0) | 1/59 (1.7) |
| Symptoms at admission | |||
| Chest pain | 91/113 (80.5) | 41/54 (75.9) | 50/59 (84.7) |
| Dyspnoea | 27/112 (24.1) | 12/54 (22.2) | 15/58 (25.9) |
| Syncope | 7/114 (6.1) | 4/54 (7.4) | 3/60 (5.0) |
| Clinical examination | |||
| Heart rate (beats/min) | 82.5 ± 16.8 | 84.1 ± 14.4 | 80.9 ± 18.8 |
| Systolic blood pressure (mmHg) | 129.3 ± 23.2 | 129.3 ± 23.4 | 129.3 ± 23.2 |
| Acute heart failure | 7/113 (6.2) | 2/53 (3.8) | 5/60 (8.3) |
| Cardiogenic shock | 4/112 (3.6) | 2/52 (3.8) | 2/60 (3.3) |
| Psychological events | |||
| Identifiable | 74/115 (64.3) | 41/56 (73.2) | 33/59 (55.9) |
| Mental stress b | 50/71 (70.4) | 25/38 (65.8) | 25/33 (75.8) |
| Physical stress b | 18/69 (26.1) | 10/37 (27.0) | 8/32 (25.0) |
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