We thank Dr. Madias for his interest in and comments concerning our report, which describes the incidence, characteristics, risk factors, and outcomes of Takotsubo cardiomyopathy with and without ventricular arrhythmia. In Takotsubo cardiomyopathy, albeit several physiological hypotheses have been suggested, a hyperadrenergic mechanism, excessive sympathetic responsiveness associated with a reduced parasympathetic modulation of heart rate is more commonly evocated. Several investigators have suggested that diabetes mellitus (DM), responsible of autonomic nervous system neuropathy and adrenal cathecholamine hyposecretion, could have a protective effect on Takotsubo cardiomyopathy. Several investigations explored the association between DM and TC, and investigators noted that the prevalence of DM in patients with TC is lower than expected for age matched cohort.
In our report including 90 patients, we found a significant difference on the prevalence of DM between patients presenting with TC versus patients presenting with suspected acute coronary syndrome. However, only 8 patients (9%) of our cohort presented with TC and type 2 DM and results should be cautiously interpreted ( Table 1 ). The average length of the disease was 6 ± 3.2 years and those patients were older. The most common initial symptom was chest pain (62%), and all of them presented a triggering event (emotional or surgical stress). Apical TC and apical-sparing variant were identified in 75% and 25% of patients, respectively. No significant difference was observed in patients with TC with or without diabetes. Regarding diabetes biomarkers in patients with DM, mean blood glucose level was 10.2 ± 3.2 mmol/L and glycated hemoglobin A1c level was 9.7 ± 2.1%. Concerning antidiabetic drugs used, we found a large majority of antihyperglycemic agent orally administrated: sulfonylureas (e.g., glimepiride and glipizide) or biguanide metformin in 6 patients, and 1 patient received dipeptidyl peptidase-4 inhibitors (sitagliptin). We also noted that 2 patients required a combination of therapy (insulin therapy + oral antihyperglycemic agents) during and after the hospital stay, and one other patient was previously treated by insulin infusion therapy. Three of them (37%) were known to present peripheral diabetic neuropathy.
| Suspected ACS population (n = 5484) | TC population (n = 90) | TC and DM (n = 8) | |
|---|---|---|---|
| Mean age, y | 65.5± 12 | 71.9±12.7 | 73.4±10.2 |
| Women, n (%) | 1679 (30) | 87 (97) | 7 (87) |
| Cardiovascular risk factors | |||
| Current smoker, n (%) | 2106 (38) | 25 (28) | 4 (50) |
| Hypertension, n (%) | 2508 (47) | 41 (46) | 6 (75) |
| Diabetes mellitus, n (%) | 943 (17) | 8 (9) | 8 (100) |
| Dyslipidemia, n (%) | 2536 (46) | 26 (29) | 3 (37.5) |
| Family history of CAD, n (%) | 965 (18) | 7 (8) | 0 (0) |
| In-hospital mortality, n (%) | 286 (5) | 2 (2) | 0 (0) |
| Duration of hospitalization, days | 4.7±4.6 | 9.8±9.2 | 9.6±6.3 |
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