Impact of ST-segment elevation on the outcome of Takotsubo syndrome

Figures & data

Table 1 Baseline characteristics of 41 TTS patients with ST elevation and 64 STEMI patients

Variables	TTS (n=138)	Matched ACS (n=138)	TTS with ST elevation (n=41)	STEMI (n=64)	P-valuea
Demographics
Age, mean ± SD (years)	67±11	66±15	68±12	68±16	1.00
Female, n (%)	117 (84.8)	117 (84.8)	38 (92.7)	59 (92.2)	0.93
Symptoms, n (%)
Dyspnea	54 (39.1)	44 (31.9)	13 (31.7)	17 (26.6)	0.57
Chest pain	69 (50.4)	107 (77.5)	20 (48.8)	50 (78.1)	<0.01
Clinical parameter
SBP, mmHg, IQR	141 (62–240)	137 (60–240)	135 (80–220)	130 (60–210)	0.49
DBP, mmHg, IQR	79 (40–151)	76 (7–120)	81 (50–111)	74 (7–120)	0.44
Heart rate, bpm, IQR	99±26	81±19	99±20	80±18	<0.01
ECG data
ST-segment elevation, n (%)	41 (29.9)	64 (46.4)	41 (100.0)	64 (100.0)	1.00
Inversed T-waves, n (%)	123 (93.2)	69 (50.0)	36 (92.3)	21 (32.8)	<0.01
PQ interval, mean ± SD	159±28	166±31	157±28	169±33	0.09
QTc (ms), mean ± SD	475 (62–604)	457 (358–614)	475 (130–604)	456 (373–614)	0.14
Laboratory values, mean ± SD
Troponin I (U/L; IQR)	63.15 (0.01–2,738.00)	20.02 (0.03–233.88)	77.44 (0.06–2,631)	29.10 (0.03–233.88)	0.37
Creatine phosphokinase (U/L; IQR)	587 (39–26,600)	1,028 (35–10,250)	475 (48–939)	1,353 (53–6,260)	0.56
CKMB (U/L; IQR)	35 (1–415)	79 (0–741)	77 (4–167)	108 (0–589)	0.49
C-reactive protein (mg/L; IQR)	48.2 (0.4–467.1)	45.2 (1.0–594.0)	29.8 (1.4–467.1)	45.2 (1.0–323.7)	0.65
Hemoglobin, mean ± SD	12.2±2.0	12.8±1.9	12.4±2.4	12.8±2.2	0.32
Creatinine (mg/dL; IQR)	1.12 (0.40–5.56)	1.10 (0.43–6.44)	0.97 (0.40–1.85)	0.98 (0.43–1.87)	0.82
Echocardiography data, n (%)
LVEF%, mean ± SD	39±10	49±15	39±9	45±16	0.01
LVEF% follow-up, mean ± SD	52±11	49±15	54±10	45±16	<0.01
Mitral regurgitation	66 (47.8)	39 (28.3)	19 (46.3)	14 (21.9)	<0.01
Tricuspid regurgitation	54 (39.1)	20 (14.5)	14 (34.1)	9 (14.1)	<0.01
Medical history, n (%)
Smoking	41 (29.7)	45 (32.6)	10 (24.4)	19 (29.7)	0.38
Diabetes mellitus	31 (22.5)	49 (35.5)	5 (12.2)	19 (29.7)	0.02
BMI >25 kg/m^2	36 (31.3)	74 (53.6)	10 (24.4)	29 (45.3)	0.11
Hypertension	82 (59.4)	98 (71.0)	25 (61.0)	39 (60.9)	0.80
COPD	28 (20.3)	12 (8.7)	9 (22.0)	4 (6.3)	0.04
Atrial fibrillation	26 (18.8)	19 (13.8)	5 (12.2)	8 (12.5)	0.96
History of malignancy	17 (12.3)	8 (5.8)	2 (5.1)	3 (4.7)	1.00
Drugs on admission, n (%)
Beta-blocker	46 (35.4)	32 (23.7)	14 (35.0)	13 (20.6)	0.11
ACE inhibitor	51 (39.2)	31 (22.6)	17 (41.5)	14 (21.9)	0.03
ARB	12 (9.3)	8 (5.8)	4 (10.2)	4 (6.3)	0.49
Aldosterone inhibitor	1 (0.8)	2 (1.5)	1 (2.5)	0 (0.0)	0.39
Aspirin	36 (27.7)	31 (22.6)	14 (35.0)	11 (17.2)	0.04
Statin	26 (20.0)	17 (12.4)	10 (25.0)	10 (15.6)	0.24
OAD	6 (4.6)	11 (8.0)	1 (2.5)	5 (7.8)	0.25
Insulin	12 (9.3)	17 (12.4)	2 (5.1)	5 (7.8)	0.59
Therapeutic anticoagulation	12 (9.3)	9 (6.5)	4 (10.2)	4 (6.3)	0.47
Heparin	6 (4.6)	3 (2.2)	3 (7.7)	1 (1.6)	0.16
Drugs on discharge, n (%)
Beta-blocker	103 (74.6)	110 (79.7)	32 (78.0)	48 (75.0)	0.94
ACE inhibitor	82 (59.4)	85 (61.6)	24 (58.5)	32 (50.0)	0.54
ARB	10 (7.2)	20 (14.5)	5 (12.2)	10 (15.6)	0.62
Aldosterone inhibitor	2 (1.4)	2 (1.5)	0 (0.0)	1 (1.6)	1.00
Aspirin	53 (38.4)	113 (81.9)	17 (41.5)	49 (76.6)	<0.01
Statin	48 (34.8)	110 (79.7)	17 (41.5)	46 (71.8)	<0.01
OAD	4 (2.9)	8 (5.8)	0 (0.0)	4 (6.3)	0.32
Insulin	14 (10.1)	18 (13.0)	3 (7.7)	6 (9.4)	0.78
Therapeutic anticoagulation	33 (23.9)	10 (7.2)	10 (24.4)	5 (7.8)	0.02
Heparin	18 (13.0)	8 (5.8)	7 (17.1)	4 (6.3)	0.18

Notes:

a P-values for the comparison between TTS in the presence of ST elevation as compared with STEMI. Statically significant P-value (P<0.05) shown in bold.

Abbreviations: ACE, angiotensin-converting enzyme; ACS, acute coronary syndrome; ARB, angiotensin receptor blocker; CKMB, creatin kinase muscle/brain; ECG, electrocardiogram; LVEF, left ventricular ejection fraction; OAD, oral antidiabetic drugs; STEMI, ST elevation myocardial infarction; TTS, Takotsubo syndrome.

Table 2 Inhospital events and treatment strategy in TTS patients with ST elevation and STEMI patients

Variables	TTS (n=138)	Matched ACS (n=138)	TTS with ST elevation (n=41)	STEMI (n=64)	P-valuea
Life-threatening arrhythmia	12 (8.8)	16 (11.6)	5 (12.2)	11 (17.2)	0.59
NPPV and/or intubation	80 (58.0)	16 (11.6)	28 (68.3)	13 (20.3)	<0.01
Inotropic agents	23 (16.7)	18 (13.0)	8 (19.5)	14 (21.9)	0.77
Resuscitation	4 (12.5)	17 (12.3)	3 (7.3)	11 (17.2)	0.15
Cardiac electronic device implantation	4 (2.9)	9 (6.5)	1 (2.4)	5 (7.8)	0.25
Admission to ICU, length of stay, days (IQR)	5 (0–52)	3 (0–14)	4 (0–20)	3 (0–11)	0.43
Inhospital death	10 (7.2)	17 (12.3)	3 (7.3)	13 (20.3)	0.10
Cardiogenic shock	25 (18.5)	16 (11.6)	6 (15.4)	13 (20.3)	0.51
Thromboembolic events	18 (13.0)	3 (2.2)	9 (22.0)	3 (4.7)	0.02

Notes:

a P-values for the comparison between TTS in the presence of ST elevation as compared with STEMI. Data presented as n (%). Statically significant P-value (P<0.05) shown in bold.

Abbreviations: ACS, acute coronary syndrome; ICU, intermediate care unit; NPPV, noninvasive positive pressure ventilation; STEMI, ST elevation myocardial infarction; TTS, Takotsubo syndrome.

Figure 1 Short- and long-term mortality rate in TTS patients with ST-segment elevation as compared with STEMI patients over mean follow-up of 5 years.

Notes: Expansion of FU in TTS patients: 0–3893. Expansion of FU in MI patients: 0–3934 days.
Abbreviations: FU, follow-up; MI, myocardial infarction; STEMI, ST elevation myocardial infarction; TTS, Takotsubo syndrome.

Table 3 Outcome in 41 TTS patients with ST elevation and 64 STEMI patients

Variables	TTS (n=138)	Matched ACS (n=138)	TTS with ST elevation (n=41)	STEMI (n=64)	RR (95% CI)	P-valuea
Inhospital mortality	10 (7.2)	17 (12.3)	3 (7.3)	13 (20.3)	0.4 (0.1–1.2)	0.10
30-day mortality	10 (7.2)	17 (12.3)	4 (9.8)	13 (20.3)	0.5 (0.7–1.4)	0.18
1-year mortality	14 (10.1)	18 (13.0)	4 (9.8)	13 (20.3)	0.5 (0.7–1.4)	0.18
2-year mortality	21 (15.2)	19 (13.8)	5 (12.2)	14 (21.9)	0.6 (0.2–1.4)	0.30
3-year mortality	23 (16.7)	19 (13.8)	7 (17.1)	14 (21.9)	0.8 (0.3–1.8)	0.55
4-year mortality	29 (21.0)	19 (13.8)	8 (19.5)	14 (21.9)	0.9 (0.4–1.9)	0.77
Long-term mortality	35 (25.4)	22 (15.9)	11 (26.8)	14 (21.9)	1.2 (0.6–2.4)	0.56
Cardiovascular cause of death	11 (8.0)	17 (12.3)	6 (14.6)	11 (17.2)	0.9 (0.3–2.1)	0.73
Non-cardiovascular cause of death	15 (10.9)	5 (3.6)	2 (4.9)	3 (4.7)	1.0 (0.2–6.0)	1.00
Unknown cause of death	9 (6.5)	0 (0.0)	3 (7.3)	0 (0.0)		0.06
30-day stroke	4 (2.9)	1 (0.7)	2 (4.9)	0 (0.0)		0.15
1-year stroke	5 (3.6)	2 (1.4)	2 (4.9)	0 (0.0)		0.15
2-year stroke	7 (5.1)	2 (1.4)	3 (7.3)	0 (0.0)		0.06
3-year stroke	7 (5.1)	3 (2.2)	3 (7.3)	1 (1.6)	4.7 (0.5–43.5)	0.30
4-year stroke	8 (5.8)	4 (2.9)	3 (7.3)	1 (1.6)	4.7 (0.5–43.5)	0.30
Long-term stroke	9 (6.5)	6 (4.3)	3 (7.3)	3 (4.7)	1.6 (0.3–7.4)	0.68
30-day life-threatening arrhythmia	12 (8.7)	16 (11.6)	5 (12.2)	11 (17.2)	0.7 (0.3–1.9)	0.59
1-year life-threatening arrhythmia	13 (9.4)	16 (11.6)	5 (12.2)	11 (17.2)	0.7 (0.3–1.9)	0.59
2-year life-threatening arrhythmia	14 (10.1)	16 (11.6)	5 (12.2)	11 (17.2)	0.7 (0.3–1.9)	0.59
3-year life-threatening arrhythmia	14 (10.1)	16 (11.6)	5 (12.2)	11 (17.2)	0.7 (0.3–1.9)	0.59
4-year life-threatening arrhythmia	14 (10.1)	17 (12.3)	5 (12.2)	11 (17.2)	0.7 (0.3–1.9)	0.59
Long-term life-threatening arrhythmia	14 (10.1)	17 (12.3)	5 (12.2)	11 (17.2)	0.7 (0.3–1.9)	0.59
30-day heart failure	3 (2.2)	8 (5.8)	2 (4.9)	7 (10.9)	0.4 (0.1–1.1)	0.48
1-year heart failure	4 (2.9)	14 (10.1)	2 (4.9)	8 (12.5)	0.4 (0.1–1.7)	0.31
2-year heart failure	5 (3.6)	15 (10.9)	2 (4.9)	8 (12.5)	0.4 (0.1–1.7)	0.31
3-year heart failure	5 (3.6)	18 (13.0)	2 (4.9)	10 (15.6)	0.3 (0.1–0.7)	0.12
4-year heart failure	5 (3.6)	19 (13.8)	2 (4.9)	10 (15.6)	0.3 (0.1–0.7)	0.12
Long-term heart failure	5 (3.6)	19 (13.8)	2 (4.9)	10 (15.6)	0.3 (0.1–0.7)	0.12
30-day recurrence	0 (0.0)	3 (2.2)	0 (0.0)	0 (0.0)
1-year recurrence	1 (0.7)	7 (5.1)	1 (2.4)	2 (3.1)	0.8 (0.1–8.3)	1.00
2-year recurrence	5 (3.6)	10 (7.2)	2 (4.9)	3 (4.7)	1.0 (0.2–6.0)	1.00
3-year recurrence	7 (5.1)	11 (8.0)	3 (7.3)	3 (4.7)	1.6 (0.3–7.4)	0.68
4-year recurrence	7 (5.1)	15 (10.9)	3 (7.3)	5 (7.8)	0.9 (0.2–3.7)	1.00
Long-term recurrence	7 (5.1)	15 (10.9)	3 (7.3)	5 (7.8)	0.9 (0.2–3.7)	1.00
30-day thromboembolic events	18 (13.0)	5 (3.6)	9 (22.0)	3 (4.7)	4.2 (1.2–14.8)	0.02
1-year thromboembolic events	18 (13.0)	6 (4.3)	9 (22.0)	3 (4.7)	4.2 (1.2–14.8)	0.02
2-year thromboembolic events	19 (13.8)	6 (4.3)	9 (22.0)	3 (4.7)	4.2 (1.2–14.8)	0.02
3-year thromboembolic events	24 (17.4)	8 (5.8)	13 (31.7)	4 (6.3)	4.7 (1.6–13.5)	<0.01
4-year thromboembolic events	26 (18.8)	10 (7.2)	14 (34.1)	5 (7.8)	4.1 (1.6–10.5)	<0.01
Long-term thromboembolic events	29 (21.0)	12 (8.7)	15 (36.6)	6 (9.4)	3.6 (1.5–8.7)	<0.01

Notes:

a P-values for the comparison between TTS in the presence of ST elevation with compared with STEMI. Data presented as n (%) unless stated otherwise. Statically significant P-value (P<0.05) shown in bold.

Abbreviations: ACS, acute coronary syndrome; STEMI, ST elevation myocardial infarction; TTS, Takotsubo syndrome.

Table 4 Causes of death in TTS patients with ST elevation and STEMI patients

Variables	TTS (n=41)	STEMI (n=64)
Sudden cardiac death	2	1
Cardiac decompensation	2	1
Cardiogenic shock	2	7
Ventricular fibrillation	0	1
Septic shock	0	1
Anal carcinoma	1	0
COPD	1	0
Lung edema	0	1
Pulmonary embolism	0	1
Myocardial perforation	0	1
Unknown cause of death	3	0

Abbreviations: STEMI, ST elevation myocardial infarction; TTS, Takotsubo syndrome.

Table 5 Univariate analysis for the end point in TTS patients with ST-segment elevation

	Univariate analysis
	HR	95% CI	P-value
Male	2.2	1.0–5.0	0.04
Age (years)	1.0	0.9–1.0	0.45
EF <35%	2.1	1.1–4.3	0.02
COPD	1.1	0.4–2.4	0.85
ST-segment elevation	0.9	0.4–1.9	0.81
GFR <60 mL/min	2.4	1.2–4.9	0.01
Cardiogenic shock	4.6	2.2–9.3	<0.01
Inotropic drugs	3.9	1.9–7.8	<0.01
DM type II	1.0	0.4–2.2	0.97
Hypertension	0.7	0.3–1.5	0.41
Apical ballooning	1.8	0.7–4.3	0.18
History of cancer	2.8	1.3–6.4	<0.01
Smoking	0.8	0.3–1.7	0.64

Note: Statically significant P-value (P<0.05) shown in bold.

Abbreviations: DM, diabetes mellitus; GFR, glomerular filtration rate; EF, ejection fraction; TTS, Takotsubo syndrome.