Author + information
- Rodolfo Citro, MD, PhD∗ (, )
- Eduardo Bossone, MD, PhD,
- Guido Parodi, MD, PhD,
- Fausto Rigo, MD,
- Federico Nardi, MD,
- Gennaro Provenza, MD,
- Concetta Zito, MD, PhD,
- Giuseppina Novo, MD, PhD,
- Giovanni Vitale, MD,
- Costantina Prota, MD,
- Angelo Silverio, MD,
- Olga Vriz, MD,
- Antonello D’Andrea, MD, PhD,
- Francesco Antonini-Canterin, MD,
- Jorge Salerno-Uriarte, MD,
- Federico Piscione, MD,
- Tako-tsubo Italian Network Investigators
- ↵∗Department of Heart Sciences, Experimental and Clinical Physiology Institute, University of Insubria, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, Heart Tower Room 810, Largo Città di Ippocrate, Salerno 84131, Italy
Takotsubo syndrome (TTS) is an acute clinical condition characterized by transient left ventricular dysfunction and reversible heart failure, the pathogenetic mechanism of which remains unclear. Although left ventricular apical ballooning is the most frequent morphological pattern, other variant forms have been described (1). In addition, right ventricular involvement (RVi), characterized by the presence of right ventricular (RV) apical dysfunction (biventricular ballooning), has been documented using echocardiography or cardiac magnetic resonance imaging. However, the prevalence, clinical profile, and in-hospital course of TTS patients with RVi are still not well defined. To date, although RVi has been associated with a higher complication rate (2), no correlation with short-term cardiac morbidity or mortality has been reported. The aim of this study was to describe the prevalence and prognostic impact of RVi in TTS.
TTS patients with typical left ventricular apical ballooning enrolled in the Tako-tsubo Italian Network from January 2002 to June 2014 were included. Eleven hospitals contributed by providing data from a minimum of 11 to a maximum of 32 patients for each center. Patients presenting more than 24 h after symptom onset were excluded. The structure and methods of the Tako-tsubo Italian Network have been previously published (2). Data were prospectively recorded on a standardized form including information on patient demographics, pre-existing comorbidities, signs and symptoms at presentation, medical history, trigger events (emotional or physical), ST-segment elevation changes on admission, and clinical observations during hospitalization. The Charlson comorbidity index was calculated. Blood samples were collected every 6 h to measure peak troponin I concentrations in the acute phase. Brain natriuretic peptide (BNP) levels were also recorded daily during the acute phase. Standard transthoracic 2-dimensional echocardiography was performed within 6 h of hospital admission. The echocardiography transducer was adjusted to the level of the RV chamber to achieve optimal visualization of RV size and endocardial borders. To define RVi, the RV wall motion was evaluated qualitatively by visual assessment, in the parasternal long axis, apical, and subcostal 4-chamber views. All patients underwent coronary angiography and left ventriculography within 24 h of symptom onset to confirm the TTS diagnosis. Acute heart failure, cardiogenic shock, and in-hospital mortality were considered major adverse events. The study was approved by the local ethics committee, and all patients gave consent for the use of their medical records for research purposes.
The study population included 339 patients (mean age 69.7 ± 11.2 years; 91.7% female patients). RVi was observed in 56 patients (16.5% of the overall population). Demographic, clinical, electrocardiographic, and echocardiographic features of the overall population and a comparison at univariate analysis of the same variables in patients with and without RVi are reported in Table 1. In the overall population, acute heart failure was the most frequent major adverse event (n = 57, 16.8%). Cardiogenic shock and in-hospital death occurred in 23 (6.8%) and 6 (1.8%) patients, respectively.
On multivariate analysis, RVi (hazard ratio [HR]: 2.561; 95% confidence interval [CI]: 1.227 to 5.346; p = 0.012), Charlson comorbidity index (HR: 1.275; 95% CI: 1.097 to 1.483; p = 0.002), and systolic pulmonary artery pressure (HR: 1.045; 95% CI: 1.014 to 1.077; p = 0.005) were independent correlates of acute heart failure. The same variables, RVi (HR: 2.327; 95% CI: 1.151 to 4.706; p = 0.019), Charlson comorbidity index (HR: 1.254; 95% CI: 1.088 to 1.444; p = 0.002), and systolic pulmonary artery pressure (HR: 1.047; 95% CI: 1.016 to 1.078; p = 0.002) remained independent predictors even if a composite endpoint including all major adverse events was considered.
The prevalence of extensive RVi in TTS patients with typical left ventricular apical ballooning is relatively low (16.5%). This patient subset has a different clinical profile characterized by significantly more frequent occurrence of dyspnea at onset, ST-segment elevation on the electrocardiogram, a greater number of pre-existing comorbidities (especially chronic obstructive pulmonary disease), higher Charlson comorbidity index score, higher wall motion score index, and more frequent occurrence of moderate to severe mitral regurgitation. Along with Charlson comorbidity index and systolic pulmonary artery pressure, RVi is an independent predictor of acute heart failure and of a composite endpoint including adverse events, such as acute heart failure, cardiogenic shock, and in-hospital mortality.
Echocardiography should be systematically performed in the acute phase of TTS to identify patients with RVi. This patient subset should be considered at higher risk and monitored more strictly to promptly start an appropriate therapeutic strategy.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation