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Coronary slow flow is associated with a worse clinical outcome in patients with Takotsubo syndrome
  1. Rocco A Montone1,
  2. Leonarda Galiuto1,2,
  3. Maria Chiara Meucci1,2,
  4. Marco Giuseppe Del Buono1,2,
  5. Federico Vergni1,2,
  6. Massimiliano Camilli1,2,
  7. Tommaso Sanna1,2,
  8. Daniela Pedicino1,2,
  9. Antonino Buffon1,2,
  10. Domenico D'Amario1,
  11. Luca Giraldi3,
  12. Carlo Trani1,2,
  13. Giovanna Liuzzo1,2,
  14. Antonio G Rebuzzi1,2,
  15. Giampaolo Niccoli1,2,
  16. Filippo Crea1,2
  1. 1 Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
  2. 2 Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
  3. 3 Section of Hygiene, Institute of Public Health, Catholic University of the Sacred Heart, Rome, Italy
  1. Correspondence to Dr Giampaolo Niccoli, Department of Cardiovascular Medecine, Institute of Cardiology, Rome 00168, Italy; gniccoli73{at}


Objective Patients with Takotsubo syndrome (TTS) present an acute microvascular dysfunction that leads to an impaired myocardial perfusion and, in more severe forms, an impaired epicardial flow. However, clinical relevance of a delayed coronary flow, the coronary slow flow (CSF), has never been investigated. We studied the prognostic value of CSF occurring in the acute phase of TTS.

Methods This cohort study prospectively evaluated patients with a diagnosis of TTS. CSF was defined as angiographically non-obstructive coronary arteries with thrombolysis in myocardial infarction-2 flow. The incidence of overall mortality and major adverse cardiovascular events (MACEs), defined as the composite of TTS recurrence, cardiac rehospitalisation, cerebrovascular events and mortality, was assessed at follow-up.

Results We enrolled 101 patients (mean age 71.0±11.1 years, 86 (85.1%) female); CSF occurred in 18 (17.8%) patients. At admission, patients with CSF presented more frequently with Killip class III/IV, moderate-to-severe left ventricle systolic dysfunction and right ventricle dysfunction. During the index admission, patients with CSF had a higher rate of intrahospital complications (12 (66.7%) vs 28 (33.7%), p=0.01). At long-term follow-up, patients with CSF had a significantly higher occurrence of overall mortality (9 (50%) vs 19 (22.9%), p=0.011), mainly due to non-cardiac causes (89.3%), and a higher rate of MACE (10 (55.5%) vs 27 (32.5%), p=0.06). At multivariable Cox regression, CSF was independently associated with death from any causes.

Conclusions Patients with TTS presenting with CSF have a worse clinical presentation with a higher rate of intrahospital complications and a poor long-term clinical outcome.

  • Takotsubo syndrome: cardiac catheterisation and angiography
  • microvascular dysfunction
  • acute coronary syndromes

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  • Contributors All authors gave substantial contributions to the conception or design of the work, or the acquisition, analysis or interpretation of data; drafting the work or revising it critically for important intellectual content. All authors approved the final version published. All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval All procedures performed in this study were in accordance with the ethical standards of our institutional committee (Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore; code 26710/13) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.