Coronary slow flow is associated with a worse clinical outcome in patients with Takotsubo syndrome

Rocco A Montone; Leonarda Galiuto; Maria Chiara Meucci; Marco Giuseppe Del Buono; Federico Vergni; Massimiliano Camilli; Tommaso Sanna; Daniela Pedicino; Antonino Buffon; Domenico D'Amario; Luca Giraldi; Carlo Trani; Giovanna Liuzzo; Antonio G Rebuzzi; Giampaolo Niccoli; Filippo Crea

doi:10.1136/heartjnl-2019-315909

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Heart failure and cardiomyopathies

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Coronary slow flow is associated with a worse clinical outcome in patients with Takotsubo syndrome

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ACUTE OR PRE-EXISTING CORONARY SLOW FLOW IN TAKOTSUBO CARDIOMYOPATHY: DOES IT MATTER ?
KENAN YALTA, TULIN YALTA and MUHAMMET GURDOGAN
Published on: 27 May 2020

Published on: 27 May 2020
ACUTE OR PRE-EXISTING CORONARY SLOW FLOW IN TAKOTSUBO CARDIOMYOPATHY: DOES IT MATTER ?
- KENAN YALTA, cardiologist trakya university
- Other Contributors:
  TULIN YALTA, pathologist
  
  MUHAMMET GURDOGAN, cardiologist
ACUTE OR PRE-EXISTING CORONARY SLOW FLOW IN TAKOTSUBO CARDIOMYOPATHY: DOES IT MATTER ?

Kenan YALTA, MD a
Tulin YALTA, MD b
Muhammet GURDOGAN, MD a

aTrakya University, Cardiology Department, Edirne, TURKEY
b Trakya University, Pathology Department, Edirne, TURKEY
Corresponding Author: Kenan YALTA Trakya University, Cardiology Department, Edirne, TURKEY
Email- kyalta@gmail.com, akenanyalta@trakya.edu.tr Phone: 0090505657985

In the setting of takotsubo cardiomyopathy (TTC), coronary microvascular dysfunction has been mostly considered as a causative factor (1,2). In their recently published article (1), Montone RA et al have demonstrated, for the first time, the prognostic value of coronary slow flow (CSF) phenomenon in TTC patients. Of note, as we previously discussed, on a theoretical basis, the particular prognostic value of CSF phenomenon in these patients (3), we feel now pleased to notice that this theory has been fully confirmed by a well-designed study (1). Nevertheless, we would like to make a few comments on this issue:
Firstly; temporal emergence of CSF phenomenon might possibly matter in TTC as well. Accordingly; an acutely evolving CSF pattern (due to severe adrenergic discharge (1)) as compared with a sole pre-existing one (emerging long before the index TTC as part of generalized...
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ACUTE OR PRE-EXISTING CORONARY SLOW FLOW IN TAKOTSUBO CARDIOMYOPATHY: DOES IT MATTER ?

Kenan YALTA, MD a
Tulin YALTA, MD b
Muhammet GURDOGAN, MD a

aTrakya University, Cardiology Department, Edirne, TURKEY
b Trakya University, Pathology Department, Edirne, TURKEY
Corresponding Author: Kenan YALTA Trakya University, Cardiology Department, Edirne, TURKEY
Email- kyalta@gmail.com, akenanyalta@trakya.edu.tr Phone: 0090505657985

In the setting of takotsubo cardiomyopathy (TTC), coronary microvascular dysfunction has been mostly considered as a causative factor (1,2). In their recently published article (1), Montone RA et al have demonstrated, for the first time, the prognostic value of coronary slow flow (CSF) phenomenon in TTC patients. Of note, as we previously discussed, on a theoretical basis, the particular prognostic value of CSF phenomenon in these patients (3), we feel now pleased to notice that this theory has been fully confirmed by a well-designed study (1). Nevertheless, we would like to make a few comments on this issue:
Firstly; temporal emergence of CSF phenomenon might possibly matter in TTC as well. Accordingly; an acutely evolving CSF pattern (due to severe adrenergic discharge (1)) as compared with a sole pre-existing one (emerging long before the index TTC as part of generalized endothelial dysfunction) might have stronger cardiovascular prognostic implications in the acute course of TTC (3). In contrast, a pre-existing CSF pattern might be associated with a poor long-term prognosis largely driven by the underlying systemic condition. In this context, CSF pattern in the settings of malignancy and neurological disease might have possibly risen as a pre-existing phenomenon in the present study (1).
Secondly; it seems quite challenging to identify whether a CSF pattern in TTC patients appears to be an acute or pre-existing phenomenon (or both) based on a single coronary angiogram (CAG) (unless making a comparison with previous CAG data). However, a sole pre-existing CSF pattern might be relatively mild and diffuse in nature as compared with a sole or superimposed acute CSF in these patients. Accordingly, did the extent and severity of CSF patterns significantly differ between those with acute cardiac complications (mostly arising due to an acute CSF) and those with exclusively long-term events on follow-up (mostly due to the systemic condition (1) associated with pre-existing CSF) ? In particular, potential prediction of an acute or exclusively pre-existing CSF pattern based on angiographic features might help establish further clinical strategies to improve prognosis (for instance; close supervision for expected acute complications or further diagnostic tests (1) for an obscure malignancy, etc.).
Lastly; vasodilator strategies in TTC patients with a CSF pattern (particularly with a predominant acute component) might be of significant benefit (4). Moreover, given the potential association of future TTC recurrences with excessive adrenergic discharge during the index event (2), TTC patients likely to have an acute CSF pattern might need well-known radical measures including sympathetic ganglion blockade, etc for TTC prevention. Accordingly, we wonder their acute and long-term management strategies in TTC patients with a CSF pattern (1).
In summary, CSF pattern might be considered as a prognostic rather than a causative factor in TTC patients (1,3). However, further categories of this phenomenon (acute vs pre-existing) along with their specific implications in these patients still remain to be established.
Conflict of Interest: None

REFERENCES:
1- Montone RA, Galiuto L, Meucci MC, et al. Coronary slow flow is associated with a worse clinical outcome in patients with Takotsubo syndrome. Heart. 2020 Jan 10. pii: heartjnl-2019-315909. doi: 10.1136/heartjnl-2019-315909. [Epub ahead of print]
2- Kawaji T, Shiomi H, Morimoto T, et al. Clinical impact of left ventricular outflow tract obstruction in takotsubo cardiomyopathy. Circ J. 2015; 79(4): 839-46.
3- Yalta K, Yilmaztepe M, Ucar F, et al. Coronary slow flow in the setting of Tako-tsubo cardiomyopathy: A causative factor? An innocent bystander? Or a prognostic sign? Int J Cardiol. 2015; 198:229-31.
4- Yalta K, Sivri N, Yalta T. Neuropeptide Y-induced coronary microvascular dysfunction: a significant contributor to the adverse outcomes in stress cardiomyopathy? Int J Cardiol. 2011; 147(2): 284.
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Conflict of Interest:
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