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To the Editor,
In an excellent analysis published in the recent issue of the journal, “Heart” Lau et al. investigated the long-term clinic outcomes of patients with Takotsubo syndrome (TTS) in a large cohort. The results demonstrated that increasing age, male gender, diabetes mellitus, pulmonary disease and chronic kidney disease were associated with a higher risk of recurrence or death1. We wish to highlight a few points relevant to the article.
Núñez-Gil et al reported their findings whilst categorizing patients with TTS based upon proposed etiology. Individuals with idiopathic or emotional triggers were considered as having the primary disease, whereas those with likely physical causative factors were deemed to have a secondary form of the pathology. The analysis of both groups revealed a disparity in clinical outcomes; patients with underlying physical triggers displayed higher risk of both short and long-term adverse events 2. Similar findings have also been reported in other studies 3.
Prior published data has theorized that a history of diabetes mellitus may be relatively protective against developed of TTS possibly due to an ameliorated sympathetic response when compared to non-diabetics due to involvement related to diabetic neuropathy 4. Comparatively poorer outcomes in diabetic TTS patients as seen in this study may be possibly explained by the fact that these diabetic patients may have been overwhelmingly sicker to generate enough catecho...
Prior published data has theorized that a history of diabetes mellitus may be relatively protective against developed of TTS possibly due to an ameliorated sympathetic response when compared to non-diabetics due to involvement related to diabetic neuropathy 4. Comparatively poorer outcomes in diabetic TTS patients as seen in this study may be possibly explained by the fact that these diabetic patients may have been overwhelmingly sicker to generate enough catecholaminic surge to have TTS 1.
The present analysis is similar to previous data and suggests that patients with underlying physical triggers may be at a disproportionate risk for unfavorable clinical outcomes 1, 4. We continue to suggest that patients with TTS be categorized and separately analyzed based upon primary or secondary disease etiology to allow for a better understanding of these two distinct entities and its related risk prognostication 4. We are also intrigued by the role of diabetes and TTS related adverse events and look forward to further research highlighting this association.
1. Lau C, Chiu S, Nayak R, Lin B, Lee MS. Survival and risk of recurrence of takotsubo syndrome. Heart. 2021 Jan 8:heartjnl-2020-318028. doi: 10.1136/heartjnl-2020-318028. Epub ahead of print. PMID: 33419884.
2. Núñez-Gil IJ, Almendro-Delia M, Andrés M, Sionis A, Martin A, Bastante T, Córdoba-Soriano JG, Linares JA, González Sucarrats S, Sánchez-Grande-Flecha A, Fabregat-Andrés O, Pérez B, Escudier-Villa JM, Martin-Reyes R, Pérez-Castellanos A, Rueda Sobella F, Cambeiro C, Piqueras-Flores J, Vidal-Perez R, Bodí V, García de la Villa B, Corbí-Pascua M, Biagioni C, Mejía-Rentería HD, Feltes G, Barrabés J; RETAKO investigators. Secondary forms of Takotsubo cardiomyopathy: A whole different prognosis. Eur Heart J Acute Cardiovasc Care. 2016 Aug;5(4):308-16. doi: 10.1177/2048872615589512. Epub 2015 Jun 4. PMID: 26045512.
3. Chhabra L, Sareen P, Mwansa V, Khalid N. Mortality in Takotsubo cardiomyopathy should also be accounted based on predisposing etiology. Ann Noninvasive Electrocardiol. 2019 Jul;24(4):e12664. doi: 10.1111/anec.12664. Epub 2019 Jun 2. PMID: 31155779; PMCID: PMC6931614.
4. Khalid N, Ahmad SA, Umer A, Chhabra L. Role of Microcirculatory Disturbances and Diabetic Autonomic Neuropathy in Takotsubo Cardiomyopathy. Crit Care Med. 2015 Nov;43(11):e527. doi: 10.1097/CCM.0000000000001183. PMID: 26468716.