Persistent Long-Term Structural, Functional, and Metabolic Changes After Stress-Induced (Takotsubo) Cardiomyopathy.

Scally C, Rudd A, Mezincescu A, Wilson H, Srivanasan J, Horgan
G, Broadhurst P, Newby DE, Henning A, Dawson DK

Circulation. 2018 Mar 6;137(10):1039-1048

BACKGROUND: Takotsubo cardiomyopathy is an increasingly recognized acute heart
failure syndrome precipitated by intense emotional stress. Although there is an
apparent rapid and spontaneous recovery of left ventricular ejection fraction,
the long-term clinical and functional consequences of takotsubo cardiomyopathy
are ill-defined.
METHODS: In an observational case-control study, we recruited 37 patients with
prior (>12-month) takotsubo cardiomyopathy, and 37 age-, sex-, and
comorbidity-matched control subjects. Patients completed the Minnesota Living
with Heart Failure Questionnaire. All participants underwent detailed clinical
phenotypic characterization, including serum biomarker analysis, cardiopulmonary
exercise testing, echocardiography, and cardiac magnetic resonance including
cardiac 31P-spectroscopy.
RESULTS: Participants were predominantly middle-age (64±11 years) women (97%).
Although takotsubo cardiomyopathy occurred 20 (range 13-39) months before the
study, the majority (88%) of patients had persisting symptoms compatible with
heart failure (median of 13 [range 0-76] in the Minnesota Living with Heart
Failure Questionnaire) and cardiac limitation on exercise testing (reduced peak
oxygen consumption, 24±1.3 versus 31±1.3 mL/kg/min, P<0.001; increased VE/Vco2
slope, 31±1 versus 26±1, P=0.002). Despite normal left ventricular ejection
fraction and serum biomarkers, patients with prior takotsubo cardiomyopathy had
impaired cardiac deformation indices (reduced apical circumferential strain,
-16±1.0 versus -23±1.5%, P<0.001; global longitudinal strain, -17±1 versus
-20±1%, P=0.006), increased native T1 mapping values (1264±10 versus 1184±10 ms,
P<0.001), and impaired cardiac energetic status (phosphocreatine/γ-adenosine
triphosphate ratio, 1.3±0.1 versus 1.9±0.1, P<0.001).
CONCLUSIONS: In contrast to previous perceptions, takotsubo cardiomyopathy has
long-lasting clinical consequences, including demonstrable symptomatic and
functional impairment associated with persistent subclinical cardiac dysfunction.
Taken together our findings demonstrate that after takotsubo cardiomyopathy,
patients develop a persistent, long-term heart failure phenotype.