Patients with takotsubo (stress) cardiomyopathy had a higher frequency of neurologic or psychiatric disorders than did those with an acute coronary syndrome and therefore were at a substantial risk for adverse events in a study of 1,750 patients with takotsubo cardiomyopathy. Age- and sex-matched patients with takotsubo cardiomyopathy (nearly 90% women; mean age, 67 years) were compared with individuals with an acute coronary syndrome and researchers found:

• Rates of neurologic or psychiatric disorders were higher (56% vs 26%) and the mean left ventricular ejection fraction was markedly lower (40.7 vs 51.5) among patients with takotsubo cardiomyopathy.

• Rates of severe in-hospital complications included shock and death were similar in the 2 groups (P=93).

• Rate of major adverse cardiac and cerebrovascular events was 10% per patient-year, and the rate of death was 5.6% per patient-year during long-term follow-up.

• Beta-blockers, previously thought to be helpful with takotsubo cardiomyopathy, did not appear in this study and ACE inhibitors may have a positive effect.

Citation: Templin C, Ghadrio JR, Diekmann J, et al. Clinical features and outcomes of takotsubo (stress) cardiomyopathy. N Engl J Med 2015;373:929-938. doi: 10.1056/NEJMoa1406761.

Commentary: Takotsubo (stress) cardiomyopathy is characterized by transient left ventricular dysfunction, typically with a ballooning of the left ventricular apex that is not explained by coronary disease or myocarditis. It is most common in women over 60 years of age, can have an emotional or physical trigger, and can have EKG findings and elevated troponins that are similar to that seen with acute coronary syndromes (ACS). It is hypothesized that takotsubo cardiomyopathy may be due to myocardial stunning that may have a neuropathic cause. This is a disorder that, while not common, is worth knowing about. It is not possible to distinguish this from an acute coronary syndrome upon initial presentation, since the EKG and troponins may look very similar to ACS. While previously thought of as a benign disorder, this study shows that these patients have significant morbidity over time. —Neil Skolnik, MD