Ethnic comparison in takotsubo syndrome: novel insights from the International Takotsubo Registry

Yoichi Imori, Ken Kato, Victoria L Cammann, Konrad A Szawan, Manfred Wischnewsky, Sara Dreiding, Michael Würdinger, Maximilian Schönberger, Vanya Petkova, David Niederseer, Rena A Levinson, Davide Di Vece, Sebastiano Gili, Burkhardt Seifert, Masaki Wakita, Noriko Suzuki, Rodolfo Citro, Eduardo Bossone, Susanne Heiner, Maike Knorr, Thomas Jansen, Thomas Münzel, Fabrizio D'Ascenzo, Jennifer Franke, Ioana Sorici-Barb, Hugo A Katus, Annahita Sarcon, Jerold Shinbane, L Christian Napp, Johann Bauersachs, Milosz Jaguszewski, Reiko Shiomura, Shunichi Nakamura, Hitoshi Takano, Michel Noutsias, Christof Burgdorf, Iwao Ishibashi, Toshiharu Himi, Wolfgang Koenig, Heribert Schunkert, Holger Thiele, Behrouz Kherad, Carsten Tschöpe, Burkert M Pieske, Lawrence Rajan, Guido Michels, Roman Pfister, Shingo Mizuno, Alessandro Cuneo, Claudius Jacobshagen, Gerd Hasenfuß, Mahir Karakas, Hiroki Mochizuki, Alexander Pott, Wolfgang Rottbauer, Samir M Said, Ruediger C Braun-Dullaeus, Adrian Banning, Toshiaki Isogai, Akihisa Kimura, Florim Cuculi, Richard Kobza, Thomas A Fischer, Tuija Vasankari, K E Juhani Airaksinen, Yasuhiro Tomita, Monika Budnik, Grzegorz Opolski, Rafal Dworakowski, Philip MacCarthy, Christoph Kaiser, Stefan Osswald, Leonarda Galiuto, Filippo Crea, Wolfgang Dichtl, Tsutomu Murakami, Yuji Ikari, Klaus Empen, Daniel Beug, Stephan B Felix, Clément Delmas, Olivier Lairez, Tetsuo Yamaguchi, Ibrahim El-Battrawy, Ibrahim Akin, Martin Borggrefe, John D Horowitz, Martin Kozel, Petr Tousek, Petr Widimský, Ekaterina Gilyarova, Alexandra Shilova, Mikhail Gilyarov, Michael Neuhaus, Philippe Meyer, Jose David Arroja, Christina Chan, Paul Bridgman, Jan Galuszka, Gregor Poglajen, Pedro Carrilho-Ferreira, Fausto J Pinto, Christian Hauck, Lars S Maier, Kan Liu, Carlo Di Mario, Carla Paolini, Claudio Bilato, Matteo Bianco, Lucas Jörg, Hans Rickli, David E Winchester, Christian Ukena, Michael Böhm, Jeroen J Bax, Abhiram Prasad, Charanjit S Rihal, Shigeru Saito, Yoshio Kobayashi, Thomas F Lüscher, Frank Ruschitzka, Wataru Shimizu, Jelena R Ghadri, Christian Templin, Yoichi Imori, Ken Kato, Victoria L Cammann, Konrad A Szawan, Manfred Wischnewsky, Sara Dreiding, Michael Würdinger, Maximilian Schönberger, Vanya Petkova, David Niederseer, Rena A Levinson, Davide Di Vece, Sebastiano Gili, Burkhardt Seifert, Masaki Wakita, Noriko Suzuki, Rodolfo Citro, Eduardo Bossone, Susanne Heiner, Maike Knorr, Thomas Jansen, Thomas Münzel, Fabrizio D'Ascenzo, Jennifer Franke, Ioana Sorici-Barb, Hugo A Katus, Annahita Sarcon, Jerold Shinbane, L Christian Napp, Johann Bauersachs, Milosz Jaguszewski, Reiko Shiomura, Shunichi Nakamura, Hitoshi Takano, Michel Noutsias, Christof Burgdorf, Iwao Ishibashi, Toshiharu Himi, Wolfgang Koenig, Heribert Schunkert, Holger Thiele, Behrouz Kherad, Carsten Tschöpe, Burkert M Pieske, Lawrence Rajan, Guido Michels, Roman Pfister, Shingo Mizuno, Alessandro Cuneo, Claudius Jacobshagen, Gerd Hasenfuß, Mahir Karakas, Hiroki Mochizuki, Alexander Pott, Wolfgang Rottbauer, Samir M Said, Ruediger C Braun-Dullaeus, Adrian Banning, Toshiaki Isogai, Akihisa Kimura, Florim Cuculi, Richard Kobza, Thomas A Fischer, Tuija Vasankari, K E Juhani Airaksinen, Yasuhiro Tomita, Monika Budnik, Grzegorz Opolski, Rafal Dworakowski, Philip MacCarthy, Christoph Kaiser, Stefan Osswald, Leonarda Galiuto, Filippo Crea, Wolfgang Dichtl, Tsutomu Murakami, Yuji Ikari, Klaus Empen, Daniel Beug, Stephan B Felix, Clément Delmas, Olivier Lairez, Tetsuo Yamaguchi, Ibrahim El-Battrawy, Ibrahim Akin, Martin Borggrefe, John D Horowitz, Martin Kozel, Petr Tousek, Petr Widimský, Ekaterina Gilyarova, Alexandra Shilova, Mikhail Gilyarov, Michael Neuhaus, Philippe Meyer, Jose David Arroja, Christina Chan, Paul Bridgman, Jan Galuszka, Gregor Poglajen, Pedro Carrilho-Ferreira, Fausto J Pinto, Christian Hauck, Lars S Maier, Kan Liu, Carlo Di Mario, Carla Paolini, Claudio Bilato, Matteo Bianco, Lucas Jörg, Hans Rickli, David E Winchester, Christian Ukena, Michael Böhm, Jeroen J Bax, Abhiram Prasad, Charanjit S Rihal, Shigeru Saito, Yoshio Kobayashi, Thomas F Lüscher, Frank Ruschitzka, Wataru Shimizu, Jelena R Ghadri, Christian Templin

Abstract

Background: Ethnic disparities have been reported in cardiovascular disease. However, ethnic disparities in takotsubo syndrome (TTS) remain elusive. This study assessed differences in clinical characteristics between Japanese and European TTS patients and determined the impact of ethnicity on in-hospital outcomes.

Methods: TTS patients in Japan were enrolled from 10 hospitals and TTS patients in Europe were enrolled from 32 hospitals participating in the International Takotsubo Registry. Clinical characteristics and in-hospital outcomes were compared between Japanese and European patients.

Results: A total of 503 Japanese and 1670 European patients were included. Japanese patients were older (72.6 ± 11.4 years vs. 68.0 ± 12.0 years; p < 0.001) and more likely to be male (18.5 vs. 8.4%; p < 0.001) than European TTS patients. Physical triggering factors were more common (45.5 vs. 32.0%; p < 0.001), and emotional triggers less common (17.5 vs. 31.5%; p < 0.001), in Japanese patients than in European patients. Japanese patients were more likely to experience cardiogenic shock during the acute phase (15.5 vs. 9.0%; p < 0.001) and had a higher in-hospital mortality (8.2 vs. 3.2%; p < 0.001). However, ethnicity itself did not appear to have an impact on in-hospital mortality. Machine learning approach revealed that the presence of physical stressors was the most important prognostic factor in both Japanese and European TTS patients.

Conclusion: Differences in clinical characteristics and in-hospital outcomes between Japanese and European TTS patients exist. Ethnicity does not impact the outcome in TTS patients. The worse in-hospital outcome in Japanese patients, is mainly driven by the higher prevalence of physical triggers.

Trial registration: URL: https://www.clinicaltrials.gov ; Unique Identifier: NCT01947621.

Keywords: Broken heart syndrome; Ethnicity; Race; Takotsubo syndrome.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Collaborators from Japan and Europe. Participants in this study included 10 centers from Japan and 32 centers from 9 countries in Europe (including Austria, Czech Republic, Finland, France, Germany, Italy, Poland, Switzerland, and the UK)
Fig. 2
Fig. 2
Predictiveness curves of both models. Predictiveness curves of Model I (without ethnicity) and Model II (with ethnicity) were almost identical
Fig. 3
Fig. 3
Decision trees. Decision trees for Japanese patients (a) and European patients (b). Presence of physical stressors was the most important prognostic factor for in-hospital mortality in the Japanese and European cohorts. The second most important prognostic factor was LVEF for Japanese patients, and the white blood cell count for European patients. LVEF left ventricular ejection fraction, SBP systolic blood pressure, WBC white blood cell count

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