Cardiac arrest in takotsubo syndrome: results from the InterTAK Registry

Sebastiano Gili, Victoria L Cammann, Susanne A Schlossbauer, Ken Kato, Fabrizio D'Ascenzo, Davide Di Vece, Stjepan Jurisic, Jozef Micek, Slayman Obeid, Beatrice Bacchi, Konrad A Szawan, Flurina Famos, Annahita Sarcon, Rena Levinson, Katharina J Ding, Burkhardt Seifert, Olivia Lenoir, Eduardo Bossone, Rodolfo Citro, Jennifer Franke, L Christian Napp, Milosz Jaguszewski, Michel Noutsias, Thomas Münzel, Maike Knorr, Susanne Heiner, Hugo A Katus, Christof Burgdorf, Heribert Schunkert, Holger Thiele, Johann Bauersachs, Carsten Tschöpe, Burkert M Pieske, Lawrence Rajan, Guido Michels, Roman Pfister, Alessandro Cuneo, Claudius Jacobshagen, Gerd Hasenfuß, Mahir Karakas, Wolfgang Koenig, Wolfgang Rottbauer, Samir M Said, Ruediger C Braun-Dullaeus, Adrian Banning, Florim Cuculi, Richard Kobza, Thomas A Fischer, Tuija Vasankari, K E Juhani Airaksinen, Grzegorz Opolski, Rafal Dworakowski, Philip MacCarthy, Christoph Kaiser, Stefan Osswald, Leonarda Galiuto, Filippo Crea, Wolfgang Dichtl, Klaus Empen, Stephan B Felix, Clément Delmas, Olivier Lairez, Ibrahim El-Battrawy, Ibrahim Akin, Martin Borggrefe, Ekaterina Gilyarova, Alexandra Shilova, Mikhail Gilyarov, John D Horowitz, Martin Kozel, Petr Tousek, Petr Widimský, David E Winchester, Christian Ukena, Fiorenzo Gaita, Carlo Di Mario, Manfred B Wischnewsky, Jeroen J Bax, Abhiram Prasad, Michael Böhm, Frank Ruschitzka, Thomas F Lüscher, Jelena R Ghadri, Christian Templin, Sebastiano Gili, Victoria L Cammann, Susanne A Schlossbauer, Ken Kato, Fabrizio D'Ascenzo, Davide Di Vece, Stjepan Jurisic, Jozef Micek, Slayman Obeid, Beatrice Bacchi, Konrad A Szawan, Flurina Famos, Annahita Sarcon, Rena Levinson, Katharina J Ding, Burkhardt Seifert, Olivia Lenoir, Eduardo Bossone, Rodolfo Citro, Jennifer Franke, L Christian Napp, Milosz Jaguszewski, Michel Noutsias, Thomas Münzel, Maike Knorr, Susanne Heiner, Hugo A Katus, Christof Burgdorf, Heribert Schunkert, Holger Thiele, Johann Bauersachs, Carsten Tschöpe, Burkert M Pieske, Lawrence Rajan, Guido Michels, Roman Pfister, Alessandro Cuneo, Claudius Jacobshagen, Gerd Hasenfuß, Mahir Karakas, Wolfgang Koenig, Wolfgang Rottbauer, Samir M Said, Ruediger C Braun-Dullaeus, Adrian Banning, Florim Cuculi, Richard Kobza, Thomas A Fischer, Tuija Vasankari, K E Juhani Airaksinen, Grzegorz Opolski, Rafal Dworakowski, Philip MacCarthy, Christoph Kaiser, Stefan Osswald, Leonarda Galiuto, Filippo Crea, Wolfgang Dichtl, Klaus Empen, Stephan B Felix, Clément Delmas, Olivier Lairez, Ibrahim El-Battrawy, Ibrahim Akin, Martin Borggrefe, Ekaterina Gilyarova, Alexandra Shilova, Mikhail Gilyarov, John D Horowitz, Martin Kozel, Petr Tousek, Petr Widimský, David E Winchester, Christian Ukena, Fiorenzo Gaita, Carlo Di Mario, Manfred B Wischnewsky, Jeroen J Bax, Abhiram Prasad, Michael Böhm, Frank Ruschitzka, Thomas F Lüscher, Jelena R Ghadri, Christian Templin

Abstract

Aims: We aimed to evaluate the frequency, clinical features, and prognostic implications of cardiac arrest (CA) in takotsubo syndrome (TTS).

Methods and results: We reviewed the records of patients with CA and known heart rhythm from the International Takotsubo Registry. The main outcomes were 60-day and 5-year mortality. In addition, predictors of mortality and predictors of CA during the acute TTS phase were assessed. Of 2098 patients, 103 patients with CA and known heart rhythm during CA were included. Compared with patients without CA, CA patients were more likely to be younger, male, and have apical TTS, atrial fibrillation (AF), neurologic comorbidities, physical triggers, and longer corrected QT-interval and lower left ventricular ejection fraction on admission. In all, 57.1% of patients with CA at admission had ventricular fibrillation/tachycardia, while 73.7% of patients with CA in the acute phase had asystole/pulseless electrical activity. Patients with CA showed higher 60-day (40.3% vs. 4.0%, P < 0.001) and 5-year mortality (68.9% vs. 16.7%, P < 0.001) than patients without CA. T-wave inversion and intracranial haemorrhage were independently associated with higher 60-day mortality after CA, whereas female gender was associated with lower 60-day mortality. In the acute phase, CA occurred less frequently in females and more frequently in patients with AF, ST-segment elevation, and higher C-reactive protein on admission.

Conclusions: Cardiac arrest is relatively frequent in TTS and is associated with higher short- and long-term mortality. Clinical and electrocardiographic parameters independently predicted mortality after CA.

Keywords: Acute heart failure; Broken heart syndrome; Cardiac arrest; Outcome; Takotsubo syndrome.

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Figure 1
Figure 1
Study design. CPR, cardiopulmonary resuscitation; ECG, electrocardiogram; PEA, pulseless electrical activity.
Figure 2
Figure 2
Landmark survival analysis showing a significantly higher mortality rate in patients with cardiac arrest during the first 60 days (P < 0.001) and during the 5-year follow-up (P < 0.001). TTS, takotsubo syndrome.
Figure 3
Figure 3
Univariable (A) and multivariable (B) predictors of 60-day mortality in patients with cardiac arrest (CA) and known initial heart rhythm. Acute intracranial haemorrhage and T-wave inversion are independently associated with an increased risk of 60-day mortality after CA, whereas female sex is associated with a decreased risk. Black: statistically significant predictors; grey: not significant. BNP, brain natriuretic peptide; CI, confidence interval; HR, hazard ratio; LVEF, left ventricular ejection fraction; TIA, transient ischaemic attack; ULN, upper limit of normal range; WBC, white blood cell count.
Take home figure
Take home figure
Cardiac arrest affects a relevant number of patients presenting with takotsubo syndrome and is associated with higher short and long-term mortality. Although typically occurring at presentation, cardiac arrest can also occur in the subsequent acute phase in patients with takotsubo syndrome. Among patients with cardiac arrest and takotsubo syndrome, simple clinical and electrocardiographic parameters may help to identify those at higher risk of death.
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/6612368/bin/ehz170f4.jpg

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