title: Secondary forms of Takotsubo cardiomyopathy: A whole different prognosis.
abstract: BACKGROUND
  Takotsubo syndrome (TKS) usually mimics an acute coronary syndrome. However, several clinical forms have been reported. Our aim was to assess if different stressful triggers had prognostic influence on TKS, and to establish a working classification.
  
  
  METHODS
  We performed an analysis including patients with TKS between 2003-2013 from our prospective local database and the RETAKO National Registry, fulfilling Mayo criteria. Patients were divided in two groups regarding their potential triggers: (a) none/psychic stress as 'primary forms' and (b) physical factors (asthma, surgery, trauma, etc.) as 'secondary forms'.
  
  
  RESULTS
  Finally, 328 patients were included, 90.2% women, with a mean age of 69.7 years. Patients were divided into primary TKS (n=265) and 63 secondary TKS groups. Age, gender, previous functional class and cardiovascular risk profile displayed no differences between groups before admission. However, primary-TKS patients suffered a main complaint of chest pain (89.4% vs 50.7%, p<0.0001) with frequent vegetative symptoms. Regarding treatment before admission, there were no differences either. During admission, differences were related to more intensive antithrombotic and anxiolytic drug use in the primary TKS group. Inotropic and mechanical ventilation use was higher in the secondary cohort. After discharge, a more frequent prescription of beta-blockers and statins in primary-TKS patients was seen. Secondary forms displayed more in-hospital stay and evolutive complications: death (hazard ratio (HR): 3.41; 95% confidence interval (CI): 1.14-10.16, p=0.02), combined event variable (MACE) (HR: 1.61; 95% CI: 1.01-2.6, p=0.04) and recurrences (HR: 1.85; 95% CI: 1.06-3.22, p=0.02).
  
  
  CONCLUSIONS
  Secondary TKS could present or mark worse short and long-term prognoses in terms of mortality, recurrences and readmissions. We propose a simple working nomenclature for TKS.
authors.affiliation: Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid ibnsky@yahoo.es.
authors.forename: Iván J
authors.initials: IJ
authors.lastname: Núñez-Gil
authors.affiliation: Servicio de Cardiología, H Virgen de la Macarena, Sevilla.
authors.forename: Manuel
authors.initials: M
authors.lastname: Almendro-Delia
authors.affiliation: Servicio de Cardiología, H Vall d'Hebron, Barcelona.
authors.forename: Mireia
authors.initials: M
authors.lastname: Andrés
authors.affiliation: Unidad de Cuidados Intensivos Cardiológicos, Servicio de Cardiología, Hospital de Sant Pau, Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau), Barcelona.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Sionis
authors.affiliation: Servicio de Cardiología, H Universitario de Salamanca.
authors.forename: Ana
authors.initials: A
authors.lastname: Martin
authors.affiliation: Servicio de Cardiología, H de la Princesa, Madrid.
authors.forename: Teresa
authors.initials: T
authors.lastname: Bastante
authors.affiliation: Servicio de Cardiología, Complejo Hospitalario Universitario de Albacete.
authors.forename: Juan G
authors.initials: JG
authors.lastname: Córdoba-Soriano
authors.affiliation: Servicio de Cardiología, H Clínico Lozano Blesa, Zaragoza.
authors.forename: José A
authors.initials: JA
authors.lastname: Linares
authors.affiliation: Servicio de Cardiología, H Universitario Arnau de Vilanova, Lérida.
authors.forename: Silvia
authors.initials: S
authors.lastname: González Sucarrats
authors.affiliation: Servicio de Cardiología, H Universitario de Canarias, Tenerife.
authors.forename: Alejandro
authors.initials: A
authors.lastname: Sánchez-Grande-Flecha
authors.affiliation: Servicio de Cardiología, Consorcio Hospital General Universitario de Valencia, Valencia.
authors.forename: Oscar
authors.initials: O
authors.lastname: Fabregat-Andrés
authors.affiliation: Servicio de Cardiología, Hospital Carlos Haya, Málaga.
authors.forename: Beatriz
authors.initials: B
authors.lastname: Pérez
authors.affiliation: Servicio de Cardiología, Hospital Puerta de Hierro, Majadahonda, Madrid.
authors.forename: Juan M
authors.initials: JM
authors.lastname: Escudier-Villa
authors.affiliation: Servicio de Cardiología, Hospital Fundación Jiménez Díaz, Madrid.
authors.forename: Roberto
authors.initials: R
authors.lastname: Martin-Reyes
authors.affiliation: Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid.
authors.forename: Alberto
authors.initials: A
authors.lastname: Pérez-Castellanos
authors.affiliation: Servicio de Cardiología, Hospital Universitario GermansTrias i Pujol, Badalona, Barcelona.
authors.forename: Ferrán
authors.initials: F
authors.lastname: Rueda Sobella
authors.affiliation: Servicio de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela.
authors.forename: Cristina
authors.initials: C
authors.lastname: Cambeiro
authors.affiliation: Servicio de Cardiología, Hospital General Universitario de Ciudad Real, Ciudad Real.
authors.forename: Jesús
authors.initials: J
authors.lastname: Piqueras-Flores
authors.affiliation: Servicio de Cardiología, Hospital Da Costa, Burela, Lugo.
authors.forename: Rafael
authors.initials: R
authors.lastname: Vidal-Perez
authors.affiliation: Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Valencia.
authors.forename: Vicente
authors.initials: V
authors.lastname: Bodí
authors.affiliation: Servicio de Cardiología, Hospital de Manacor, Mallorca.
authors.forename: Bernardo
authors.initials: B
authors.lastname: García de la Villa
authors.affiliation: Servicio de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela.
authors.forename: Miguel
authors.initials: M
authors.lastname: Corbí-Pascua
authors.affiliation: Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid.
authors.forename: Corina
authors.initials: C
authors.lastname: Biagioni
authors.affiliation: Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid.
authors.forename: Hernán D
authors.initials: HD
authors.lastname: Mejía-Rentería
authors.affiliation: Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid.
authors.forename: Gisela
authors.initials: G
authors.lastname: Feltes
authors.affiliation: Servicio de Cardiología, H Vall d'Hebron, Barcelona.
authors.forename: José
authors.initials: J
authors.lastname: Barrabés
mesh_terms: D054058:Acute Coronary Syndrome / Q000209:etiology* / Q000473:pathology*; D000368:Aged; D000369:Aged, 80 and over; D003937:Diagnosis, Differential; D019468:Disease Management; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010343:Patient Admission; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D054549:Takotsubo Cardiomyopathy / Q000209:etiology* / Q000473:pathology*
keywords: RETAKO; Takotsubo syndrome; classification; nomenclature; prognosis; secondary