title: Impact of triggering event in outcomes of stress-induced (Takotsubo) cardiomyopathy.
abstract: BACKGROUND
  Takotsubo syndrome is also known as stress cardiomyopathy because of the regularity with which it has been associated with physical or emotional stress. Such stress may well be a "trigger" of the syndrome.
  
  
  OBJECTIVE
  This analysis was undertaken to describe our experience with this disorder and in particular to examine the effects of the underlying trigger on outcomes.
  
  
  METHODS
  We conducted a retrospective review of the medical records of 345 consecutive patients treated at our institution from 2006 to 2014. All presented with acute cardiac symptoms, a characteristic left ventricular contraction pattern (typical, atypical), and no major obstructive coronary artery disease. Patients were grouped based on their triggering event: (a) medical illness; (b) post-operative period; (c) emotional distress; or (d) no identified trigger. Baseline demographic characteristics, death in hospital, length of stay in hospital, and cardiac complications were abstracted from the patients' medical records.
  
  
  RESULTS
  The mean±SD age of the population was 72±12 years and 91% were women. No significant difference in baseline characteristics was noted between the groups except for a higher prevalence of African Americans in the group with a medical illness. ST elevation was noted in 13.3% of patients and the average peak troponin level was 5±12 ng/dl. An inotropic drug was required in 49 (14.2%) patients, an intra-aortic balloon pump in 37 (10.7%) patients, and mechanical ventilation in 54 (15.7%) patients; 43.5% required treatment in the intensive care unit. Overall, 12 (3.5%) patients died. In only two (16.7%) patients was a there a direct cardiac cause of death. In those patients in whom the cardiac manifestations seemed to be triggered by a medical illness, the death rate was 7.1% and this was significantly higher than in the other groups ( p=0.03). Medical illness (odds ratio=6.25, p=0.02) and ST elevation (odds ratio=5.71, p=0.04) were both significantly associated with death.
  
  
  CONCLUSIONS
  Our study showed that different triggers for Takotsubo syndrome confer different prognoses, with medical illness conferring the worst prognosis. Overall, the in-hospital death rate was low and mostly related to non-cardiac death secondary to the underlying medical illness. Although an unidentified trigger was prevalent in a third of this population, efforts should be made to identify the triggering event to classify the risk group of patients with Takotsubo syndrome.
authors.affiliation: Medstar Washington Hospital Center, Washington DC, USA.
authors.forename: Charan
authors.initials: C
authors.lastname: Yerasi
authors.affiliation: Medstar Washington Hospital Center, Washington DC, USA.
authors.forename: Edward
authors.initials: E
authors.lastname: Koifman
authors.affiliation: Medstar Washington Hospital Center, Washington DC, USA.
authors.forename: Gaby
authors.initials: G
authors.lastname: Weissman
authors.affiliation: Medstar Washington Hospital Center, Washington DC, USA.
authors.forename: Zuyue
authors.initials: Z
authors.lastname: Wang
authors.affiliation: Medstar Washington Hospital Center, Washington DC, USA.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Torguson
authors.affiliation: Medstar Washington Hospital Center, Washington DC, USA.
authors.forename: Jiaxiang
authors.initials: J
authors.lastname: Gai
authors.affiliation: Medstar Washington Hospital Center, Washington DC, USA.
authors.forename: Joseph
authors.initials: J
authors.lastname: Lindsay
authors.affiliation: Medstar Washington Hospital Center, Washington DC, USA.
authors.forename: Lowell F
authors.initials: LF
authors.lastname: Satler
authors.affiliation: Medstar Washington Hospital Center, Washington DC, USA.
authors.forename: Augusto D
authors.initials: AD
authors.lastname: Pichard
authors.affiliation: Medstar Washington Hospital Center, Washington DC, USA.
authors.forename: Ron
authors.initials: R
authors.lastname: Waksman
authors.affiliation: Medstar Washington Hospital Center, Washington DC, USA.
authors.forename: Itsik
authors.initials: I
authors.lastname: Ben-Dor
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002316:Cardiotonic Agents / Q000627:therapeutic use; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007423:Intra-Aortic Balloon Pumping / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012121:Respiration, Artificial / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013315:Stress, Psychological / Q000145:classification* / Q000150:complications; D016019:Survival Analysis; D054549:Takotsubo Cardiomyopathy / Q000209:etiology* / Q000628:therapy*
chemical_list: D002316:Cardiotonic Agents
keywords: Takotsubo cardiomyopathy; mortality; outcomes; triggers