Multiple Unfavorable Echocardiographic Findings in Takotsubo Cardiomyopathy Are Associated with Increased In-Hospital Events and Mortality

Background: Various unfavorable echocardiographic findings other than apical ballooning, such as right ventricular involvement, mitral regurgitation, left ventricular outflow tract obstruction, and left ventricular thrombus, occur in takotsubo cardiomyopathy. Occasionally, these findings are observed simultaneously in a single patient. This study was performed to investigate the prevalence and characteristics of patients with multiple unfavorable echocardiographic findings in takotsubo cardiomyopathy and their associations with adverse outcomes.

Methods: The echocardiographic images of 113 patients with takotsubo cardiomyopathy (mean age, 72.7 ± 11.4 years; 29 men) were retrospectively reviewed. According to the number of unfavorable echocardiographic findings, patients were classified into a low-risk group (zero or one finding), an intermediate-risk group (two findings), and a high-risk group (three or more findings). In-hospital events were defined as a composite of acute heart failure, shock, ventricular tachyarrhythmia, and in-hospital death.

Results: Apical ballooning, right ventricular involvement, mitral regurgitation, left ventricular outflow tract obstruction, and left ventricular thrombus were observed in 92 (81.4%), 21 (18.6%), 17 (15.0%), 11 (9.7%), and three (2.7%) patients, respectively. There were 77 (68.1%), 25 (22.1%), and 11 (9.7%) patients in the low-, intermediate-, and high-risk groups, respectively. Logistic regression analysis indicated that being in the high-risk group had a significant association with in-hospital events (odds ratio, 8.74, P = .003) and death (odds ratio, 16.9; P = .027) compared with being in the low-risk group. Net reclassification improvement indicated that adding this risk group classification to known clinical factors that are associated with adverse outcomes could yield incremental information regarding patients with takotsubo cardiomyopathy with in-hospital events (net reclassification improvement, 0.59; P = .002).

Conclusions: Multiple unfavorable echocardiographic findings in takotsubo cardiomyopathy are not uncommon and are associated with increased in-hospital events and mortality.