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QUARTERLY FOCUS ISSUE: HEART FAILURE: CLINICAL RESEARCH

Natural History and Expansive Clinical Profile of Stress (Tako-Tsubo) Cardiomyopathy

Scott W. Sharkey, MD^_*, Denise C. Windenburg, BA^_*, John R. Lesser, MD^_*, Martin S. Maron, MD, Robert G. Hauser, MD^_*, Jennifer N. Lesser^_*, Tammy S. Haas, RN^_*, James S. Hodges, PhD and Barry J. Maron, MD^_*,_*

^_* Hypertrophic Cardiomyopathy Center and Cardiovascular Research Division, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
Division of Biostatistics, University of Minneapolis, Minneapolis, Minnesota

Manuscript received May 8, 2009; revised manuscript received July 24, 2009, accepted August 20, 2009.

^_* Reprint requests and correspondence: Dr. Barry J. Maron, Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, 920 East 28th Street, Suite 620, Minneapolis, Minnesota 55407 (Email: hcm.maron{at}mhif.org).

Objectives: This study was designed to define more completely the clinical spectrum and consequences of stress cardiomyopathy (SC) beyond the acute event.

Background: Stress cardiomyopathy is a recently recognized condition characterized by transient cardiac dysfunction with ventricular ballooning.

Methods: Clinical profile and outcome were prospectively assessed in 136 consecutive SC patients.

Results: Patients were predominantly women (n = 130; 96%), but 6 were men (4%). Ages were 32 to 94 years (mean age 68 ± 13 years); 13 (10%) were 50 years of age. In 121 patients (89%), SC was precipitated by intensely stressful emotional (n = 64) or physical (n = 57) events, including 22 associated with sympathomimetic drugs or medical/surgical procedures; 15 other patients (11%) had no evident stress trigger. Twenty-five patients (18%) were taking beta-blockers at the time of SC events. Three diverse ventricular contraction patterns were defined by cardiovascular magnetic resonance (CMR) imaging, usually with rapid return to normal systolic function, although delayed >2 months in 5%. Right and/or left ventricular thrombi were identified in 5 patients (predominantly by CMR imaging), including 2 with embolic events. Three patients (2%) died in-hospital and 116 (85%) have survived, including 5% with nonfatal recurrent SC events. All-cause mortality during follow-up exceeded a matched general population (p = 0.016) with most deaths occurring in the first year.

Conclusions: In this large SC cohort, the clinical spectrum was heterogeneous with about one-third either male, 50 years of age, without a stress trigger, or with in-hospital death, nonfatal recurrence, embolic stroke, or delayed normalization of ejection fraction. Beta-blocking drugs were not absolutely protective and SC was a marker for increased noncardiac mortality. These data support expanded management and surveillance strategies including CMR imaging and consideration for anticoagulation.

Key Words: cardiomyopathy • stress • left ventricle • heart failure

Abbreviations and Acronyms   CMR = cardiovascular magnetic resonance   ECG = electrocardiogram   EF = ejection fraction   LV = left ventricle/ventricular   RV = right ventricle/ventricular   SC = stress cardiomyopathy

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