Background Patients with Takotsubo syndrome (TTS) who develop cardiogenic shock may present with left ventricular outflow tract obstruction (LVOTO). The prognosis and treatment of this population have not been defined in previous studies. The aim of this study is to describe the clinical presentation, management, evolution and prognosis of a subgroup of patients with TTS and cardiogenic shock according to whether they present with LVOTO or not. Methods We analysed patients with TTS recruited from 2003 to 2022 in a multicentre registry. Patients were selected if they presented cardiogenic shock during their admission. This analysis was compared according to the presence or absence of LVOTO. Results 322 patients were included, 58 (18%) of whom had LVOTO. The majority were treated with vasoactive and inotropic therapy (VIT) and its use was strongly associated with having LVOTO (77.6% vs 57.6%, p<0.001). Only five (3.3%) patients without LVOTO and two (4.4%) in the LVOTO group treated with VIT developed or worsened the obstruction. Furthermore, patients with LVOTO presented higher in-hospital complications including ventricular arrhythmias (15.5% vs 8.7%, p=0.017), major bleeding (13.8% vs 6.1%, p=0.042) and acute kidney failure (48.3% vs 28.4%, p=0.003). However, at both 90 days and 5 years, the cumulative incidence of all-cause death was not significantly different between the patients with and without LVOTO (HR 1.20, 95% CI 0.60 to 2.40 for 90 days, and HR 1.69, 95% CI 0.89 to 3.21 for 5 years). Conclusions LVOTO is not uncommon in patients with TTS and cardiogenic shock. It is associated with a more aggressive in-hospital course and our data is unable to rule out an association between the presence of LVOTO and long-term prognosis of patients with TTS. The development or worsening of LVOTO directly related to inotropic or vasoactive support was low.

Background: Cardiogenic shock (CS) is a significant complication of Takotsubo syndrome (TTS), contributing to heightened mortality and morbidity. Despite this, the Society for Cardiovascular Angiography and Interventions (SCAI) staging system for CS severity lacks validation in patients with TTS and CS. This study aimed to characterize a patient cohort with TTS using the SCAI staging system and assess its utility in cases of TTS complicated by CS. Methods and Results: From a TTS national registry, 1591 consecutive patients were initially enrolled and stratified into 5 SCAI stages (A through E). Primary outcome was all‐cause in‐hospital mortality; secondary end points were TTS‐related in‐hospital complications and 1‐year all‐cause mortality. After exclusions, the final cohort comprised 1163 patients, mean age 71.0±11.8 years, and 87% were female. Patients were categorized across SCAI shock stages as follows: A 72.1%, B 12.2%, C 11.2%, D 2.7%, and E 1.8%. Significant variations in baseline demographics, comorbidities, clinical presentations, and in‐hospital courses were observed across SCAI shock stages. After multivariable adjustment, each higher SCAI shock stage showed a significant association with increased in‐hospital mortality (adjusted odds ratio: 1.77–29.31) compared with SCAI shock stage A. Higher SCAI shock stages were also associated with increased 1‐year mortality. Conclusions: In a large multicenter patient cohort with TTS, the functional SCAI shock stage classification effectively stratified mortality risk, revealing a continuum of escalating shock severity with higher stages correlating with increased in‐hospital mortality. This study highlights the applicability and prognostic value of the SCAI staging system in TTS‐related CS.

Background: Sex‐related differences in Takotsubo syndrome have been described, but no information is available in patients who develop cardiogenic shock. Methods and Results: Of 412 patients with Takotsubo syndrome with cardiogenic shock, 71 (17.2%) were men. Male patients were older (71.1±12.2 versus 65.3±17.1 years, P <0.001), more frequently smokers (47 [66.2%] versus 66 [19.4%], P <0.01), with higher prevalence of neoplasms (6 [8.5%] versus 8 [2.3%], P =0.01), lower left ventricular ejection fraction (31% versus 37%, P <0.001), more frequent invasive mechanical ventilation (30 [42.3%] versus 90 [26.4%], P =<0.01), higher rate of infections (43 [60.6%] versus 148 [43.4%], P =<0.01), and longer in‐hospital stay (19±20 days versus 13±15 days, P =0.02). A total of 55 patients (13.3%) died during hospital admission, and 90 patients (21.8%) died at the end of the 5‐year follow‐up. Male sex was not significantly associated with the in‐hospital (odds ratio, 1.31 [95% CI, 0.64–2.68]) or 5‐year mortality rate (hazard ratio, 1.66 [95% CI, 0.93–2.94]). In the matched cohort, no significant differences in the short‐ and long‐term mortality rate were found either. Conclusions: Cardiogenic shock due to Takotsubo syndrome has high short‐ and long‐term mortality rates that are similar in men and women.

Takotsubo syndrome (TTS) during the peripartum period is a relevant cause of morbidity in this population; its clinical course and prognosis, compared to the general TTS population, is yet to be elucidated. Our aim was to analyze the clinical features and prognosis of peripartum TTS in a nationwide prospective specifically oriented registry database and consider the published literature. Peripartum TTS patients from the prospective nationwide RETAKO registry—as well as peripartum TTS patients from the published literature—were included, and multiple comparisons between groups were performed in order to assess for statistically and clinically relevant prognostic differences between the groups. Patients with peripartum TTS exhibit a higher prevalence of secondary forms, dyspnea, atypical symptoms, and echocardiographic patterns, as well as less ST-segment elevation than the general TTS population. In the literature, patients with peripartum TTS had a higher Killip status on admission. TTS during the peripartum period has a higher prevalence of angina and dyspnea, as well as physical triggers, neither of which are related to a worse prognosis. Killip status on admission was higher in the literature for patients with TTS but with excellent mid- and long-term prognoses after the acute phase, despite mostly being secondary forms.

Background: There is evidence that pacemaker implantation can trigger Takotsubo syndrome (TTS). However, limited information is available on the prognosis of TTS caused by this trigger, so our study aims to elucidate the clinical features, presentation, and prognostic factors associated with this syndrome in this specific situation. Methods: We analyzed a group of patients with TTS triggered by pacemaker implantation (n = 41), including consecutive cases from the multicenter registry on takotsubo syndrome (RETAKO) and patients identified through a systematic literature search, and compared them to the general RETAKO cohort (n = 1559). We performed a 1:3 propensity score matching (PSM) based on dyslipidemia, diabetes mellitus, smoker/ex-smoker status, syncope, angina, vagal symptoms, and physical/mixed trigger, generating two balanced groups. Results: Compared to other triggers, TTS associated with pacemaker implantation was linked to a longer corrected QT interval (551.2 ms vs. 502.5 ms, p = 0.005), lower left ventricular ejection fraction (34.8% vs. 47.3%, p < 0.001), a higher proportion of acute kidney injury (29.3% vs. 11.0%, p = 0.001), and an increased rate of cardiogenic shock (20.6% vs. 8.8%, p = 0.029). However, there were no differences in all-cause mortality (12.2% vs. 13.1%, p = 0.858) or TTS recurrence (0.0% vs. 3.9%, p = 0.639). After PSM, the previously observed differences were no longer present, with no significant differences in death or recurrences. Conclusions: TTS following pacemaker implantation predominantly presents with greater rates of cardiogenic shock and acute kidney injury, without differences in all-cause mortality or TTS recurrence. After PSM, no differences were found regarding cardiovascular outcomes, suggesting that the physical nature of the trigger could account for the initial differences observed.