Natural History of Cardiac Arrest in Patients With Takotsubo Cardiomyopathy Kuljit Singh, MDa,b,*, Kristin Carson, Dip Lab Medb, Benjamin Hibbert, MD, PhDa, and Michel Le May, MDa Cardiac arrest (CA) is relatively rare but lethal complication of takotsubo cardiomyopathy (TTC). In most instances, patients are diagnosed with TTC after CA, making it difficult to distinguish if TTC is the precipitant or the consequence of the index event. In this systematic review, patient-level data were obtained to seek out the characteristics of patients in whom the underlying cause of CA is TTC. A comprehensive search of 4 major databases (Embase, Ovid MEDLINE, PubMed, and Google Scholar) was performed from their inception to the last week of September 2014. Of 186 citations, 62 case studies were included in the analysis, providing patient-level data on 77 patients. In 60 patients (78%), the diagnosis of TTC was made after CA. Patients presenting with CA were younger (mean age 49.5 – 16 vs 64.9 – 11 years, p 2,000 patients67 and various clinical studies2 have indicated the mean age of patients with TTC to be in the mid-60s, as found in the primary TTC group. The relatively young age in the secondary TTC group raises the suspicion of genetic


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disorders and channelopathies as the real causes of CA. However, in patients in whom reliable histories of chest pain and dyspnea before CA are present, as found in nearly 20% of patients in our secondary TTC group, TTC as a cause of CA can be determined with certainty. These patients do not require AICDs, because the risk for recurrence of CA with TTC is extremely low. At the moment, there are no clinical guidelines for the long-term management of patients with TTC who experience CA. We noted that current practice of management differed significantly among centers. Only 1/3 of patients underwent EP studies or device implantation. Patients who develop CA after TTC, when QTc interval duration is longest, probably do not require AICD placement or EP study. In contrast, in patients in whom there is no history of symptoms to suggest TTC and CA occurs at a relatively younger age, we recommend screening for other common causes for CA (Figure 2). The main purpose of this review was to identify characteristics of patients with TTC who develop CA. Furthermore, we wanted to clarify if patients presenting with CA, who are diagnosed with TTC, have other underlying reasons for CA and TTC changes to the left ventricle are not merely postresuscitation myocardial stunning. We found that in most patients, CA was triggered by TTC directly through prolongation of QTc and hypotension, or indirectly by noncardiac conditions that initially stimulated TTC, such as SAH and pheochromocytoma. However, occasional cases of TTC can unmask underlying iatrogenic or genetic long-QTc syndrome. Such cases can be suspected by extreme prolongation of QTc duration (>800 ms in 1 case), which is unusual for TTC. Only in 1 case was ARVD was found, but it is difficult to ascertain if ARVD was the real cause of CA or just an incidental diagnosis. In patients who undergo AICD or pacemaker implantation, follow-up with device interrogation can help determine if these patients develop ventricular arrhythmias in the absence of TTC. This study had some limitations. First of all, it represents only a small proportion of the patients with TTC with CA who were hospitalized and underwent early invasive imaging to diagnose TTC. Second, detailed information on electrocardiographic, clinical, and biochemical parameters was not available in all the studies. Third, there was no control group available to ascertain whether the patients with TTC who developed CA were different from those who did not. Nonetheless, the data from the patients who developed CA and TTC while being monitored perioperatively provided strong support that hypotension is the triggering event of CA at the time of TTC development. Furthermore, this analysis not only consolidated the evidence that a long QTc interval is the underlying cause of CA during the subacute phase but also demonstrates that patients with QTc intervals >600 ms are those at risk for ventricular arrhythmias in the acute phase of TTC and should be monitored until the QTc interval stabilizes. Disclosures The authors have no conflicts of interest to disclose. 1. Akashi YJ, Nef HM, Mollmann H, Ueyama T. Stress cardiomyopathy. Annu Rev Med 2010;61:271e286.

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Natural history of cardiac arrest in patients with takotsubo cardiomyopathy.

Cardiac arrest (CA) is relatively rare but lethal complication of takotsubo cardiomyopathy (TTC). In most instances, patients are diagnosed with TTC a...
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