Tetsuro Ueda

Out-of-hospital versus in-hospital Takotsubo cardiomyopathy: Analysis of 3719 patients in the Diagnosis Procedure Combination database in Japan

BACKGROUND Although Takotsubo cardiomyopathy (TC) generally occurs after a stressful event out-of-hospital, it occasionally occurs secondary to acute medical illness after hospital admission. No study has examined and compared patient backgrounds and in-hospital outcomes between patients with out-of-hospital TC and those with in-hospital TC. METHODS AND RESULTS Using the Diagnosis Procedure Combination inpatient database in Japan, we identified 3719 eligible patients with a diagnosis of TC who underwent coronary angiography without any revascularization procedure between 2010 and 2013, including 419 patients with in-hospital TC and 3300 patients with out-of-hospital TC. There was no significant difference in age between those with in-hospital TC and those with out-of-hospital TC (74.2 ± 10.9 years versus 73.4 ± 11.3 years, p=0.211). Patients with in-hospital TC had a higher proportion of males than out-of-hospital TC patients (31.3% versus 21.3%, p<0.001). Patients with in-hospital TC had significantly higher proportions of several chronic comorbidities and acute medical illnesses. In-hospital mortality was significantly higher in patients with in-hospital TC than in patients with out-of-hospital TC (17.9% versus 5.4%, p<0.001). In the multivariable logistic regression analysis, in-hospital TC was significantly associated with higher in-hospital mortality (adjusted odds ratio 2.02; 95% confidence interval, 1.43 to 2.85; p<0.001), even after adjustment for patient backgrounds. Malignancy, chronic liver disease, rheumatic disease, sepsis, pneumonia, cerebrovascular diseases, acute renal failure, and acute gastrointestinal diseases were also significantly associated with higher in-hospital mortality. CONCLUSIONS In-hospital TC was associated with more severe clinical background and poorer short-term prognosis than out-of-hospital TC.

Characterization of predictors of in-hospital cardiac complications of takotsubo cardiomyopathy: Multi-center registry from Tokyo CCU Network

BACKGROUND Takotsubo cardiomyopathy (TC) is an acute cardiac syndrome characterized by transient left ventricular dysfunction and relatively good prognosis after discharge. However, cardiac complications during hospitalization remain to be fully determined. We attempted to determine features characterizing patients with adverse clinical outcome by comparing those with cardiac complication and without cardiac complication during hospitalization. METHODS AND RESULTS We investigated 107 patients with TC from the Tokyo CCU Network database, comprising 67 cardiovascular centers in the metropolitan area during January 1 to December 31, 2010. Cardiac complications were defined as cardiac death, pump failure (Killip grade≥II), sustained ventricular tachycardia or fibrillation (SVT/VF), and advanced atrioventricular block (AVB). Cardiac complications were observed in 41 patients (37 pump failure complicated by 3 cardiac deaths and 2 SVT/VF and 2 AVB without pump failure), and there was no cardiac complication in the remaining 66 patients. There was no difference in age, peak creatinine kinase level, C-reactive protein level and ST elevation on electrocardiogram. Multiple logistic regression analysis showed that white blood cell count (p=0.039) and brain natriuretic peptide (p=0.001) were independent predictors of in-hospital adverse cardiac complications. CONCLUSIONS Cardiac complications are relatively high in patients with TC during hospitalization. High white blood cell count and brain natriuretic peptide level are associated with poor clinical outcome in patients with TC.

Gender Differences in Patients with Takotsubo Cardiomyopathy: Multi-Center Registry from Tokyo CCU Network

Background The clinical features of gender differences in takotsubo cardiomyopathy (TC) remain to be determined. The aim of this study was to evaluate the differences in clinical characteristics of male and female patients with TC. Methods We obtained the clinical information of 368 patients diagnosed with TC (84 male, 284 female) from the Tokyo CCU Network database collected from 1 January 2010 to 31 December 2012; the Network is comprised of 71 cardiovascular centers in the Tokyo (Japan) metropolitan area. We attempted to characterize clinical differences during hospitalization, comparing male and female patients with TC. Results There were no significant differences in apical ballooning type, median echocardiography ejection fraction, serious ventricular arrhythmias (such as ventricular tachycardia or fibrillation), or cardiovascular death between male and female patients. Male patients were younger than female patients (median age at hospitalization for male patients was 72 years vs. 76 years for female patients; p = 0.040). Prior physical stress was more common in male than female patients (50.0% vs.31.3%; p = 0.002), while emotional stress was more common in female patients (19.0% vs. 31.0%; p = 0.039). Severe pump failure (defined as Killip Class > III) (20.2% vs. 10.6%; p = 0.020) and cardiopulmonary supportive therapies (28.6% vs. 12.7%, p < 0.001) were more common in male than female patients. Multivariate analysis revealed that male gender (odds ratio = 4.32, 95% CI = 1.41–13.6, p = 0.011) was an independent predictor of adverse composite cardiac events, including cardiovascular death, severe pump failure, and serious ventricular arrhythmia. Conclusions Cardiac complications in our dataset appeared to be more common in male than female patients with TC during their hospitalization. Further investigation is required to clarify the underlying mechanisms responsible for the observed gender differences.

Hospital Volume and Cardiac Complications of Endomyocardial Biopsy: A Retrospective Cohort Study of 9508 Adult Patients Using a Nationwide Inpatient Database in Japan

Recent research on complications with endomyocardial biopsy (EMB) has been based on single‐center or 2‐center studies in high‐volume cardiovascular centers. No study has examined the association between hospital volume and the complication rate after EMB.

Serious Cardiac Complications in Coronary Spasm Provocation Tests Using Acetylcholine or Ergonovine: Analysis of 21 512 Patients From the Diagnosis Procedure Combination Database in Japan

Previous studies on complications with coronary spasm provocation tests were based on small sample sizes or were limited to high‐volume centers. The risk of provocation tests using acetylcholine (ACH) or ergonovine (ER) remains to be fully examined by a large‐scale multicenter study.

Predictive Value of QRS Duration at Admission for In-Hospital Clinical Outcome of Takotsubo Cardiomyopathy

BACKGROUND Prolonged QRS duration (pQRSd) on electrocardiogram (ECG) is a strong predictor of poor outcome in heart failure, myocardial infarction, and myocarditis, but it is unclear whether pQRSd also predicts poor outcomes of takotsubo cardiomyopathy (TC).Methods and Results:Between 1 January 2010 and 31 December 2012, we retrospectively enrolled 299 patients with TC (mean age, 73.5±11.7 years; 21.4% male) from the Tokyo CCU Network database, which consists of 71 cardiovascular centers in the metropolitan area. In-hospital clinical outcomes were compared between patients with pQRSd on admission ECG (QRS ≥120 ms; n=34) and those with normal QRS duration (<120 ms; n=265). The in-hospital mortality rate for pQRSd was significantly higher than that for normal QRS duration (23.5% vs. 3.8%, P<0.001). Similarly, prevalence of ventilator use (38.2% vs. 11.4%, P<0.001), ventricular tachycardia or fibrillation (14.7% vs. 1.5%, P<0.001), and circulatory failure requiring catecholamine or cardiopulmonary supportive devices (41.2% vs. 14.0%, P<0.001) was significantly higher in the pQRSd group. On multivariate logistic regression analysis, pQRSd was an independent predictor for both in-hospital mortality (OR, 5.06; 95% CI: 1.79-14.30, P=0.002) and cardiac death (OR, 7.34; 95% CI: 1.33-40.51, P=0.02). CONCLUSIONS TC with pQRSd is associated with poor in-hospital clinical outcome. Aggressive intervention may be required to prevent severe complications in these patients.

Apical Takotsubo syndrome versus anterior acute myocardial infarction: findings from the Tokyo Cardiovascular Care Unit network registry

Background: Although the typical apical form of Takotsubo syndrome and anterior acute myocardial infarction have similar electrocardiographic and echocardiographic presentations, data on the clinical differences between the two disorders are limited. Methods: Using the Tokyo Cardiovascular Care Unit network registry, we identified patients hospitalised with apical Takotsubo syndrome (n=540; 2010–2014) or anterior acute myocardial infarction (n=2,806; 2013–2014) and created 522 age and sex-matched pairs (mean age 74.1 years; women 78.5%). We compared the clinical characteristics and inhospital outcomes between the two groups. Results: On admission, patients with apical Takotsubo syndrome showed a lower body mass index, less frequent chest pain/tightness, lower systolic blood pressure, higher heart rate, lower creatine kinase, higher C-reactive protein and brain natriuretic peptide, and less frequent ST-elevation than patients with anterior acute myocardial infarction. Patients with apical Takotsubo syndrome received catecholamine (12.8% vs. 24.5%, P<0.001) and intra-aortic balloon pumping (5.9% vs. 15.1%, P<0.001) less frequently. Despite similar all-cause mortality (5.4% vs. 7.9%, P=0.134), patients with apical Takotsubo syndrome showed lower cardiac mortality (2.1% vs. 6.7%, P<0.001; risk difference −4.6% (95% confidence interval −7.1% to −2.1%)) but higher non-cardiac mortality (3.3% vs. 1.1%, P=0.033; 2.1% (0.3%–3.9%)). In subgroup comparisons, patients with physically triggered Takotsubo syndrome had higher non-cardiac mortality (7.0%) than those with non-physically triggered Takotsubo syndrome (1.2%, P=0.001) or anterior acute myocardial infarction (1.1%, P<0.001). Conclusions: This study found that cardiac and non-cardiac mortality risks differed significantly between apical Takotsubo syndrome and anterior acute myocardial infarction. Our findings underscore the importance of differentiating between the two disorders for appropriate management.

Differences in Initial Electrocardiographic Findings of Apical Takotsubo Syndrome According to the Time From Symptom Onset

No previous study has examined the differences in patient characteristics and initial electrocardiographic findings of Takotsubo syndrome (TTS) according to the time from onset to electrocardiography. Using the Tokyo Cardiovascular Care Unit network registry 2011-2012, we retrospectively identified 106 apical TTS patients in whom symptom onset time was specified, and classified the patients into 5 groups according to the time from onset to the initial electrocardiography: <3 hours (n = 45), 3 to 6 hours (n = 20), 6 to 12 hours (n = 12), 12 to 24 hours (n = 13), and ≥24 hours (n = 16). There was no significant difference across the groups in age, gender, symptoms, triggers, vital signs, blood tests, or in-hospital outcomes. In the electrocardiographic findings, ST-elevation was more frequent in leads V2-V4 than in the other leads, especially in the <24 hour groups, but did not differ significantly across groups. T-wave inversion was more frequent in leads V3-V6, especially in the ≥24 hour group, and differed significantly across groups. The total number of leads with T-wave inversion was significantly larger in the ≥24 hour group than in the <24 hour groups (mean, 5.9 leads vs 1.5 to 2.9 leads; p < 0.001). Isolated ST-elevation was the most frequent pattern of ST-T change in precordial leads (42% to 56%) in the <24 hour groups, while isolated T-wave inversion was the most frequent (44%) in the ≥24 hour group (p = 0.018). Neither ST-elevation nor T-wave inversion was observed in precordial leads in 10 (9%) patients. In conclusion, our results suggest that the initial electrocardiographic findings of apical TTS are affected by the time from onset to electrocardiography and display a wide variation in ST-T changes.