American Heart Association
American Heart Association
December 06, 2018
4 min read

Broken heart syndrome complicated by cardiogenic shock tied to unfavorable short-, long-term outcomes

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CHICAGO — When patients with takotsubo syndrome survive cardiogenic shock, they remain at greater risk for unfavorable outcomes, including risk for mortality for years afterward, according to new data from the International Takotsubo Registry presented at the American Heart Association Scientific Sessions.

Takotsubo syndrome, also known as broken heart syndrome, is often triggered by physical or emotional stress. In about 1 in 10 cases, patients with takotsubo syndrome develop cardiogenic shock.

“Although takotsubo syndrome has been long considered a benign disease, our recent studies reported mortality rates comparable to acute myocardial infarction both at short- and long-term follow-up. Cardiogenic shock is the most relevant cause of mortality in patients with takotsubo syndrome, but limited information is available on its incidence and prognostic implications. Hence, we designed and conducted the present analysis to expressly investigate clinical features and outcomes of this unique setting of patients,” Christian Templin, MD, PhD, head of acute cardiac care at the University Heart Center at University Hospital Zurich, Switzerland, told Cardiology Today.

The current study focused on 198 patients in the International Takotsubo Registry who developed cardiogenic shock in comparison with 1,880 patients who did not develop cardiogenic shock.

In this registry, patients with cardiogenic shock were younger (63.4 years vs. 67.2 years) and more frequently male (14.1% vs. 9.3%) compared with those without cardiogenic shock. Those with cardiogenic shock were more likely to have the syndrome triggered by physical stress such as surgery or an asthma attack (66.7% vs. 33%; P < .001) and less likely to have emotional triggers (10.6% vs. 31.7%; P < .001).

“One of the most interesting features of takotsubo syndrome patients experiencing cardiogenic shock was the higher prevalence of physical trigger. We believe that it might have an impact not only on the short-term, but also on the long-term outcomes of this group of patients,” Templin, who is also the deputy head of interventional cardiology at the Andreas Grüntzig Heart Catheterization Laboratories at University Hospital Zurich, told Cardiology Today.

The new report also highlights differences in outcomes and mortality among patients with takotsubo syndrome complicated by cardiogenic shock, including:

  • higher rate of atrial fibrillation (13.1% vs. 5.7%; P < .001) upon admission;
  • more likely to have X-rays or ultrasound showing apical ballooning of the left ventricle (80.3% vs. 70.2%; P < .001) and lower left ventricular ejection fraction (32.7% vs. 41.6%; P < .001) upon admission;
  • more likely to have a history of CV risk factors such as diabetes (21% vs. 14.8%; P = .023) or smoking (27.4% vs. 19.3%; P = .01);
  • more likely to have neurologic disorders (31.7% vs. 23.4%; P = .013); and
  • less likely to be on treatment with ACE inhibitors or angiotensin receptor blockers (30.3% vs. 39.1%; P = .038) and statins (13.2% vs. 20.7%; P = .033).

Apical takotsubo syndrome, physical stress, LVEF less than 45%, diabetes and AF on admission were independent predictors associated with cardiogenic shock in this population.

When researchers examined the effect of takotsubo syndrome and cardiogenic shock on death, they found that these patients had an increased rate of in-hospital mortality (23.5% vs. 2.3%; P < .001), as well as at 60 days (P < .001) and at 5 years (P < .001).

“Beyond the higher short-term mortality, for the first time this analysis found people who experienced broken heart syndrome complicated by cardiogenic shock were at high risk of death years later, underlining the importance of careful long-term follow-up, especially in this patient group,” Templin said in a press release.

Moreover, 39% of patients with cardiogenic shock received cardiac mechanical support, including intra-aortic balloon pump, Impella heart pump (Abiomed) and/or extracorporeal mechanical oxygenation (ECMO). These patients had a lower rate of mortality in the hospital compared with those who did not receive mechanical support (12.8% vs. 28.3%; P = .046).

“Although these devices should be used with caution, it could be considered as a bridge-to-recovery in patients without contraindications,” Templin said in the release.

Takotsubo syndrome occurs most often in older women. In this study, however, those with takotsubo syndrome and cardiogenic shock were mostly men. Commenting on this finding, Templin said, “The higher prevalence of atrial fibrillation and other comorbidities among male takotsubo syndrome patients could partly explain this data. Nevertheless, after adjustment in a multivariable logistic regression model, male sex did not result to be independently associated with cardiogenic shock in patients with takotsubo syndrome.”

Use of these findings could help management of patients with takotsubo syndrome.

“The history and parameters that are easily detectable on admission to the hospital could be helpful to identify broken heart syndrome patients at higher risk of developing cardiogenic shock. For such patients, close monitoring could reveal initial signs of cardiogenic shock and allow prompt management,” Templin said.


Further research is needed to develop appropriate management in hospital and during follow-up in this patient population, according to the researchers.

“Due to the lack of guidelines, no specific indications are currently available for the long-term management of patients with takotsubo syndrome. A close follow-up including multiple cardiac imaging assessment could be beneficial, especially for patients with takotsubo syndrome complicated by cardiogenic shock,” Templin told Cardiology Today. by Katie Kalvaitis


Di Vece D, et al. Posted SaMDP9. Presented at: American Heart Association Scientific Sessions; Nov. 10-12, 2018; Chicago.

Di Vece D, et al. Circulation. 2018;doi:10.1161/CIRCULATIONAHA.118.036164.

Disclosures: The study was funded by the University of Zurich and the Zurich Heart House-Foundation of Cardiovascular Research. The authors report no relevant financial disclosures.