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N Engl J Med. 2015 Sep 3;373(10):929-38. doi: 10.1056/NEJMoa1406761.

Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy.

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From University Heart Center, Department of Cardiology (C. Templin, J.R.G., J.D., D.R.B., M.J., V.L.C., V.G., C.A.N., M.S., P.E., F.R., T.F.L.), and Department of Psychiatry and Psychotherapy (K. Eisenhardt, J.J.), University Hospital Zurich, and Division of Biostatistics, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich (B.S.), Zurich, Spitalregion Rheintal Werdenberg Sarganserland, Altstätten (J.H.), Department of Cardiology, Kantonsspital Lucerne, Lucerne (F. Cuculi, P.E.), Department of Cardiology, Kantonsspital Winterthur, Winterthur (T.A.F.), and Department of Cardiology, University Hospital Basel, Basel (C.K., S.O.) - all in Switzerland; Department of Cardiology and Angiology, Hannover Medical School, Hannover (L.C.N., J.B.), Department of Cardiology, Heidelberg University Hospital, Heidelberg (J.F., H.A.K.), Deutsches Herzzentrum München, Technische Universität München (C.B., H.S., W.K.), and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (H.S., W.K.), Munich, University Heart Center Lübeck, Medical Clinic II, Department of Cardiology, Angiology and Intensive Care Medicine, Lübeck (C.M., H.T.), DZHK, partner site Hamburg/Kiel/Lübeck (C.M., H.T., M.K.), Division of Cardiology, Asklepios Clinics St. Georg Hospital (A.C., K.-H.K.), and Department of General and Interventional Cardiology, University Heart Center Hamburg (M.K.), Hamburg, Department of Cardiology, Charité, Campus Rudolf Virchow, Berlin (C. Tschöpe, H.-P.S.), Department of Internal Medicine III, Heart Center University of Cologne, Cologne (G.M., R.P.), Department of Internal Medicine III, Cardiology, Angiology, and Intensive Care Medicine, Saarland University, Homburg (C.U., M.B.), Department of Cardiology, University Hospital Essen, Essen (R.E.), Clinic for Cardiology and Pneumology, Georg August University Göttingen (C.J., G.H.), and DZHK, partner site Göttingen (C.J., G.H.), Göttingen, Department of Internal Medicine II



The natural history, management, and outcome of takotsubo (stress) cardiomyopathy are incompletely understood.


The International Takotsubo Registry, a consortium of 26 centers in Europe and the United States, was established to investigate clinical features, prognostic predictors, and outcome of takotsubo cardiomyopathy. Patients were compared with age- and sex-matched patients who had an acute coronary syndrome.


Of 1750 patients with takotsubo cardiomyopathy, 89.8% were women (mean age, 66.8 years). Emotional triggers were not as common as physical triggers (27.7% vs. 36.0%), and 28.5% of patients had no evident trigger. Among patients with takotsubo cardiomyopathy, as compared with an acute coronary syndrome, rates of neurologic or psychiatric disorders were higher (55.8% vs. 25.7%) and the mean left ventricular ejection fraction was markedly lower (40.7±11.2% vs. 51.5±12.3%) (P<0.001 for both comparisons). Rates of severe in-hospital complications including shock and death were similar in the two groups (P=0.93). Physical triggers, acute neurologic or psychiatric diseases, high troponin levels, and a low ejection fraction on admission were independent predictors for in-hospital complications. During long-term follow-up, the rate of major adverse cardiac and cerebrovascular events was 9.9% per patient-year, and the rate of death was 5.6% per patient-year.


Patients with takotsubo cardiomyopathy had a higher prevalence of neurologic or psychiatric disorders than did those with an acute coronary syndrome. This condition represents an acute heart failure syndrome with substantial morbidity and mortality. (Funded by the Mach-Gaensslen Foundation and others; number, NCT01947621.).

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