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Oral anticoagulation in high risk Takotsubo syndrome: when should it be considered and when not?

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Abstract

Standard pharmacological therapy in Takotsubo syndrome (TTS) is still debated and there is a lack of prospective data. In their recent work in BMC Cardiovascular Disorders Abanador-Kamper et al. found that stroke in TTS has an event rate of 2.8% after 30 days and 4.2% after 12 months and they question which patients need oral anticoagulation. According to our clinical data, TTS patients with LV thrombi may be at high risk of stroke. These patients are characterized by apical ballooning pattern, high prevalence of ST-elevation and higher troponin I levels. We have recently proposed a therapeutic algorithm for oral anticoagulation in TTS. In case of apical ballooning pattern and increased admission levels of troponin-I (> 10 ng/mL), oral anticoagulation should be considered, while in case of midventricular/basal ballooning or apical ballooning associated with troponin-I levels < 10 ng/ml, oral anticoagulation should not be considered. A simple combination of echocardiographic parameters (apical ballooning pattern),ECG data (ST-elevation at admission and persistent after 72 h) and laboratory values (troponin serum levels) could be useful for an appropriate therapeutic management of oral anticoagulation in TTS.

We read with great interest the article from Abanador-Kamper et al. entitled “Temporarily increased stroke rate after Takotsubo syndrome: need for an anticoagulation?” [1]. In this study 72 patients with Takotsubo Syndrome (TTS) were enrolled and all were evaluated by cardiac magnetic resonance imaging during the acute phase and 2 months later. The stroke rate was 2.8% after 30 days and 4.2% after 12 months. Patients with stroke presented with apical ballooning and no one of them received prior anticoagulation.

Left ventricular (LV) thrombus formation was found in one patient (1.3%) with acute stroke. However, the real rate of LV thrombi may have been underestimated because thrombus formation can happen even 2 weeks after the acute event [2]. Stroke could also be a trigger for TTS due to the dysfunction of central autonomic network associated with cerebral infarction, especially involving the territory of middle cerebral artery or basilar artery [3]. Unfortunately, Abanador-Kamper et al. did not provide additional information regarding serum levels of troponin and ECG data.

In a multicenter study enrolling 541 TTS patients we found that 12 patients (2.2%) developed LV thrombi (all female presenting with apical ballooning pattern) [4]. Among these patients, 2 out of 12 (17%) had a stroke before anticoagulation initiation. These patients were characterized by a high prevalence of ST-elevation and higher troponin I levels. Troponin I levels > 10 ng/mL were the only predictor of LV thrombosis (normal values = 0.5 ng/ml).

According to this data we proposed a therapeutic algorithm for oral anticoagulation (Fig. 1). In case of an apical ballooning pattern and increased admission levels of troponin-I (> 10 ng/mL), oral anticoagulation should be considered, while in case of mid-ventricular/basal ballooning or apical ballooning associated with troponin-I levels < 10 ng/ml, oral anticoagulation should not be considered. Moreover, we also found that the presence of persistent ST-elevation during the first 72 h after admission is associated with LV thrombosis [5].

Fig. 1
figure1

Therapeutic algorithm proposal for oral anticoagulation (OAC) management during the acute phase of Takotsubo syndrome. This Figure has been reproduced from Santoro et al. Journal of the American Heart Association, 2017;6: e006990

A simple combination of echocardiographic parameters (apical ballooning pattern), ECG data (ST-elevation at admission and persistence after 72 h) and laboratory values (troponin serum levels) could be useful for an appropriate therapeutic management of oral anticoagulation in TTS.

The high rates of stroke during the first 30 day after TTS remarks the urgent need of randomized trials assessing the role of anticoagulation in TTS.

Response to “Oral anticoagulation in high risk Takotsubo syndrome: When should it be considered and when not?”

AuthorGroup Author AuthorName GivenNameNadine FamilyNameAbanador-Kamper Contact Emailnabanador@gmail.com Author AuthorName GivenNameLars FamilyNameKamper Author AuthorName GivenNameJudith FamilyNameWolfertz Author AuthorName GivenNameMarc FamilyNameVorpahl Author AuthorName GivenNamePatrick FamilyNameHaage Author AuthorName GivenNameMelchior FamilyNameSeyfarth Affiliation OrgIDgrid.490185.1 OrgNameDepartment of Cardiology, Helios University Hospital Wuppertal, University Witten/Herdecke OrgAddress CityWuppertal CountryGermany Affiliation OrgID0000 0000 9024 6397 OrgIDgrid.412581.b OrgNameCenter for Clinical Medicine Witten/Herdecke University Faculty of Health OrgAddress CityWuppertal CountryGermany Affiliation OrgIDgrid.490185.1 OrgNameDepartment of Diagnostic and Interventional Radiology, Helios University Hospital Wuppertal, University Witten/Herdecke OrgAddress CityWuppertal CountryGermany

We thank the authors for this important contribution and agree that prospective RCTs are urgently needed to define a therapeutic algorithm in patients with TTS and the need for anticoagulation.

References

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    Abanador-Kamper N, Kamper L, Wolfertz J, Vorpahl M, Haage P, Seyfarth M. Temporarily increased stroke rate after Takotsubo syndrome: need for an anticoagulation? BMC Cardiovasc Disord. 2018;18:117.

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    Singh V, Mayer T, Salanitri J, Salinger MH. Cardiac MRI documented left ventricular thrombus complicating acute Takotsubo syndrome: an uncommon dilemma. Int J Cardiovasc Imaging. 2007;23:591–59.

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    Santoro F, Carapelle E, Cieza Ortiz SI, Musaico F, Ferraretti A, d'Orsi G, Specchio LM, Di Biase M, Brunetti ND. Potential links between neurological disease and Tako-Tsubo cardiomyopathy: a literature review. Int J Cardiol. 2013;168(2):688–91.

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    Santoro F, Stiermaier T, Tarantino N, L. De Gennaro C. Moeller F. Guastafierro M.F. Marchetti R. Montisci T. Graft P. Caldarola H. Thiele M. Di Biase N.D. Brunetti I. Eitel. Left ventricular thrombi in Takotsubo syndrome: incidence, predictors and management. Results from the German Italian stress cardiomyopathy (GEIST) registry. J Am Heart Assoc. 2017;6(12). https://doi.org/10.1161/JAHA.117.006990.

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    Santoro F, Stiermaier T, Tarantino N, Guastafierro F, Graf T, Moller C, Di Martino LFM, Thiele H, Di Biase M, Eitel I, Brunetti ND. Impact of persistent ST elevation on outcome in patients with Takotsubo syndrome. Results from the GErman Italian STress cardiomyopathy (GEIST) registry. Int J Cardiol. 2018;255:140–4.

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Author information

FS conceived the idea for the study, supervised it and wrote the manuscript with NDB. FG, NT, TS and IE revised the article. All authors edited and approved the final version of the manuscript.

Correspondence to Francesco Santoro or Nadine Abanador-Kamper.

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Santoro, F., Stiermaier, T., Guastafierro, F. et al. Oral anticoagulation in high risk Takotsubo syndrome: when should it be considered and when not?. BMC Cardiovasc Disord 18, 205 (2018) doi:10.1186/s12872-018-0930-1

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Keywords

  • Oral anticoagulation
  • Left ventricular thrombi
  • Stroke
  • Prognosis
  • Follow-up
  • Broken heart syndrome
  • Apical ballooning
  • Takotsubo syndrome