INTRODUCTION: Takotsubo’s cardiomyopathy (TTC) is a transient and reversible dysfunction of the left ventricle with a characteristic balloon shape and wall motion abnormalities on echocardiogram. Symptoms, biochemical, and electrocardiographic profiles are indistinguishable from an acute myocardial infarction (MI), but angiography reveals clean coronary arteries. Risk factors, pathogenesis, treatment and outcomes of TTC remain largely unknown. Previous studies on TTC have been in medical intensive care unit (ICU) patients despite increased recognition in trauma patients; there are no large studies in trauma or surgical patient population. We aim to investigate the clinical characteristics leading to Takotsubo’s cardiomyopathy and resulting outcomes in critically injured patients.
METHODS: A retrospective chart review of injured patients diagnosed with TTC on echocardiogram in a surgical ICU over a 5 year period was performed. Controls with 1:1 ratio were randomly selected from remainder of the injured patients admitted to the surgical ICU. Factors including Injury Severity Score (ISS), acute physiology and chronic health evaluation (APACHE) II score, abbreviated injury scale (AIS), and mechanism of injury were collected. Mortality, length of stay (LOS), ICU LOS, ventilator days, and need for blood transfusion were primary outcomes. Bivariate analysis were conducted with twosided chi-square tests, t-test or Wilcoxon two-sample test.
RESULTS: Of the 2283 injured patients admitted to the SICU in 5 years, 416 (18.2%) received echocardiograms during their hospital course and 63 patients (2.8%) were diagnosed with TTC. Sixty three controls were randomly selected from the remaining 2220 patients. Forty nine (78%) patients with TTC were male. Most patients (60%) with TTC were >=60 compared to 35% of controls(p = 0.0043). The majority of TTC patients (57%) suffered a fall which was associated with TTC (p=0.037). Median APACHE II score for TTC patients was higher compared to controls (10 Vs 7; p= 0.0001). ISS was not predictive or significantly different (median 17; p=0.321). Patients with AIS Head >= 3 (59% Vs 41%; OR: 6.654) and AIS chest >=3 were more likely to develop TTC (62% Vs 38%; OR: 6.32) respectively, however the association did not reach statistical significance due to low frequencies. Prior history of Afib (18%), prior MI (16%), or need for hemodialysis (1.6%) were not associated with TTC (p= 0.192, 0.256, 0.094). Patients with TTC had longer length of stay (14 days Vs. 7 days, p=0.0182), longer ICU LOS (6 days Vs. 3 days; p=0.031), and more ventilator dependent days (median 2 days Vs 0 days; p=0.024). Patients with TTC required more blood transfusions compared to controls (median 0 Vs 1, p=0.012). Mortality was not significantly different between TTC and controls (9.5% Vs 4.8%; p=0.299). Most patients with TTC (60%) needed to be discharged to a facility and required additional care compared to only 43% of controls (p=0.05).
CONCLUSION: Incidence of TTC in our study is 2.8% which is comparable to the incidence described in the medical patients. Age >= 60, mechanism of injury, and higher APACHE II scores were significant risk factors. TTC patients had a similar mortality rate, but hospital LOS, ICU LOS, ventilator dependent days and blood transfusions were significantly higher for TTC patients compared to controls. Larger studies are needed to address some of the complex risk factors identified by our study in further details.
