Gender differences in the manifestation of tako-tsubo cardiomyopathy
Introduction
Tako-tsubo cardiomyopathy (TTC), initially described in Japan, has increasingly been recognized in western countries over the past years [1], [2], [3], [4], [5], [6], [7], [8]. This cardiac syndrome mimics acute myocardial infarction (AMI) and is characterized by transient left ventricular regional dysfunction, ischemic electrocardiographic changes and elevation of cardiac markers in the absence of significant coronary artery disease. In all studies reported so far, there is a marked gender discrepancy of TTC which affects predominantly elderly females.
Men and women with AMI have a different clinical presentation and outcome [9], [10], [11], [12] but currently little is known about discrepancies in the clinical profile of TTC according to sex. This study, therefore, sought to evaluate in a large registry whether there are gender differences in the manifestation of TTC.
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Patients
A German TTC registry was initiated in 2006 by the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausaerzte (ALKK) in order to characterize the clinical spectrum of this syndrome in a western population. Patients were prospectively included into the registry according to the following criteria: 1) acute chest symptoms (angina, dyspnea) or syncope; 2) ischemic ECG changes with ST-segment elevation and/or T-wave inversion; 3) reversible left ventricular regional akinesia not corresponding to
Clinical characteristics of patients included in the TTC registry
From 36 heart centers all over Germany and 1 center in Austria, 324 patients were included in the registry. Mean age was 68 ± 12 (range 27–90) years; 296 (91%) of patients were female and 28 (9%) were male. A triggering event was identified in 250 patients (77%) with a similar distribution of emotional (36%) and physical stress (32%); 29 patients (9%) experienced both stress modalities. Main symptoms at presentation were angina in 233 patients (72%), dyspnea in 50 (15%) and syncope in 10 (3%).
Discussion
Tako-tsubo cardiomyopathy, a reversible form of acute heart failure frequently precipitated by a stressful event, has a clinical presentation which is indistinguishable from myocardial infarction [1], [2], [3], [4], [5], [6], [7], [8]. This entity has therefore emerged as an important differential diagnosis of an acute coronary syndrome.
Consistent among all published studies is a marked sex disparity in that TTC most commonly occurs in postmenopausal women whereas the prevalence in males is
Limitations
Our multicenter registry did not receive complete data sets from all patients. When it became obvious from the expanding literature that many patients develop complications we extended our initial case report form. But despite intense efforts we were not always successful in obtaining the missing data. It is possible that we were not able to capture all cases of TTC in all centers since the diagnosis depends to some degree on clinically considering the syndrome as a differential diagnosis. This
Conclusions
TTC predominantly occurs in elderly females. In this large registry, males were affected in 9% of patients with a similar clinical profile. In contrast to myocardial infarction, age distribution and symptoms in TTC were not different among both sexes. In males, physical stress as a triggering event and shock or cardiac arrest on presentation were more frequent. In females, the QTc interval was longer than in males only on the day of admission. Since male patients with TTC show a
Acknowledgments
The following institutions and investigators participated in the German Tako-Tsubo registry initiated by the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte: Klinikum Aschaffenburg (W. Pistner, R. Uebis), HELIOS Klinikum Aue (T. Ketteler), Klinikum Augsburg (T. Müller-Honold, W. von Scheidt), Herz- und Gefäß-Klinik Bad Neustadt a. d. Saale (R. Schamberger, S. Kerber), DRK Kliniken Berlin Köpenick (A. Bublak, H.-F. Vöhringer), DRK Kliniken Berlin Westend (R. Schoeller),
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2023, CJC OpenCitation Excerpt :In addition, long term outcome has not been well studied. There is also uncertainty as to whether sex is an independent predictor for in-hospital mortality after adjustment for significant difference in comorbidities between men and women.7,9,13–15 The United States Veteran Affairs (VA) system serves mostly male patients.16