Gender differences in the manifestation of tako-tsubo cardiomyopathy

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Abstract

Objective

This study evaluated if there are gender differences in the manifestation of tako-tsubo cardiomyopathy (TTC).

Background

TTC predominantly occurs in elderly females and mimics acute myocardial infarction (AMI) where men and women are known to have a different clinical profile.

Methods

324 patients from 37 hospitals were prospectively included in a TTC registry. Clinical, electrocardiographic, angiographic and outcome data from male and female patients were compared.

Results

Of 324 patients 296 (91%) were female and 28 (9%) male. Mean age (68 ± 12 vs 66 ± 12 years) and prehospital delay were similar. A triggering event preceded TTC onset in 76% of women and 86% of men. Physical stress was more frequent in men (30% vs 57%, p = 0.005) whereas more women experienced emotional or no stress. The prevalence of angina and dyspnea did not differ. Fewer females were admitted in cardiogenic shock and/or after out of hospital cardiac arrest (1% vs 14%, p = 0.0006), and cardiac troponin was lower (median 7.2 vs 10.7 times the upper limit of normal, p = 0.03). The QTc interval was longer in females than in males only on the day of admission (468 ± 52 vs 441 ± 51 ms, p = 0.047). Overall, complications during the acute course (53% vs 40%) were comparable in both sexes.

Conclusions

In this large TTC registry, males and females showed a similar clinical profile. In males, physical stress as a trigger event and shock or cardiac arrest as presenting symptoms were more frequent. The QTc interval was longer in females only on admission but similar in males and females during the following days.

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.

Section snippets

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),

References (33)

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