Ischemic ECG patterns at admission identify Takotsubo patients at increased risk of mortality
A A Agam, P S Soegaard, M P A Andersen, C T P Torp-Pedersen, H C C Christensen, C B Binding, K I Iversen, H B Bundgaard, C P Pocwiartek, C G Graff, K K Kragholm, R B H HasselbalchAbstract
Background
Takotsubo syndrome (TTS) is a reversible acute heart failure syndrome. Electrocardiographic (ECG) abnormalities are common at presentation and may reflect underlying disease severity, but their prognostic significance remains incompletely understood.
Purpose
We aimed to determine whether distinct ischemic ECG patterns at admission identify TTS patients at higher risk of all-cause and cardiovascular mortality.
Methods
In this nationwide, register-based cohort study, we included all patients with a first-time TTS diagnosis between 2008 and 2021 who had an ECG recorded within 24 hours of admission. Patients were stratified by ECG pattern: ST-segment elevation, ST-segment depression, T-wave inversion, or no ischemic changes. The primary outcome was 1-year all-cause mortality; cardiovascular death was assessed as a secondary outcome. Cox regression models were adjusted for age, sex, diabetes, chronic obstructive pulmonary disease, atrial fibrillation, acute coronary syndrome, hypercholesterolemia, and cancer, with death from other causes treated as a competing risk.
Results
A total of 1,244 patients were included (mean age 70.8 years; 89.1% women) and stratified by ECG pattern as follows: no ischemic changes (n = 707, 56.8%), ST-segment elevation (n = 226, 18.2%), ST-segment depression (n = 95, 7.6%), and T-wave inversion (n = 216, 17.4%). One-year all-cause mortality was highest among patients with ST-segment elevation (15.0%) compared with no ischemic changes (7.6%), T-wave inversion (6.5%), and ST-segment depression (5.3%). After adjustment, ST-segment elevation was independently associated with a significantly increased risk of all-cause mortality (HR 1.53, 95% CI 1.19–1.96) whereas ST-segment depression and T-wave inversion were not. Cardiovascular death occurred infrequently but was more common among patients with ST-segment elevation. In adjusted analyses, patients with ST-segment elevation had a significantly increased risk of cardiovascular death (HR 2.65, 95% CI 1.16-5.70) compared with those without ST-segment elevation.
Conclusions
ST-segment elevation on admission ECG identifies TTS patients at higher risk of both all-cause and cardiovascular mortality, highlighting its potential role in risk stratification and guiding closer monitoring and management.Figure 1Figure 2