Nationwide trends in incidence and outcomes of takotsubo (stress) cardiomyopathy, 2015-2025
J Lusk, K Oladuja, R Mentz, S Greene, D Bhatt, S Aymes, J Sara, A Arazang, E O'Brien, B Mac Grory, G FonarowAbstract
Background/Introduction
Takotsubo (Stress) cardiomyopathy is an uncommon but increasingly recognized condition causing acute heart failure, with severe complication rates comparable to those of acute coronary syndrome (1-3). The contemporary epidemiology and outcomes of this condition have not been studied since the release of the 2018 International Takotsubo Diagnostic Criteria (4) and after the COVID-19 pandemic in a large, nationwide sample in the United States.
Purpose
To evaluate trends in the incidence and outcomes of Takotsubo cardiomyopathy in the United States.
Methods
We used Epic Cosmos, a nationwide dataset built in collaboration with U.S. health systems using the Epic electronic medical record, which includes inpatient and outpatient records for more than 300 million patients across nearly 43,000 clinics and 1,915 hospitals. Trends in the annual age and sex-adjusted cumulative incidence of Takotsubo cardiomyopathy, identified via ICD-10-CM I51.81 in any inpatient admission, were estimated using Poisson regression. We examined trends in in-hospital mortality, cardiovascular and neurological complications, and length of stay (LOS) from 2015-2025. For each calendar year, the denominator included patients who were alive and had at least one encounter in the preceding two years as of January 1.
Results
Of 67,763,731 patients at risk in 2015 and 166,450,170 at risk in 2025, 4,039 (5.96 per 100,000) and 24,902 (14.96 per 100,000) developed Takotsubo cardiomyopathy, respectively. This corresponded to age and sex-adjusted cumulative incidences of 6.36 (95% CI 6.16-6.55 per 100,000) and 14.55 (95% CI 14.37-14.73 per 100,000), yielding an annual percent change (APC) of 7.42% (95% CI 5.23-7.62%, p<.001). Trends are visualized graphically in Figure 1, stratified by age (A) and sex (B). Rates of complications (A), including atrial fibrillation, cardiac arrest, cardiogenic shock, acute heart failure, myocardial rupture, and stroke, as well as in-hospital mortality (B) are shown in Figure 2. In general, rates of most complications increased from 2015-2025, especially cardiogenic shock, which was observed in nearly 1 in 5 patients by 2025. In-hospital mortality rose from 7.3% in 2015 to 9.9% in 2021 and then fell to 8.4% in 2025. The proportion of patients with LOS <3 days decreased from 26.0% to 22.8%, (APC -1.33%, 95% CI -1.69 to -0.98%, p<.001) and the proportion of patients with a LOS>14 days increased from 13.8% to 15.6% (APC 1.57%, 95% CI 1.11-2.04%, p<.001).
Conclusions
The incidence of Takotsubo cardiomyopathy increased substantially from 2015 to 2025, with associated increases in rates of mortality and complications during this time. Notable increases in mortality were observed during the COVID-19 pandemic. Future research to improve outcomes for patients with Takotsubo cardiomyopathy is needed.Figure 1Figure 2