Takotsubo syndrome: from apical hypokinesia to long-term outcomes
T Constantino, I Cardoso, P Bras, I Almeida, J Viegas, V Ferreira, R Ferreira, S Aguiar RosaAbstract
Introduction
Takotsubo syndrome (TTS) is characterised by transient left ventricular dysfunction, usually precipitated by emotional or physical stress. Despite its reputation as a benign entity, reported mortality and complication rates can be similar to those of acute coronary syndromes.
Purpose
To describe the clinical profile, precipitating factors, imaging patterns - Echocardiogram and Cardiac Magnetic Resonance (CMR) - and outcomes of patients with TTS in a Portuguese tertiary centre, integrating multimodality imaging and biomarkers, and to explore prognostic associations with troponin and NT-proBNP.
Methods
We performed a retrospective cohort study of 39 consecutive TTS admissions (2022–2025), diagnosed using ECG, clinical, imaging and biomarker data. These variables were analysed. Primary endpoints were overall mortality, TTS-related mortality and MACE (overall mortality, recurrence, heart failure hospitalisation, ventricular arrhythmias, myocardial infarction or stroke). Troponin elevation was defined as >99th percentile upper reference limit (URL); for international comparability, are 26 ng/L (hs-cTnI) and ~14 ng/L (hs-cTnT).
Results
Mean age was 65.3 ± 14.2 years; 36/39 (92.3%) were women (Figure 2). Emotional triggers were identified in 15/39 (38.5%), physical in 5/39 (12.8%) and none in 18/39 (46.2%). NT-proBNP was 2,577 [671–6,442] pg/mL (Table 2). LVEF was 55.0 ± 8.8% (n = 25). Apical ballooning predominated (echo 38/38; ventriculography 37/37). CMR was performed in 21/39; myocardial oedema was present in 14/20 (70.0%) with T2 58.0 [48.0–64.2] ms (Figure 1), predominantly apical and without ischaemic LGE. Baseline cTnI was available in 14/39: 4,889.7 [2,670.8–25,661.3] and baseline cTnT in 23/39 was 517 [154.5–1,041], all elevated. Median follow-up was 16.4 months (n = 38). MACE occurred in 7/39 (17.9%); all-cause death 6/39 (15.4%); TTS-related mortality 1/39 (2.6%). NT-proBNP was higher in non-survivors (17,725 vs 2,326; p = 0.015) and in MACE (14,296 vs 2,013; p = 0.008). Baseline cTnT did not differ (629.5 [349–1,198] vs 181.0 [154.5–397]; p = 0.404). Baseline cTnI was higher in non-survivors (36,600 [21,774–89,747.1] vs 3,838.2 [2,076.1–6,052.3]; p = 0.038). In patients with follow-up cTnT (~1 year; n = 11), values remained higher in non-survivors (79.8 [60.7–98.9] vs 6.8 [3.7–13.6]; p = 0.036).
Conclusion
In this cohort, TTS occurred predominantly in older women and showed a consistent apical phenotype. NT-proBNP offered robust prognostic discrimination. Baseline cTnI, but not cTnT, was associated with adverse outcomes, whereas persistent cTnT elevation at follow-up identified a higher-risk subgroup. CMR demonstrated transient myocardial oedema, supporting the reversibility of myocardial injury. Overall, these findings emphasise the added value of biomarkers and multimodality imaging for diagnostic confirmation and risk stratification in TTS, and support the need for prospective multicentre validation.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.