A comprehensive analysis of nearly 200,000 patients with Takotsubo cardiomyopathy revealed persistently high mortality rates, with no improvement over a 5-year period, and a striking gender disparity in outcomes—with men experiencing more than twice the mortality rate of women.
Investigators utilized the Nationwide Inpatient Sample (NIS) database to evaluate trends, mortality, and complications in patients admitted with Takotsubo cardiomyopathy (TC) from 2016 to 2020. The findings highlight the ongoing challenges in managing this condition, despite increased recognition.
"[TC] is associated with high mortality and complications with no improvement in outcome over the 5-year study with higher mortality in men," reported lead author Mohammad Reza Movahed, MD, PhD, and colleagues from the University of Arizona Sarver Heart Center. "Further improvement in care is needed to improve outcomes."
Significant Findings
The analysis identified 199,890 patients with TC in the database, with 83% being female. Overall mortality was high, at 6.58%, with no significant improvement observed during the study period. Most notably, mortality was more than double in men compared to women (11.2% versus 5.5%).
The incidence of TC increased during the study period, rising from 0.19% to 0.21% for women and from 0.05% to 0.07% for men among all hospitalizations. The researchers observed a higher prevalence with age, White race, and higher income quartiles.
Major complications were substantial and included:
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Cardiogenic shock: 6.66%
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Atrial fibrillation: 20.79%
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Cardiac arrest: 3.42%
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Congestive heart failure: 35.93%
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Stroke: 5.38%
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Myocardial rupture: 0.02%.
When compared to patients without TC, those with the condition demonstrated significantly higher odds of adverse outcomes, including cardiogenic shock (odds ratio [OR] = 12.71, 95% confidence interval [CI] = 12.19-13.26, P < .001), cardiac arrest (OR = 4.79, 95% CI = 4.53–5.06, P <. 001), congestive heart failure (OR = 3.52, 95% CI = 3.44–3.60, P < .001), and myocardial rupture (OR = 5.79, 95% CI = 2.74–12.20, P < .001).
After multivariate analysis adjusting for age, sex, race/ethnicity, and common cardiovascular and pulmonary risk factors, TC remained independently associated with all-cause mortality (OR = 2.67, 95% CI = 2.5-2.8, P < .001).
Worsening Trends
Certain complications showed an apparent increase over the study period. Mortality increased from 5.63% to 8.38%, cardiogenic shock from 5.81% to 7.41%, cardiac arrest from 2.64% to 4.47%, congestive heart failure from 34.77% to 37.61%, and stroke from 4.97% to 5.9% from 2016 to 2020, respectively.
The researchers noted that the increase in mortality from 2019 to 2020, which exceeded 1.5%, might be partially attributed to the COVID-19 pandemic, as "COVID-19 emerged in late 2019 and multiple studies reported significant increases in TC due to this pandemic."
Demographic and Socioeconomic Patterns
The study identified several demographic patterns, with White people having the highest rate of TC, accounting for 0.16% of the total population studied, followed by Native Americans at 0.13%, while the lowest rate was among the Black population, at 0.07%.
Socioeconomic factors revealed that patients with TC tended to have higher household incomes and were treated in larger hospital bed sizes. Most patients were on Medicare (0.18% vs 0.08% for Medicaid or no charge). Among hospital types, TC rates were highest in private, nonprofit facilities (0.14%), and among teaching hospitals, urban teaching hospitals had the highest rate (0.14%).
The median length of stay for patients admitted with TC remained consistent from 2016 to 2020: a median of 4 days.
Why Men Face Higher Mortality Risk
The exact reason for the marked gender disparity in mortality remains unclear and represents an important area for future research. The authors noted that previous studies have suggested potential explanations: "A recent meta-analysis confirmed a double mortality rate in men. In a large TC registry, men had more physical stress as a trigger event and cardiac arrest as presenting symptoms that could be one explanation for higher mortality. Hormonal differences with higher levels of catecholamines in men can also play an important factor."
The authors emphasized that these findings reveal important clinical implications: "Clinicians need to improve care of these patients to reduce mortality and study the reason for sex differences in outcome."
Study Limitations
Study limitations included the use of administrative data with potential coding errors, lack of outpatient data, and the inability to differentiate between TC subtypes. The authors also noted that NIS entries represent hospitalizations rather than individual patients, so a patient hospitalized multiple times would have multiple entries.
The authors declared having no competing interests.