1. Division of Cardiovascular Diseases No relevant author disclosures
Acute Heart Failure in Apical Ballooning Syndrome (Takotsubo/Stress Cardiomyopathy) Clinical Correlates and Mayo Clinic Risk Score
Malini Madhavan, MBBS; Charanjit S. Rihal, MD, FACC; Amir Lerman MD, FACC; Abhiram Prasad, MD, FRCP, FACC
Division of Cardiovascular Diseases
Mayo Clinic, Rochester
No relevant author disclosures
J. Am. Coll. Cardiol. 2011;57;

2. Background
Apical ballooning syndrome (ABS) is characterized by transient regional systolic dysfunction of the left ventricle in the absence of obstructive coronary artery disease
Acute heart failure (HF) is the most common complication
Acute HF can cause significant morbidity in ABS

3. Aims
To examine the frequency and prognosis of patients with acute HF complicating ABS
To identify the risk factors for acute HF in ABS

4. Methods Study Population
Study cohort
118 consecutive ABS patients identified between January 2002 and January 2008
Validation cohort
52 consecutive ABS patients identified between Feb 2008 and December 2009

5. Methods Mayo diagnostic criteria for ABS
Transient akinesis, hypokinesis or dyskinesis of the left ventricular mid segments with or without apical involvement. The regional wall motion abnormalities extend beyond a single epicardial vascular distribution
Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture,
New ECG abnormalities (either ST-segment elevation and/or T wave inversion) or elevated cardiac troponin,
The absence of pheochromocytoma or myocarditis
Prasad et al. Am Heart J 155(3):408-17

6. Methods: Definitions Acute heart failure Cardiogenic shock
New onset symptoms such as dyspnea, and
At least 2 of the following physical signs - pulmonary rales, elevated central venous pressure, and the presence of a third heart sound
Cardiogenic shock
Systolic blood pressure of <90 mm Hg for greater than 1 hour secondary to cardiac dysfunction associated with signs of hypoperfusion
Patients with systolic blood pressure increase to >90 mm Hg within 1 hour after administration of inotropic agents, who met other criteria for cardiogenic shock

7. Clinical Characteristics
Variable
No Acute HF
(N=65)
Acute HF
(N=53)
p-value
Age (years)
67 (12)
73 (12)
0.02
Female gender
63 (97%)
52 (98%)
0.7
Presenting symptom
Chest Pain
Dyspnea
51 (78%)
26 (40%)
23 (43%)
35 (66%)
<0.0001
0.005
Precipitating factor
Emotional stress
Physical stress
19 (30%)
23 (35%)
11 (21%)
37 (70%)
0.0003
Electrocardiogram
ST-segment elevation
Deep T wave inversion
23 (36%)
39 (60%)
31 (58%)
26 (49%)
0.01
0.2

8. Clinical Characteristics
Variable
No Acute HF
(N=65)
Acute HF
(N=53)
p-value
Biomarkers
Admission Troponin T (ng/ml)
Peak Troponin T (ng/ml)
BNP (pg/ml) (N=48)
0.37 (0.42)
0.55 (0.56)
783 (753)
0.71 (0.85)
0.93 (0.90)
1161 (1010)
0.009
0.01
0.1
Angiography
Ejection fraction (%)
LVEDP (mm Hg)
Grade 3 or 4 MR
46 (11)
23 (7)
5 (10%)
35 (13)
28 (7)
8 (21%)
0.0001
0.001
0.08
Admission Echocardiogram
Wall motion score index
44 (13)
1.74 (0.41)
36 (13)
2.05 (0.47)
0.004
0.0006

9. Independent Predictors of Acute HF Multivariate Analysis
Odds Ratio*
95% confidence interval
P value
Age (years)
1.06
0.001
Physical stress trigger
4.01
1.64 – 10.36
0.002
Admission Troponin T
2.43
1.05 – 6.59
0.04
LV Ejection fraction
0.96
0.01
ST-segment elevation
1.34
0.5 – 3.52
0.7
*Per unit change in variable

10. Troponin T Stratified by Severity of HF

11. Mayo Clinic Risk Score for Acute HF in ABS
One point was assigned to each of the following independent risk factors:
Age > 70 years
Presence of physical stressor
Ejection fraction < 40%
Troponin T was not included due to heterogeneity in assay and cut-off value used at different institutions

12. Mayo Clinic Risk Score for Acute HF in ABS
Significant positive correlation between the frequency of acute HF and the risk score in the:
Development cohort – C statistic 0.77, p<0.001
Validation cohort – C statistic 0.77, p=0.002

13. Acute HF Stratified by Mayo Risk Score
Development cohort
Validation cohort

14. Outcome in ABS No acute HF (N=65) Acute HF (N=53) P value
Cardiogenic shock
N/A
25 (47%)
Cardio respiratory support
Inotrope use
Intra-aortic balloon pump use
Mechanical ventilation
3 (5%)
20 (38%)
9 (17%)
15 (28%)
<0.001
Duration of hospitalization (days)
5.4 (8.7)
11.2 (5.4)
0.0004
Outcome at discharge
Residual HF
Death in hospital
0 (0%)
6 (11%)
3 (6%)
0.09
Discharge medications
Beta blocking agent
ACE inhibitor/ ARB
Furosemide
49 (77%)
39 (61%)
6 (9%)
41 (82%)
37 (74%)
20 (40%)
0.5
0.1
0.0001
Follow-up echocardiogram
Time from presentation (days)
Ejection fraction (%)
Wall motion score index
74 (148)
62 (6)
1.08 (0.21)
78 (120)
60 (10)
1.13 (0.29)
0.9
0.3
0.4

15. Conclusions Heart Failure is a common complication of ABS
Approximately 50% developed HF
One in five developed cardiogenic shock
Patients who developed acute HF had,
Greater myocardial injury and stunning
Greater morbidity and longer hospitalization
Prognosis is good with resolution of HF with supportive management in the majority of patients
Mortality secondary to cardiogenic shock occurred in 3 patients

16. Conclusions
The Mayo Clinic risk score is predictive of acute HF in patients with ABS
Risk stratification using the Mayo Clinic risk score may:
Assist in triaging high risk patients to an intensive care unit for management
Allow physicians to identify patients in whom early initiation of beta-adrenergic blockers may be harmful