ABC | Volume 114, Nº3, March 2020

Original Article Factors Associated with Recurrence in Takotsubo Syndrome: A Systematic Review Felipe Alverenga Duarte Campos, 1 Luiz Eduardo Fonteles Ritt, 1 ,2 J oão Paulo Soares Costa, 1 Constança Margarida Cruz, 1,3 Gilson Soares Feitosa-Filho, 1,4 Queila Borges de Oliveira, 2 Eduardo Sahade Darzé 1,2 Escola Bahiana de Medicina e Saúde Pública, 1 Salvador, BA – Brazil Hospital Cárdio Pulmonar, 2 Salvador, BA – Brazil Hospital Santo Antônio - Obras Sociais Irmã Dulce, 3 Salvador, BA – Brazil Faculdade de Tecnologia e Ciências, Curso de Medicina, 4 Salvador, BA – Brazil Mailing Address: Luiz Eduardo Fonteles Ritt • Hospital Cardio Pulmonar - Centro de Estudos Clínicos – Av. Anita Garibaldi, 2199. Postal Code 40170130, Ondina, Salvador, BA – Brazil E-mail: luizritt@hotmail.com, lefr@cardiol.br Manuscript received December 08, 2018, revised manuscript April 12, 2019, accepted May 15, 2019 DOI: https://doi.org/10.36660/abc.20180377 Abstract Background: Takotsubo syndrome (TTS) is characterized by a temporary systolic dysfunction of the left ventricle (LV) related to a stressful event. However, the factors associated with its recurrence are still not well established. Objective: To analyze the main factors associated with TTS recurrence. Methods: A systematic review was performed using the PRISMA model. Observational studies, published between January 2008 and October 2017, which presented a recurrence rate of at least 3% and/or 5 or more patients with recurrence, and who met at least 80% of the STROBE criteria were included. Results: six articles reached the criteria to compose this systematic review. The recurrence rate ranged from 1 to 3.5% per year (global recurrence rate 3.8%). One study associated higher recurrence rate with the female gender, four reported the time between the first and second episodes, one study associated body mass index (BMI) and hypercontractility of the LV middle anterior wall to a higher recurrence rate. No association between recurrence and electrocardiographic changes were determined. Beta-blockers use was not associated with recurrence rates. Conclusions: Female gender, time from the first episode of the syndrome, low BMI and midventricular obstruction were reported as potential predictors of TTS recurrence. (Arq Bras Cardiol. 2020; 114(3):477-483) Keywords: Takotsubo Syndrome; Takotsubo cardiomyopathy; Recurrence. Preamble and case report A 62-year-old female patient was admitted for elective rhytidoplasty and blepharoplasty surgeries. She weighed 61 kg and was 1.65 m tall, with a history of glaucoma and hypothyroidism. She was considered at low cardiovascular risk for the procedure, with no personal or family history of cardiovascular disease. During surgery, under general anesthesia, she presented idioventricular rhythm followed by circulatory shock and cardiorespiratory arrest. She was successfully resuscitated and her electrocardiography (ECG) showed an ST elevation pattern in lateral leads. She was promptly submitted to cardiac catheterization that showed no coronary lesion but akinesia in apical and medial ventricular walls and hyperkinesia of the basal parts, a pattern that resembles the Takotsubo Syndrome (TTS). This pattern was confirmed in an ECG which showed an ejection fraction of 40%. After adjustments for heart failure therapy, she was discharged from the hospital in 10 days, clinically stable. In six months, she had already recovered her global and segmental functions. After 1 year, she was planning to undergo another plastic surgery and asked about her recurrence risk. This question was the main drive for this systematic review. Introduction TTS, also called Takotsubo cardiomyopathy or broken heart syndrome, 1,2 is characterized by a temporary left ventricle systolic and diastolic dysfunction, usually associated with an event of great emotional or physical stress. It presents clinically with acute chest pain, dyspnea, electrocardiographic changes, and the presence of elevated cardiac injury biomarkers, being very similar to an acute coronary syndrome despite the absence of significant coronary stenosis related to the affected area. 3 It is estimated that about 2% of patients with suspected acute coronary syndrome actually have TTS. 4 Postmenopausal women are the group most affected by this condition, probably due to hormonal issues, although men and young people can also have TTS. It is suggested that the pathophysiology of the disease is related to a large and abrupt discharge of catecholamines. 2 Therefore, the use of beta-blockers (BB) has been proposed as a prevention strategy. 3 477