ABC | Volume 114, Nº3, March 2020

Original Article Campos et al. Takotsubo syndrome recurrence Arq Bras Cardiol. 2020; 114(3):477-483 medium-ventricular hypercontractility were also reported as predisposing to TTS recurrence. Use of BB or other heart failure (HF) medications was not proven to reduce the chance of recurrence. Some authors may understand that new episodes of TTS are not recurrence, but instead a clinical spectrum of the disease. In accordance with international consensus and statements, the term recurrence was used here as after the first episode patients recover their global and segmental ventricular function recurring the disfunction in the subsequent episode. Only one study of this systematic review 10 analyzed gender as a recurrence variable, with no recurrence in men and a recurrence rate in women of 14.8%. In all other studies selected, as in the rest of the literature, 6 if not all, most patients who had recurrence were women. Although there are reports of recurrence in men, 14 they are extremely rare. These data strongly suggest that female gender is a predisposing factor to TTS recurrence. In relation to age, Patel et al. 10 found a higher rate of recurrence among women aged less than 50 years, when Table 2 – Selected studies characteristics Reference Studied population Level of Significance adopted Recurrence rate (recurrence N/total N) Analyzed data with possible recurrence association Looi et al., 9 Patients admitted to Middlemore Hospital, Auckland City Hospital and North Shore Hospital, Auckland, New Zealand. p < 0.05 7% (7/100) – Time between manifestations: recurrences occurred from 99 to 679 days after the first episode, being more frequent in the first year. – Triggering factor: 57% of patients with recurrence presented emotional stress as a trigger. – Clinical characteristics: recurrence in patients presenting ST elevation was not higher when compared to patients who did not present ST elevation (7.4 and 6.3%, respectively); p = 1.00. – Medications in use: 4 (57%) of the patients used BB on recurrence. Templin et al., 3 Patients obtained through the Mayo Clinic database. Patients with ACS from Zurich Acute Coronary Syndrome Registry. p < 0.05 3.26% (57/1750) – Time between manifestations: recurrence occurred from 25 days to 9.2 years after the first episode. – Medications in use: 29 patients (50.8%) used BB during the second episode. Patel et al., 10 Patients obtained through the Mayo Clinic database. p < 0.05 for men versus women p < 0.25 for comparison with women ≥ 50 years of age (due to multiple comparisons) 3.13% (7/224) – Gender: there were no recurrences in men and all 7 recurrences were in women (14.8%) – Age: recurrence in women aged < 50 years was more prevalent in relation to recurrence in women aged ≥ 50 years (16 and 3%, respectively; p = 0.017). Elesber et al., 11 Patients diagnosed with TTS submitted to the Mayo Clinic catheterization center database. p < 0.05 11.4% (10/100) – Time between manifestations: 4.4±4.6 mean years between episodes, with a higher recurrence rate in the first 4 years compared to subsequent years (2.9 and 1.3% a year, respectively). – Medications in use: recurrence in patients in use X without use of: aspirin (60x67%), p = 0.67; ACEI/ARB (60x51%), p = 0.59; BB (80x52%), p = 0.10; Statins (40x33%), p = 0.67. Vriz et al., 12 Patients at San Antonio Community Hospital (San Daniele del Friuli, Udine, Italy). p < 0.05 21.7% (5/23) – Age: more frequent in older patients. – Time between manifestations: recurrence occurred on an average of 105.4 ± 82.92 days after the first episode, being more frequent in the first 3 months. – Clinical characteristics: more frequent recurrence in patients with lower LVEF, lower SBP and higher troponin peak. – Medications in use: therapy with BB did not prevent recurrence. Nishida et al., 13 Patients from the BOREAS Registry database. p < 0.05 2.8% (7/251) -Clinical characteristics: low BMI, medium-ventricular hypercontractility and right ventricular involvement were both associated with a higher rate of recurrence of TTS (p = 0.048, 0.01, and 0.06, respectively). HRs of recurrence for BMI (per increase by 1 kg/cm 2 ) and MVO were 0.75 (95% CI 0.54–0.99) and 14.71 (95% CI 1.87–304.66), respectively. BB: beta-blocker; ACS: acute coronary syndrome; TTS: Takotsubo syndrome; ACEI: angiotensin converting enzyme inhibitor; ARB: angiotensin II receptor blocker; LVEF: left ventricle ejection fraction; SBP: systolic blood pressure; BMI: Body Mass Index; HRs: hazard ratios; CI: confidence interval; MVO: microvascular obstruction. 480