ABC | Volume 115, Nº2, August 2020

Original Article Almeida Junior et al. Takotsubo Multicenter Registry (REMUTA) Arq Bras Cardiol. 2020; 115(2):207-216 Introduction Takotsubo syndrome (TTS), also known as takotsubo cardiomyopathy or broken-heart syndrome, is a reversible regional dysfunction of the left (LV) and/or right ventricle (RV) in the absence of obstructive coronary disease; a large part of cases are caused by situations of acute stress. It was first described by Sato et al. in 1990, in Japan, with a series of 16 cases that presented clinical characteristics of acute coronary syndrome; all of the patients’ coronary arteries were, however, angiographically normal, and they had history of stressful event preceding the chest pain. The name is due to the similarity between the LV during systole and the “tako- tsubo,” which is a trap used in Japan for capturing octopus. In 2006, the American Heart Association classified it in the group of acquired cardiomyopathies, under the name stress- induced cardiomyopathy. The main manifestations of TTS are chest pain, dyspnea, ischemic ECG changes, slight increase in cardiac enzymes, and impairment of segmental ventricular function, without obstructive coronary disease.¹ Due to the fact that its clinical picture is similar to that of acute coronary syndromes, its main differential diagnosis is acute myocardial infarction (AMI), a clinical condition with high morbidity and mortality, and there are currently no criteria that make it possible to establish a clear distinction between the two pathologies during initial medical care. Retrospective studies have made it possible to establish the most prevalent characteristics in individuals with TTS, such as female sex (90%), age over 50 years, recent history of physical or emotional stress, acute chest pain, ST-segment elevation (STE) on electrocardiogram (ECG), and increased serum levels of troponin. , In 2016, the European Society of Cardiology (ESC) defined the diagnostic criteria for this syndrome, 1 which were utilized in this registry. Subsequently, in 2018, the ESC updated their diagnostic criteria. Essentially, the modifications were the inclusion of pheochromocytoma as a specific cause of TTS and the possibility of coexisting coronary disease and TTS. The physiopathology of this syndrome is complex, and it has not yet been fully made clear. Diverse studies indicate excessive release of adrenergic hormones (epinephrine and norepinephrine) secondary to extreme sympathetic activation and the cardiovascular response to this sudden sympathetic activation as the central factors in the physiopathology of the disease. Complications that result from TTS involve heart failure with reduced ejection fraction, generally below 25%, with apical hypokinesia (80%), moderate to severe mitral regurgitation (15% – 20%), cardiogenic shock (10% – 15%), in-hospital mortality (3% – 5%), and recurrence (5% – 10%). 4,5 Evolution tends to be benign when adequate support is provided early, with reversal of ventricular dysfunction in one to two weeks; reversal may, however, take up to three months. 4 The REMUTA study is the first multicenter registry conducted in Brazil, involving 12 private centers in the state of Rio de Janeiro. The objectives of this study were to describe the clinical and epidemiological characteristics, complementary exams, prognosis, and in-hospital treatment of patients admitted with TTS and to evaluate in-hospital mortality and mortality during 1 year of follow-up. (Veja comentário no texto original. A minha sugestão aqui seria “diagnosed”) Methods Definition of Clinical Subtypes Primary: Acute cardiac symptoms are the main reason for seeking medical attention. Secondary: This occurs in patients who were already diagnosed to the hospital for a different, non-cardiac reason; it is a complication of the primary condition or treatment thereof. Study Design This is an observational study, with retrospective analysis of medical records. For data on mortality, death certificate records of the state of Rio de Janeiro were evaluated. Inclusion and Exclusion Criteria Patients who were admitted to private hospitals with diagnosis of TTS according to the ESC criteria and those who developed TTS while already in the hospital for another reason were included in this study. Patients whose medical records were incomplete regarding data fundamental to analysis were excluded. Data Collection Clinical characteristics, laboratory data, chest X-ray, echocardiogram, ECG, cardiac nuclear magnetic resonance, and cardiac catheterization were collected from medical records. Each center coordinator identified patients with TTS in their clinical databases or in the database of the echocardiography or hemodynamics service. Following confirmation that patients met the inclusion criteria, an individual form was filled out with the data previously mentioned. Mortality data was collected from the death database of the Secretary of Health of the state of Rio de Janeiro. Objectives To describe the clinical and epidemiological characteristics, complementary exams, prognosis, and in-hospital treatment of patients diagnosed with TTS. To evaluate in-hospital mortality and mortality during one year of follow-up. Statistical Analysis Continuous variables were described as mean and standard deviation (SD) or median and interquartile range. We used unpaired Student’s t-test or Mann-Whitney test to compare continuous variables and identify univariate predictors of in-hospital mortality. Categorical variables were 208