Key result
Identifiable stressors predict an ~8-fold higher likelihood of AVB recovery in Takotsubo cardiomyopathy.
Why the study?
Due to low incidence and lack of randomised trials, evidence is limited regarding underlying mechanisms, probability of conduction recovery, and optimal timing for permanent pacemaker implantation in TCM-associated AVB.
Systematic Review (n=50)
In patients with Takotsubo cardiomyopathy and high-grade AV block, the presence of an identifiable stressor strongly predicts AV block recovery, which may help guide patient selection for permanent pacemaker implantation.
Answers are grounded in this paper and cite their sources.
May support deferring permanent pacing in TCM with high-grade AVB when stressors are present; leaves open prospective validation before practice change.
Background Atrioventricular block (AVB) in Takotsubo cardiomyopathy (TCM) is a rarely reported complication. Due to its low incidence and lack of randomised trials, there remain significant gaps in the evidence regarding its underlying mechanisms, the probability of conduction recovery and the optimal timing for permanent pacemaker implantation. Methods A systematic review was conducted on published case reports on TCM associated with high-grade AVB, diagnosed simultaneously or within the same hospital admission. Cases with low-grade AVB, sole sinus node disease or TCM induced by pacemaker implantation were excluded. Results A total of 50 cases were included in the final analysis; stratified into two groups based on AVB recovery. Fifteen patients (30%) developed complete AVB recovery. Compared with persistent AVB, those who experienced recovery were younger (median (IQR): 66 (61–73) vs 77 (65–82), p=0.02), more frequently reported identifiable emotional or physical stressors (93% vs 49%, p=0.004) and demonstrated earlier recovery of left ventricular ejection fraction (LVEF) within 1 week (60% vs 24%, p=0.02). No significant differences were observed in terms of comorbidities (hypertension in 27% vs 47%, p=0.22), presenting symptoms (chest pain in 40% vs 14%, syncope or presyncope in 27% vs 46%, p=0.22), ST elevation (27% vs 14%, p=0.28) or regional wall motion abnormalities (apical akinesia in 47% vs 46%, p=0.93). On multivariate analysis, the presence of an identifiable stressor was an independent predictor of AVB recovery (HR 8.27; 95% CI 1.07 to 63.73, p=0.04). Conclusion In patients with TCM and high-grade AVB, the absence of a clear stressor highlights the possibility of baseline conduction disorder, with a higher risk of persistent AVB. Earlier LVEF recovery and younger age may help to predict AVB recovery and guide patient selection for PPM implantation. PROSPERO registration number CRD420251173831.
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Hussein et al. (2026) conducted a systematic review in Takotsubo cardiomyopathy with high-grade atrioventricular block (n=50). Identifiable emotional or physical stressor vs. No identifiable stressor was evaluated on Atrioventricular block recovery (HR 8.27, 95% CI 1.07 to 63.73, p=0.04). The presence of an identifiable emotional or physical stressor independently predicted atrioventricular block recovery in Takotsubo cardiomyopathy (HR 8.27; 95% CI 1.07-63.73; p=0.04).
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