Takotsubo syndrome and cardiogenic shock: Authors' response

Authors' response to the commentary of Imanura et al., https://doi.org/10.1093/ehjopen/oead050. We would thank Dr Imanura for the comments on the paper ‘Impact of intra-aortic balloon counterpulsation on all-cause mortality among patients with Takotsubo syndrome complicated by cardiogenic shock: results from the German-Italian-Spanish (GEIST) registry’,1 recently published in this journal. The author questioned the population selected for mechanical support with intra-aortic balloon pump (IABP), wondering whether patients treated with IABP could be sicker. That, in general, could be reasonably true. For this reason, we provided an additional analysis using propensity score matching. It pointed out that there was no clear benefit, as a rule, for IABP therapy, in line with other conditions (e.g. acute myocardial infarction). Regarding the use of Impella, no patient received such mechanical support in the GEIST registry. Only extracorporeal membrane oxygenation (ECMO) use has been reported in case of right ventricular failure. Unfortunately, patients treated with ECMO were enrolled after the present study analysis. Nevertheless, pharmacological treatment in case of cardiogenic shock in Takotsubo syndrome (TTS) is not well established. Inotropic drugs acting on adrenergic receptors should be avoided due to the increased serum catecholamine levels during the acute phase of TTS. Levosimendan, a non-catecholamine inotrope, a calcium sensitizer, and potassium channel opener, can be used among high-risk TTS patients with cardiogenic shock.2 High-risk patients were defined those with left ventricular ejection fraction ≤35% and one additional risk marker (ST elevation at ECG's admission, troponin levels above ×3 upper limit of normal, and physical stressor).2 However, in case of left ventricular outflow obstruction, levosimendan should be avoided, and beta 1 selective blockers with short half-life could be safely used and could effectively reduce intraventricular gradient.3 Randomized clinical trials are needed to test the best pharmacological approach during the acute TTS phase, especially in case of cardiogenic shock. No data available. No funding received.