Tachycardia and Hypotension in Patients with Takotsubo Syndrome: Any Insights About Their Management?

Böhm et al.1 reported on the predictive value of high heart rate (HR) and low systolic blood pressure (SBP) in patients with takotsubo syndrome (TTS), based on an analysis of 1377 patients from the International Takotsubo (InterTAK) Registry. The authors, employing the patients' HR and SBP at admission or, in their absence, the HR and SBP values measured at the next closest time point to admission, found that all-cause mortality and major adverse cardiac and cerebrovascular events were higher in patients with high HR and low SBP, with a particularly ominous prognosis conferred by a low SBP associated with high HR.1 The authors appropriately propose that high HR and low SBP could be employed as risk metrics early in the clinical course of patients admitted with TTS, and that HR reduction might be targeted for a therapeutic strategy in TTS management.1 Indeed one could consider an algorithmic approach implementing judicious administration of fluids (to avoid pulmonary congestion) for patients with low SBP, and beta-blockers, or even ivabradine,2 for patients with high HR, providing that one is dealing with sinus node-derived high HR. Care would be exercised to ascertain whether the HR was in response to underlying heart failure (and thus served a physiological purpose), or to hypovolaemia (and thus fluid administration could lead to reduction of the high HR). The choice of beta-blockers,3 dose, and their route of administration will need to be evaluated, and such therapy could be considered for the majority of patients with TTS, and not only for patients with complicated left ventricular outflow tract obstruction. Also continuous monitoring of the role of the heightened activity of the autonomic sympathetic nervous system4, 5 on the high HR might be of value in future studies. Since there are no management guidelines for TTS, it will be a great service to us all to learn what the physicians who cared for these 1377 patients with TTS did for the management of high HR and/or low SBP, and what was the immediate and subsequent response of their patients. Also one wonders about the prognostic value of the compounded metrics of the mean HR and SBP during the first day, first and second days, first to third days, or the entire duration of hospitalization, of these 1377 patients, and whether it was different than the HR and SBP of the patients' at admission considered herein.1