Out-of-hospital versus in-hospital Takotsubo cardiomyopathy: Analysis of 3719 patients in the Diagnosis Procedure Combination database in Japan

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Highlights

  • Comparison between ‘out-of-hospital’ and ‘in-hospital’ Takotsubo cardiomyopathy (TC).

  • In-hospital TC patients were more likely to be males than out-of-hospital TC ones.

  • In-hospital TC patients had more severe clinical backgrounds.

  • In-hospital TC was significantly associated with higher in-hospital mortality.

Abstract

Background

Although Takotsubo cardiomyopathy (TC) generally occurs after a stressful event out-of-hospital, it occasionally occurs secondary to acute medical illness after hospital admission. No study has examined and compared patient backgrounds and in-hospital outcomes between patients with out-of-hospital TC and those with in-hospital TC.

Methods and results

Using the Diagnosis Procedure Combination inpatient database in Japan, we identified 3719 eligible patients with a diagnosis of TC who underwent coronary angiography without any revascularization procedure between 2010 and 2013, including 419 patients with in-hospital TC and 3300 patients with out-of-hospital TC. There was no significant difference in age between those with in-hospital TC and those with out-of-hospital TC (74.2 ± 10.9 years versus 73.4 ± 11.3 years, p = 0.211). Patients with in-hospital TC had a higher proportion of males than out-of-hospital TC patients (31.3% versus 21.3%, p < 0.001). Patients with in-hospital TC had significantly higher proportions of several chronic comorbidities and acute medical illnesses. In-hospital mortality was significantly higher in patients with in-hospital TC than in patients with out-of-hospital TC (17.9% versus 5.4%, p < 0.001). In the multivariable logistic regression analysis, in-hospital TC was significantly associated with higher in-hospital mortality (adjusted odds ratio 2.02; 95% confidence interval, 1.43 to 2.85; p < 0.001), even after adjustment for patient backgrounds. Malignancy, chronic liver disease, rheumatic disease, sepsis, pneumonia, cerebrovascular diseases, acute renal failure, and acute gastrointestinal diseases were also significantly associated with higher in-hospital mortality.

Conclusions

In-hospital TC was associated with more severe clinical background and poorer short-term prognosis than out-of-hospital TC.

Introduction

Takotsubo cardiomyopathy (TC) is a clinical syndrome characterized by acute reversible dysfunction of the left ventricle (LV) in the absence of significant coronary artery disease [1], [2], [3], [4]. Although TC is relatively rare (approximately 2%) among patients presenting with suspected acute coronary syndrome [3], [5], [6], it is now included as an important differential diagnosis of acute coronary syndrome in major guidelines and cases are increasingly being diagnosed because of widespread use of cardiovascular imaging [7], [8].

Since first described by Japanese physicians in the early 1990s [9], TC has been reported to occur predominantly in postmenopausal women after exposure to emotional or physical stress and has shown a favorable prognosis because LV function generally recovers within a period of days to weeks [1], [2], [3], [4], [10], [11]. Recent observational studies showed that the clinical spectrum of TC was heterogeneous [12], [13], [14], [15], [16], [17]. However, the determinants of the short-term outcomes of TC have not been clearly defined because they were not well examined in previous studies because of the limited sample sizes (n = 100 to 256).

Although previous studies mainly focused on patients who developed TC before admission (out-of-hospital TC), TC is increasingly being observed secondary to acute medical illness after admission, especially in critically ill patients [1], [18], [19], [20], [21], [22], [23]. Several studies showed that TC occurred in a number of patients admitted to the intensive care unit (ICU) for acute medical illness [19], [20]. In patients with in-hospital TC, the onset and prognosis were reported to be affected by acute medical illnesses and chronic comorbidities [18], [19], [20]. No previous study has examined the difference between out-of-hospital and in-hospital TCs. In 2012, using the Nationwide Inpatient Sample (NIS) database in the United States, a large-scale retrospective study (n = 24,701) showed that TC patients with underlying critical illness had a higher risk of in-hospital death, suggesting that the presence of underlying critical illness contributed to in-hospital death in TC patients [24]. However, the study was not able to examine the differences between out-of-hospital and in-hospital TCs in detail because the NIS database did not provide a timeline for diagnosis.

The objective of the present study, therefore, was to elucidate the differences in patient characteristics and in-hospital outcomes between out-of-hospital and in-hospital TCs by using the Diagnosis Procedure Combination (DPC) database in Japan.

Section snippets

Data source

The DPC database is a national administrative claims and discharge abstract database for acute care inpatients in Japan [25]. The DPC database included data for 5.0, 6.4, and 6.9 million inpatients in 2010, 2011, and 2012, respectively. As of 2012, it included data from 1057 hospitals representing approximately 50% of all inpatient admissions to acute care hospitals in Japan. The DPC database includes the following data: unique identifiers of hospitals; patient age and sex; ambulance use or

Study population

We identified 3747 patients with a diagnosis of TC who underwent coronary angiography without any revascularization procedure during hospitalization in 666 hospitals. We excluded 10 patients with pheochromocytoma and 18 patients with acute myocarditis. Of the remaining 3719 eligible patients, we identified 3300 patients with out-of-hospital TC and 419 patients with in-hospital TC.

Patient characteristics

Table 1 shows the baseline characteristics. Overall, the mean age was 73.5 ± 11.2 years, and there was no significant

Discussion

This study is the first to examine the differences in patient backgrounds and in-hospital outcomes between out-of-hospital and in-hospital TCs. Our results showed that patients with in-hospital TC had more severe clinical backgrounds and higher in-hospital mortality than those with out-of-hospital TC. In-hospital TC was significantly associated with higher in-hospital mortality, even after adjustment for patient backgrounds.

To date, there has been an increase in physician awareness of TC [1],

Conclusions

The present study, using a nationwide inpatient database in Japan, showed that patients with in-hospital TC had more severe clinical backgrounds and higher in-hospital mortality than those with out-of-hospital TC. In-hospital TC was significantly associated with higher in-hospital mortality even after adjustment for patient backgrounds, indicating that patients with in-hospital TC were at higher risk of in-hospital death.

Conflict of interest

None.

Acknowledgments

None.

Funding sources

This work was supported by grants from the Ministry of Health, Labour and Welfare, Japan (Research on Policy Planning and Evaluation grant number: H25-Policy-010) and the Council for Science and Technology Policy, Japan (Funding Program for World-Leading Innovative R&D on Science and Technology, FIRST program grant number: 0301002001001).

References (29)

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All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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