When the cause is not ischemic: cardiogenic shock due toTakotsubo syndrome versus acute coronary syndrome

Cardiogenic shock (CS) remains a critical entity with in-hospital mortality of 40-50%. While ST-elevation myocardial infarction (STEMI) is the most common cause (40-50% of CS cases), Takotsubo syndrome (TTS) can also lead to severe CS in 10-20% of cases, despite its typically reversible nature. However, few studies directly compare clinical characteristics, management requirements, and outcomes between TTS-related and STEMI-related CS in contemporary practice.

The objective was to compare clinical characteristics, management, and evolution of patients with CS secondary to STEMI versus TTS.

Retrospective study of patients admitted to the cardiological critical care unit (CICU) for CS between 2012 and 2024. History, biochemical parameters, left (LVEF) and right (RVEF) ventricular function at admission, ICU treatment, and follow-up events were analyzed. The STEMI (n=428) and TTS (n=10) groups were compared using chi-square and t-test (p<0.05).

Age was similar (71±13 vs 70.5±10 years). Females were more frequent in TTS (60% vs 27%; p=0.0502). Hypertension and diabetes were more frequent in STK, while dyslipidemia and previous ischemic heart disease predominated in STEMI (Table 1). On admission, the TTS had worse renal function (creatinine 1.51 vs 1.39 mg/dL; p=0.02), higher blood glucose (237.9 vs 217.7 mg/dL; p=0.0003), lower LVEF (27% vs 32.8%; p<0.0001), although better RVEF (57.5% vs 49.3%; p<0.0001). Patients with CS secondary to STEMI required more support with dobutamine (86% vs 70%, p=0.34) and intra-aortic balloon counterpulsation (18% vs 10%, p=0.81), noradrenaline was widely used in both groups (84% vs 90%, p=0.9). The need for intubation and IMV (Invasive Mechanical Ventilation) was comparable. Mortality in ICU was higher in STEMI (23.3% vs 10%; p=0.54), but did not reach significance. Follow-up events were similar.

CS by TTS shows a different clinical profile, with a predominance of females, worse renal and metabolic function, lower LVEF and better RVEF. Although it is associated with a potentially reversible course, it requires intensive management similar to STEMI. Its recognition as a serious cause of CS is key to optimizing stratification and individualized treatment according to the etiology of CS. Small sample size limits definitive conclusions.

Baseline characteristics compared.