A history of cancer was noted in one in six patients with takotsubo cardiomyopathy, also known as "broken heart syndrome," and was associated with reduced 5-year survival times, a new international study found.
Malignancy was observed in 16.6% of 1,604 patients with takotsubo syndrome. Within 10 years of a takotsubo event, 40% of those with a cancer history died, versus about 25% among takotsubo patients without previous malignancy (P<0.001), reported Christian Templin, MD, University Hospital Zurich in Switzerland, and colleagues in the Journal of the American Heart Association.
And while 30-day mortality rates were comparable at roughly 5%, takotsubo patients with malignancy were more likely to die or require intensive heart and respiratory support while in the hospital, the researchers found.
"Patients with broken heart syndrome might benefit if screened for cancer to improve their overall survival," Templin said in a press statement. "Our study also should raise awareness among oncologists and haematologists that broken heart syndrome should be considered in patients undergoing cancer diagnosis or treatment who experience chest pain, shortness of breath, or abnormalities on their electrocardiogram."
Indeed, a study reported in 2018 found that patients diagnosed with takotsubo syndrome had twice the risk of clinical complications following hospital discharge if they also had a history of cancer.
Takotsubo cardiomyopathy, also known as stress cardiomyopathy, is a clinical syndrome that frequently presents as chest pain mimicking acute coronary syndrome or as acute heart failure characterized by left ventricular systolic dysfunction in response to emotional, physical, or medical stress, Gregg Fonarow, MD, UCLA Medical Center, Los Angeles, told MedPage Today. Fonarow was not involved in the study.
Reports such as one from 2012 have suggested that cancer may increase the risk of developing takotsubo cardiomyopathy, noted Fonarow, who called for additional research in this area.
In the current study, takotsubo syndrome patients with cancer were somewhat older (69.5 vs 65.8 years, P<0.001) and more likely to have physical triggers prior to the syndrome compared with those without malignancy (47.9% vs 34.2%, P< 0.001). Of these, a substantial proportion of takotsubo syndrome patients with malignancy developed a takotsubo episode after a medical intervention or physical trauma (12.7% vs 5.5%, P<0.001).
However, as an earlier study suggested, those with broken heart syndrome were less likely to have emotional triggers (18% vs 30.3%, P<0.001). "It is noteworthy that the prevalence of psychiatric disorders including anxiety and depression was not significantly different in [takotsubo syndrome] patients with malignancy compared to without malignancy," Templin and colleagues wrote.
The prevalence of malignancies in takotsubo cardiomyopathy is notably higher than in acute coronary syndrome (ACS). But among such patients with malignancies in the current study, long-term mortality was similar at about 40% in both takotsubo and ACS patients.
Other study highlights
Compared to those without cancer, takotsubo patients with malignancy on initial presentation were less likely to have chest pain (67.8% vs 77.5%, P<0.001), but more likely to have dyspnea (53.5% vs 45.8%, P=0.029). They also required acute cardiac care treatment more frequently (26.7% vs 19.4%, P=0.007), often related to a greater need for invasive or noninvasive respiratory support (23.7% vs 15.7%, P=0.002) and had a higher in-hospital mortality (6.7% vs 3.4%, P=0.010).
In a multivariable analysis, independent predictors of long-term mortality were:
- Age >70
- Atrial fibrillation
- Peak troponin >10x upper limit of the normal (ULN)
- Peak creatinine kinase >10x ULN
- Left ventricular ejection fraction <45%
- Malignancy, neurologic conditions, and psychiatric disorders
For the study, researchers drew on data from the International Takotsubo Registry (InterTAK Registry), with participants (88% women) stratified by presence or absence of malignancy. The most frequent type of malignancy was breast cancer, followed by tumors affecting the gastrointestinal system, respiratory tract, internal sex organs, skin, and other areas. Subanalyses included 411 takotsubo patients and 441 ACS patients matched for age and sex.
Authors noted limitations included in the small study cohort, which did not allow examination of the potential effect of the different type and stage of cancer, or its treatment, on outcome in patients with takotsubo syndrome.
"The mechanism by which malignancy and cancer treatment may promote the development of broken heart syndrome should be explored, and our findings provide an additional reason to investigate the potential cardiotoxic effects of chemotherapy," Templin said.
More evidence links broken heart syndrome to cancer
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