Takotsubo’s Cardiomyopathy, Pressor Use, and its impact on Outcomes

Introduction: Takotsubo’s Cardiomyopathy (TCM) is fueled by catecholamine-induced cardiotoxicity. Although uncommon after aneurysmal subarachnoid hemorrhage (aSAH), TCM can increase patient morbidity and mortality for these patients. The fear of precipitating TCM with vasopressor use or augmenting blood pressure in TCM patients poses a dilemma for clinicians. This multi-institutional retrospective review hypothesizes vasopressor use after aSAH increases TCM rates.

Methods: This multi-institutional retrospective review evaluated aSAH patients aged 18-80 from 1/1/2013 through 12/31/2021. Non-aneurysmal SAH patients were excluded. Patients were separated by presence of TCM diagnosis. Baseline demographics, clinical presentation, aneurysm characteristics, adverse events, short-term outcomes, treatment variables, and vasopressor usage in average daily norepinephrine equivalent were collected. P-values < 0.05 were deemed to be significant.

Results: 311 patients were included; 13 patients (4.2%) had a diagnosis of TCM. Median TCM diagnosis day was post-bleed day 4 (IQR 2-5). High-grade rupture (Hunt-Hess score ≥3) was associated with TCM (p = 0.010). Vasopressor use after aneurysm securement was associated with TCM (p < 0.001), though daily norepinephrine equivalent was not significantly different between groups (p = 0.768). Vasospasm requiring multiple endovascular treatments, myocardial infarction, prolonged intubation, and general poor outcomes were significantly more prevalent in the TCM group, though none of these variables were significant on multivariate analysis. On multivariate analysis, vasopressor use was not significantly associated with TCM (OR 4.275, CI 0.295-61.952, p = 0.287).

Conclusion : In this small population, a majority of aSAH patients were diagnosed with TCM within 5 days post-bleed. Most TCM patients were diagnosed prior to initiating vasopressors, and vasopressor use was not predictive of TCM in aSAH patients. This suggests that even with early TCM diagnosis, vasopressors may be safely used in TCM patients with vasospasm, though large scale studies are needed to make this conclusion.