Predictors of cardiogenic shock in takotsubo syndrome: insights from a mexican population

Abstract Takotsubo syndrome (TTS), or stress-induced cardiomyopathy, is characterized by transient ventricular dysfunction that was initially perceived as benign. However, recent studies indicate a 9.5% prevalence of cardiogenic shock associated with TTS. Factors such as physical stressors, diabetes, smoking, apical ballooning pattern, left ventricular ejection fraction (LVEF) less than 45%, and atrial fibrillation are proposed as predictors to this complication, raising mortality rates up to 23%. Prior studies have not detailed the racial distribution of populations, creating uncertainty regarding the applicability of these findings to Latin American patients. This underscores the urgent need for early identification of risk factors to initiate aggressive treatment strategies and improve clinical outcomes in the Latin American population. This cross-sectional, descriptive, retrospective study included patients admitted between May 2004 and January 2025 with suspected acute coronary syndrome meeting InterTAK 2018 criteria for TTS. Individuals with a diagnosis of myocarditis, significant coronary lesions over 70% obstruction, or those with incomplete medical records were not included. Patients were classified into two groups: without CS and with CS, defined by systolic BP 90 mmHg for 30 mins, need for inotropes/vasopressors/mechanical circulatory support, and evidence of systemic hypoperfusion. Patients were also stratified using the SCAI scale. A bivariate analysis identified clinical, biochemical, and imaging factors linked to CS, using the Mann-Whitney U test for non-normally distributed continuous variables. This study evaluated 50 patients with a mean age of 60.8 ± 17 years, with being 84% female. We found that 32% experienced CS (n=16), classified mainly as SCAI D (43.8%) and E (31.13%). CS patients were younger (mean age 56 vs. 63 years) and had lower mean arterial pressure. CS patients presented a worse functional class on admission, 67% were on NYHA IV compared to 17.6% in the non-CS group. CS patients required more vasopressors, inotropes, ECMO, and had significantly elevated total leukocyte counts, C-reactive protein, troponin, and lactate levels. Echocardiography revealed a lower LVEF in CS (31.50%) vs non-CS (49%). Cardiac MRI indicated no significant difference in LVEF likely attributed to the longer wait time to perform imaging in CS patients (8 vs 2.6 days). Mortality was higher in the CS group (37.5% vs. 5.9%), as well as cardiac related deaths (68.8% vs 2.9%). This study identified critical predictors of CS in TTS among Mexican patients, including younger age, elevated leukocyte counts, CRP, troponin, lactate, and lower LVEF. The mortality rate of 32% aligns with international findings . There is a significant need for early identification of these risk factors to improve clinical outcomes in this population.