Letters to the Editor
Cancer and Takotsubo Syndrome: a Need to Explore a Very Complex Association
2017 Volume 81 Issue 1 Pages 123-
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2017 Volume 81 Issue 1 Pages 123-
To the Editor:
The association of cancer (CA) and takotsubo syndrome (TTS) has been long appreciated;1–3 Girardey et al4 set out to explore further this intricate association in a retrospective analysis of 154 patients with TTS, 44 of whom had a history of previous or current CA, and were observed in hospital and followed up for a median of 1 year, in a report published online ahead of print on September 1, 2016 in the Journal. The authors confirmed that CA is highly prevalent in patients with TTS (28.5%), and such patients were younger, had lower rates of a history of hypertension and higher rates of tobacco use, presented more often with dyspnea, had a lower rate of emotional or no trigger, and a higher rate of physical trigger, and had higher levels of peak B-type natriuretic peptide, peak leukocyte count (PLC), and C-reactive protein, than the patients with TTS without CA history. CA and PLC were independent predictors of cardiac death, and CA, PLC, and initial cardiac arrest were independent predictors of total mortality.4
The authors have done an admirably comprehensive analysis, considering the small size of their TTS series, but the issue of CA/TTS needs to be further evaluated by studies of large registries (combination of many will be even better) of TTS patients, followed prospectively over the course of many years. Regarding the effect on the emergence of TTS, or its severity, one wonders whether a history of old CA (accepted fact) vs. a recent such diagnosis (struggle to accept) might possibly make a difference, and thus require a separate analysis; also the accompaniments of CA, such as type of CA, type and severity of required procedures and surgeries, type and intensity of therapies (chemotherapy and radiotherapy), and other associated complications of CA, must be playing a role in shaping the apparent association of CA and TTS. Because a strong association of neuropsychiatric disorders (NPD) and TTS has been identified,5 and diagnoses of CA and NPD often coexist, an analysis of the CA/TTS association should factor in the morbid influences of NPD.
The authors’ thesis that the “presence of cancer may lower the threshold for stress stimuli and/or may aggravate cardiac adrenoreceptor sensitivity”, and that CA “may have affected cardiovascular outcomes through the activation of inflammatory and neurohormonal mechanisms”,4 is a good starting point; accordingly, researchers should be encouraged to measure blood levels of catecholamines, as used to be the case,6 explore whether their patients with TTS and CA, use or need to be started on anxiolytic or antidepressant therapy, and could benefit from a course of supportive cognitive behavioral therapy (CBT). Finally, because a noninvasive test of the intensity of the activation of the sympathetic nervous system (ASNS) is currently lacking, we should explore whether what is available is of any use; accordingly, the ambulatory (Holter) ECG-based assessment of heart rate variability, blood pressure variability, and blood pressure-heart rate interactions to quantify the sensitivity of baroreflex control of heart rate, as indices of ASNS activation,7 could be possibly used serially after admission of patients with TTS and CA and at follow-up, to identify patients who have chronic intense ASNS activation, and therefore may need pharmacological and/or CBT management.
None.
No funding has been received for this work.
