letter to the editors
Wien Klin Wochenschr
https://doi.org/10.1007/s00508-022-02019-w
Refinement of data is needed concerning the long-term
prognosis of patients with takotsubo syndrome
Claudia Stöllberger · Maria Winkler-Dworak · Birke Schneider
Received: 9 December 2021 / Accepted: 17 February 2022
© The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature 2022
Dear Editors,
With great interest we read the article by Pogran
et al. about the long-term outcome of patients with
takotsubo syndrome (TTS) [1]. The authors observed
147 patients with TTS admitted to a single center
between September 2006 and August 2019. During
follow-up, 49 patients (33.3%) died mainly due to
non-cardiac causes. Female gender, malignancy and
chronic kidney disease were identified as independent
predictors for non-cardiovascular death.
However, there are some important issues that need
to be addressed.
Concerning the high mortality rate the authors
should state explicitly how many patients with TTS
died during the index hospitalization and how many
patients died during follow-up. In addition, it would
be of great value if the authors could comment on the
recurrence rate of TTS in their patient cohort.
A history of malignancy was present in 17% of the
patients, which is rather high compared to 11% as re-
ported by Citro et al. [2]. In a further study, however,
even 29% of TTS patients had a history of malignancy,
a finding partly explained by a large proportion of on-
cologic patients in the critical care department [3].
Thus, it will be of interest to know how many patients
of the present study were directly admitted to the car-
Dr. C. Stöllberger, M.D. ()
Office Wehlistraße, Vienna, Austria
Steingasse 31/18, 1030 Wien, Austria
claudia.stoellberger@chello.at
M. Winkler-Dworak, Techn.D.
Vienna Institute of Demography, Wittgenstein Centre for
Demography and Global Human Capital, Vienna, Austria
B. Schneider, M.D.
Sana Kliniken, Lübeck, Germany
K Refinement of data is needed concerning the long-term prognosis of patients with takotsubo syndrome
diology department and how many were transferred
from surgery or oncology departments.
Regarding survival estimates, we suggest compar-
ing the included patients with the expected survival
for an age, sex and birth year-matched Austrian pop-
ulation using the standardized mortality ratio (SMR)
method which has been applied in similar TTS studies
[4, 5]. This would improve the impact of their findings.
The presentation of the mortality data is very con-
fusing. The Kaplan-Meier curve shows that the cu-
mulative survival rate for all-cause mortality was
around 0.5. However, according to the reported rate
of 33% deceased patients, the Kaplan-Meier curve
should decline only to 0.667.
In addition, it is difficult to understand the median
follow-up duration of 126 months. Unfortunately, the
interquartile range of the follow-up time is not given.
Since the patients were included during 156 months
(September 2006 to August 2019), and 49 of them died
during the observation period of 168 months (until
August 2020), to yield a median follow-up duration of
126 months most of the patients must have been in-
cluded very early or have died very late at the end of
the observation period, which was not the case ac-
cording to the Kaplan Meier curve. Another possi-
bility could be that “survival time” was mistaken for
“follow-up duration”, since, according to the Kaplan-
Meier curve, the median of the survival time is 126
months.
Furthermore, regarding the methods section it
is difficult to understand the terms “parametric”
and “nonparametric” variables. Do the authors
mean “continuous/categorical” and “categorical”
data? Most importantly, the authors falsely use the
term “negative predictor” in association with a hazard
ratio of >2 in several parts of the article.
In the literature there are only few data about the
long-term course of patients with TTS [2, 6, 7]. There-
 letter to the editors
fore, a correct and more detailed description of the
investigated patient cohort would be a valuable con-
tribution to our knowledge on TTS.
Conflict of interest C. Stöllberger, M. Winkler-Dworak and
B. Schneider declare that they have no competing interests.
References
1. Pogran E, Abd El-Razek A, Gargiulo L, Weihs V, Kaufmann C,
Horváth S, et al. Long-term outcome in patients with
takotsubo syndrome: a single center study from vienna.
Wien Klin Wochenschr. 2021; https://doi.org/10.1007/
s00508-021-01925-9.
2. Citro R, Radano I, Parodi G, Di Vece D, Zito C, Novo G, et al.
Long-term outcome in patients with Takotsubo syndrome
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Refinement of data is needed concerning the long-term prognosis of patients with takotsubo syndrome
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