Clinical Scorecard: A New and Straightforward Cardiac MRI Scoring System (PE2RT) for Predicting Outcomes in Takotsubo Syndrome
At a Glance
Category
Detail
Condition
Takotsubo syndrome (TTS), an acute transient cardiomyopathy with reversible left ventricular systolic dysfunction and regional wall motion abnormalities
Key Mechanisms
Transient left ventricular regional wall motion abnormalities beyond a single coronary distribution, myocardial oedema without ischemic or inflammatory late gadolinium enhancement, and complications such as pericardial/pleural effusions, right ventricular involvement, and ventricular thrombus
Target Population
Patients with clinical suspicion of Takotsubo syndrome undergoing cardiac magnetic resonance imaging
Care Setting
Tertiary care cardiovascular imaging centers with access to cardiac magnetic resonance imaging
Key Highlights
Takotsubo syndrome often mimics acute coronary syndrome but is characterized by reversible left ventricular dysfunction with typical apical ballooning or atypical forms.
Long-term prognosis of TTS is worse than previously thought, with mortality rates comparable to acute myocardial infarction.
The PE2RT score, based on presence of pericardial effusion, pleural effusion, right ventricular involvement, and ventricular thrombus on CMR, predicts major adverse cardiovascular events.
Guideline-Based Recommendations
Diagnosis
Use cardiac magnetic resonance imaging to confirm TTS diagnosis by identifying transient left ventricular regional wall motion abnormalities extending beyond a single coronary distribution.
Exclude other diagnoses such as myocarditis by absence of ischemic or inflammatory late gadolinium enhancement in affected regions.
Include patients with typical RWMA and positive LGE if consistent with TTS diagnostic criteria.
Management
Incorporate assessment of pericardial effusion (>5 mm), pleural effusion (>20 mm), right ventricular involvement, and ventricular thrombus during CMR evaluation.
Calculate the PE2RT score by summing presence of these four complications to stratify risk.
Monitoring & Follow-up
Follow patients longitudinally for major adverse cardiovascular events including cardiovascular death, rehospitalization for acute myocardial injury, arrhythmia, or heart failure symptoms.
Use PE2RT score to identify patients at higher risk who may benefit from closer clinical follow-up.
Risks
Patients with higher PE2RT scores have increased risk of long-term major adverse cardiovascular events.
Right ventricular involvement, non-apical ballooning, and physical triggers are associated with worse prognosis.
Patient & Prescribing Data
Patients diagnosed with Takotsubo syndrome confirmed by CMR
The PE2RT score aids in prognostication but specific therapeutic interventions based on score are not detailed; management should consider identified complications and risk stratification.
Clinical Best Practices
Perform comprehensive CMR including cine imaging, T2-weighted imaging for oedema, and late gadolinium enhancement sequences in suspected TTS.
Assess for presence of pericardial and pleural effusions, right ventricular involvement, and ventricular thrombus systematically.
Use the PE2RT scoring system as a simple, reproducible tool to predict long-term cardiovascular outcomes in TTS patients.
Ensure multidisciplinary collaboration between cardiologists and radiologists for accurate image interpretation and clinical correlation.
Maintain longitudinal follow-up for patients with TTS due to risk of adverse cardiovascular events despite initial recovery.
by Alexander Isaak, Johanna Bratz, Dmitrij Kravchenko, Narine Mesropyan, Irina Eckardt, Leon M. Bischoff, Leonie Weinhold, Daniel Kuetting, Claus Christian Pieper, Ulrike Attenberger, Sebastian Zimmer, Julian A. Luetkens
