Evaluation of therapy management and outcome in Takotsubo syndrome.

BACKGROUND: To date there is no validated evidence for standardized treatment of patients with Takotsubo syndrome (TTS). Medication therapy after final TTS diagnosis remains unclear. Previous data on patient outcome is ambivalent. Aim of this study was to evaluate medication therapy in TTS and to analyze patient outcome. METHODS: Within an observational retrospective cohort study we analyzed our medical records and included 72 patients with TTS that underwent cardiovascular magnetic resonance imaging (CMR) after a median of 2 days interquartile range (IQR 1-3.5). We investigated medication therapy at discharge. Medication implementation and major adverse clinical events (MACE) were prospectively evaluated after a median follow-up of 24 months (IQR 6-43). Left ventricular function, myocardial oedema and late gadolinium enhancement were analyzed in a CMR follow-up if available. RESULTS: Antithrombotic therapy was recommended in 69 (96%) patients including different combinations. Antiplatelet monotherapy was prescribed in 28 (39%) patients. Dual antiplatelet therapy was recommended in 29 (40%) patients. Length of therapy duration varied from one to twelve months. Only in one case oral anticoagulation was prescribed due to apical ballooning with a left ventricular ejection fraction <30%. In all other cases oral anticoagulation was recommended due to other indications. ß-adrenoceptor antagonists and ACE inhibitors were recommended in 63 (88%), mineralocorticoid receptor antagonists were prescribed in 31 (43%) patients. After a median of 2 months (IQR 1.3-2.9) left ventricular function significantly recovered (49.1% ± 10.1 vs. 64.1% ± 5.7, P < 0.001) and myocardial oedema significantly decreased (13.5 ± 11.3 vs. 0.6% ± 2.4, P = <0.001) in the CMR follow-up. The 30-day mortality was 1%. MACE rate after 24 months was 12%. CONCLUSION: Although therapy guidelines for TTS currently do not exist, we found that the majority of patients were treated with antithrombotic and heart failure therapy for up to twelve months. Left ventricular function and myocardial oedema recovered rapidly within the first two months. Outcome analysis showed a low bleeding rate and a high short-term survival. Therefore, TTS patients might benefit from antithrombotic and heart failure therapy at least for the first two months.

Neural correlates of developing and adapting behavioral biases in speeded choice reactions--an fMRI study on predictive motor coding.

In reaction-time (RT) tasks with unequally probable stimuli, people respond faster and more accurately in high-probability trials than in low-probability trials. We used functional magnetic resonance imaging to investigate brain activity during the acquisition and adaptation of such biases. Participants responded to arrows pointing to either side with different and previously unknown probabilities across blocks, which were covertly reversed in the middle of some blocks. Changes in response bias were modeled using the development of the selective RT bias at the beginning of a block and after the reversal as parametric regressors. Both fresh development and reversal of an existing response bias were associated with bilateral activations in inferior parietal lobule, intraparietal sulcus, and supplementary motor cortex. Further activations were observed in right temporoparietal junction, dorsolateral prefrontal cortex, and dorsal premotor cortex. Only during initial development of biases at the beginning of a block, we observed additional activity in ventral premotor cortex and anterior insula, whereas the basal ganglia (bilaterally) were recruited when the bias was adapted to reversed probabilities. Taken together, these areas constitute a network that updates and applies implicit predictions to create an attention and motor bias according to environmental probabilities that transform into specific facilitation.