Predictors of high-grade atrioventricular block recovery in Takotsubo cardiomyopathy: a systematic review of case reports

Clinical Snapshot

Key Findings

• P Value: p=0.04 for stressor association, p=0.02 for age difference

• Effect Size: Hazard ratio 8.27 for AVB recovery with identifiable stressor

• Primary Outcome: Complete atrioventricular block recovery occurred in 30% of patients (15/50)

• Nnt Or Sensitivity: Median age difference of 11 years between recovery groups (66 vs 77 years)

• Confidence Interval: 95% CI 1.07 to 63.73

Clinical Application

Findings can inform pacemaker implantation timing decisions in Australian cardiology practice Relevant for Australian cardiologists managing rare TCM-AVB cases; may influence PBS-funded pacemaker implantation timing decisions and align with CSANZ guidelines for device therapy Patients with Takotsubo cardiomyopathy complicated by high-grade atrioventricular block

Abstract

BACKGROUND: Atrioventricular block (AVB) in Takotsubo cardiomyopathy (TCM) is a rarely reported complication. Due to its low incidence and lack of randomised trials, there remain significant gaps in the evidence regarding its underlying mechanisms, the probability of conduction recovery and the optimal timing for permanent pacemaker implantation. METHODS: A systematic review was conducted on published case reports on TCM associated with high-grade AVB, diagnosed simultaneously or within the same hospital admission. Cases with low-grade AVB, sole sinus node disease or TCM induced by pacemaker implantation were excluded. RESULTS: A total of 50 cases were included in the final analysis; stratified into two groups based on AVB recovery. Fifteen patients (30%) developed complete AVB recovery. Compared with persistent AVB, those who experienced recovery were younger (median (IQR): 66 (61-73) vs 77 (65-82), p=0.02), more frequently reported identifiable emotional or physical stressors (93% vs 49%, p=0.004) and demonstrated earlier recovery of left ventricular ejection fraction (LVEF) within 1 week (60% vs 24%, p=0.02). No significant differences were observed in terms of comorbidities (hypertension in 27% vs 47%, p=0.22), presenting symptoms (chest pain in 40% vs 14%, syncope or presyncope in 27% vs 46%, p=0.22), ST elevation (27% vs 14%, p=0.28) or regional wall motion abnormalities (apical akinesia in 47% vs 46%, p=0.93). On multivariate analysis, the presence of an identifiable stressor was an independent predictor of AVB recovery (HR 8.27; 95% CI 1.07 to 63.73, p=0.04). CONCLUSION: In patients with TCM and high-grade AVB, the absence of a clear stressor highlights the possibility of baseline conduction disorder, with a higher risk of persistent AVB. Earlier LVEF recovery and younger age may help to predict AVB recovery and guide patient selection for PPM implantation. PROSPERO REGISTRATION NUMBER: CRD420251173831.

References

1. 1.Hussein, H., Derias, P., Kassem, H., Ali, W., Tran, P., & Kuehl, M. (2026). Predictors of high-grade atrioventricular block recovery in Takotsubo cardiomyopathy: a systematic review of case reports. Open Heart, 13(1), e004035. https://doi.org/10.1136/openhrt-2026-004035