Heart and Vessels

, Volume 32, Issue 10, pp 1271–1276 | Cite as

Seasonal variation in patient characteristics and in-hospital outcomes of Takotsubo syndrome: a nationwide retrospective cohort study in Japan

  • Toshiaki Isogai
  • Hiroki Matsui
  • Hiroyuki Tanaka
  • Kiyohide Fushimi
  • Hideo Yasunaga
Short Communication


Although there is reportedly seasonal variation in the occurrence of Takotsubo syndrome (TTS), it is unknown whether there is a relationship between season and patient characteristics, or whether season influences outcomes. Using the Diagnosis Procedure Combination database in Japan, we retrospectively identified 4306 patients (mean age 73.6 years) hospitalized with TTS between January 2011 and December 2013. We divided patients into four groups according to season of admission [n = 914, Spring (March–May); n = 1243, Summer (June–August); n = 1245, Autumn (September–November); n = 904, Winter (December–February)]. The outcomes were in-hospital mortality and cardiovascular complications. We compared patient backgrounds and outcomes across seasons and estimated the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for outcomes in logistic regression analyses adjusted for multiple propensity scores. Although there was no significant difference in age across seasons, the proportion of males differed significantly (from 18.5% in autumn to 23.9% in winter; p = 0.016). The incidence of psychiatric disease (from 4.9% in spring to 7.9% in summer; p = 0.025) and sepsis (from 0.8% in winter to 2.6% in summer; p = 0.019) also differed significantly with season. In-hospital mortality was not significantly influenced by season (p = 0.377): spring, 5.1%; summer, 6.0%; autumn, 4.6%; winter, 6.0%. However, in-hospital mortality ranged widely across months from 3.0% in September to 7.5% in April. The incidence of ventricular tachycardia/fibrillation was significantly different (p = 0.038): spring, 2.2% (reference); summer, 3.3% (aOR 1.46, 95% CI 0.84–2.51); autumn, 2.7% (aOR 1.27, 95% CI 0.72–2.22); winter, 4.4% (aOR 1.92, 95% CI 1.11–3.33). Although season did not appear to influence the in-hospital mortality of TTS, monthly variation may exist in the risk of death in patients with TTS. There were significant seasonal variations in the proportions of males, patients with psychiatric disease or sepsis, and the incidence of ventricular arrhythmias among patients with TTS.


Takotsubo syndrome Season Background Mortality Complication 


Compliance with ethical standards

Funding source

This study was supported by grants from the Ministry of Health, Labour and Welfare, Japan (Grant numbers: H29-Policy-Designated-009 and H27-Policy-Strategy-011); the Ministry of Education, Culture, Sports, Science and Technology, Japan (Grant number: 17H04141); and the Japan Agency for Medical Research and Development. The funders had no role in the execution of this study or interpretation of the results.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This study was approved by the Institutional Review Board at The University of Tokyo.

Informed consent

The need for informed consent for each patient was waived because all data were anonymized.


  1. 1.
    Akashi YJ, Nef HM, Lyon AR (2015) Epidemiology and pathophysiology of Takotsubo syndrome. Nat Rev Cardiol 12:387–397CrossRefPubMedGoogle Scholar
  2. 2.
    Lyon AR, Bossone E, Schneider B, Sechtem U, Citro R, Underwood SR, Sheppard MN, Figtree GA, Parodi G, Akashi YJ, Ruschitzka F, Filippatos G, Mebazaa A, Omerovic E (2016) Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 18:8–27CrossRefPubMedGoogle Scholar
  3. 3.
    Templin C, Ghadri JR, Diekmann J, Napp LC, Bataiosu DR, Jaguszewski M, Cammann VL, Sarcon A, Geyer V, Neumann CA, Seifert B, Hellermann J, Schwyzer M, Eisenhardt K, Jenewein J, Franke J, Katus HA, Burgdorf C, Schunkert H, Moeller C, Thiele H, Bauersachs J, Tschöpe C, Schultheiss HP, Laney CA, Rajan L, Michels G, Pfister R, Ukena C, Böhm M, Erbel R, Cuneo A, Kuck KH, Jacobshagen C, Hasenfuss G, Karakas M, Koenig W, Rottbauer W, Said SM, Braun-Dullaeus RC, Cuculi F, Banning A, Fischer TA, Vasankari T, Airaksinen KE, Fijalkowski M, Rynkiewicz A, Pawlak M, Opolski G, Dworakowski R, MacCarthy P, Kaiser C, Osswald S, Galiuto L, Crea F, Dichtl W, Franz WM, Empen K, Felix SB, Delmas C, Lairez O, Erne P, Bax JJ, Ford I, Ruschitzka F, Prasad A, Lüscher TF (2015) Clinical features and outcomes of Takotsubo (stress) cardiomyopathy. N Engl J Med 373:929–938CrossRefPubMedGoogle Scholar
  4. 4.
    Isogai T, Yasunaga H, Matsui H, Tanaka H, Ueda T, Horiguchi H, Fushimi K (2014) Out-of-hospital versus in-hospital Takotsubo cardiomyopathy: analysis of 3719 patients in the Diagnosis Procedure Combination database in Japan. Int J Cardiol 176:413–417CrossRefPubMedGoogle Scholar
  5. 5.
    Dias A, Franco E, Koshkelashvili N, Bhalla V, Pressman GS, Hebert K, Figueredo VM (2016) Antiplatelet therapy in Takotsubo cardiomyopathy: does it improve cardiovascular outcomes during index event? Heart Vessels 31:1285–1290CrossRefPubMedGoogle Scholar
  6. 6.
    Brinjikji W, El-Sayed AM, Salka S (2012) In-hospital mortality among patients with takotsubo cardiomyopathy: a study of the National Inpatient Sample 2008 to 2009. Am Heart J 164:215–221CrossRefPubMedGoogle Scholar
  7. 7.
    Boulay F, Berthier F, Sisteron O, Gendreike Y, Gibelin P (1999) Seasonal variation in chronic heart failure hospitalizations and mortality in France. Circulation 100:280–286CrossRefPubMedGoogle Scholar
  8. 8.
    Manfredini R, Gallerani M, Portaluppi F, Salmi R, Fersini C (1997) Chronobiological patterns of onset of acute cerebrovascular diseases. Thromb Res 88:451–463CrossRefPubMedGoogle Scholar
  9. 9.
    Mehta RH (2002) Chronobiological patterns of acute aortic dissection. Circulation 106:1110–1115CrossRefPubMedGoogle Scholar
  10. 10.
    Spencer FA, Goldberg RJ, Becker RC, Gore JM (1998) Seasonal distribution of acute myocardial infarction in the second National Registry of Myocardial Infarction. J Am Coll Cardiol 31:1226–1233CrossRefPubMedGoogle Scholar
  11. 11.
    Enquselassie F, Dobson AJ, Alexander HM, Steele PL (1993) Seasons, temperature and coronary disease. Int J Epidemiol 22:632–636CrossRefPubMedGoogle Scholar
  12. 12.
    Manfredini R, Citro R, Previtali M, Armentano C, Patella MM, Vriz O, Provenza G, Salmi R, Gallerani M, Astarita C, Gregorio G, Bossone E (2009) Summer preference in the occurrence of Takotsubo cardiomyopathy is independent of age. J Am Geriatr Soc 57:1509–1511CrossRefPubMedGoogle Scholar
  13. 13.
    Aryal MR, Pathak R, Karmacharya P, Donato AA (2014) Seasonal and regional variation in Takotsubo cardiomyopathy. Am J Cardiol 113:1592CrossRefPubMedGoogle Scholar
  14. 14.
    Isogai T, Matsui H, Tanaka H, Fushimi K, Yasunaga H (2016) Early β-blocker use and in-hospital mortality in patients with Takotsubo cardiomyopathy. Heart 102:1029–1035CrossRefPubMedGoogle Scholar
  15. 15.
    Isogai T, Matsui H, Tanaka H, Fushimi K, Yasunaga H (2017) In-hospital management and outcomes in patients with peripartum cardiomyopathy: a descriptive study using a national inpatient database in Japan. Heart Vessels. doi: 10.1007/s00380-017-0958-7 Google Scholar
  16. 16.
    Yamasaki F, Seo H, Furuno T, Hamashige N, Kawai K, Owaki T, Hujinaga H, KAMI Study Group. Kochi Acute Myocardial Infarction (2002) Effect of age on chronological variation of acute myocardial infarction onset: study in Japan. Clin Exp Hypertens 24:1–9CrossRefPubMedGoogle Scholar
  17. 17.
    Rumana N, Kita Y, Turin TC, Murakami Y, Sugihara H, Morita Y, Tomioka N, Okayama A, Nakamura Y, Ueshima H (2008) Seasonal pattern of incidence and case fatality of acute myocardial infarction in a Japanese population (from the Takashima AMI Registry, 1988 to 2003). Am J Cardiol 102:1307–1311CrossRefPubMedGoogle Scholar
  18. 18.
    Bangalore S, Pencina MJ, Kleiman NS, Cohen DJ (2013) Prognostic implications of procedural vs spontaneous myocardial infarction: results from the Evaluation of Drug Eluting Stents and Ischemic Events (EVENT) registry. Am Heart J 166:1027–1034CrossRefPubMedGoogle Scholar
  19. 19.
    Spreeuwenberg MD, Bartak A, Croon MA, Hagenaars JA, Busschbach JJ, Andrea H, Twisk J, Stijnen T (2010) The multiple propensity score as control for bias in the comparison of more than two treatment arms: an introduction from a case study in mental health. Med Care 48:166–174CrossRefPubMedGoogle Scholar
  20. 20.
    Murakami T, Yoshikawa T, Maekawa Y, Ueda T, Isogai T, Konishi Y, Sakata K, Nagao K, Yamamoto T, Takayama M, Network Scientific Committee CCU (2014) Characterization of predictors of in-hospital cardiac complications of Takotsubo cardiomyopathy: multi-center registry from Tokyo CCU Network. J Cardiol 63:269–273CrossRefPubMedGoogle Scholar
  21. 21.
    Lee SR, Lee SE, Rhee TM, Park JJ, Cho H, Lee HY, Choi DJ, Oh BH (2017) Discrimination of stress (Takotsubo) cardiomyopathy from acute coronary syndrome with clinical risk factors and coronary evaluation in real-world clinical practice. Int J Cardiol 235:154–161CrossRefPubMedGoogle Scholar
  22. 22.
    Summers MR, Lennon RJ, Prasad A (2010) Pre-morbid psychiatric and cardiovascular diseases in apical ballooning syndrome (tako-tsubo/stress-induced cardiomyopathy): potential pre-disposing factors? J Am Coll Cardiol 55:700–701CrossRefPubMedGoogle Scholar
  23. 23.
    Takei N, O’Callaghan E, Sham P, Glover G, Tamura A, Murray R (1992) Seasonality of admissions in the psychoses: effect of diagnosis, sex, and age at onset. Br J Psychiatry 161:506–511CrossRefPubMedGoogle Scholar
  24. 24.
    Danai PA, Sinha S, Moss M, Haber MJ, Martin GS (2007) Seasonal variation in the epidemiology of sepsis. Crit Care Med 35:410–415CrossRefPubMedGoogle Scholar
  25. 25.
    Muller D, Lampe F, Wegscheider K, Schultheiss HP, Behrens S (2003) Annual distribution of ventricular tachycardias and ventricular fibrillation. Am Heart J 146:1061–1065CrossRefPubMedGoogle Scholar
  26. 26.
    Anand K, Aryana A, Cloutier D, Hee T, Esterbrooks D, Mooss AN, Mohiuddin SM (2007) Circadian, daily, and seasonal distributions of ventricular tachyarrhythmias in patients with implantable cardioverter-defibrillators. Am J Cardiol 100:1134–1138CrossRefPubMedGoogle Scholar
  27. 27.
    Nishida J, Kouzu H, Hashimoto A, Fujito T, Kawamukai M, Mochizuki A, Muranaka A, Kokubu N, Shimoshige S, Yuda S, Hase M, Tsuchihashi K, Miura T (2015) “Ballooning” patterns in Takotsubo cardiomyopathy reflect different clinical backgrounds and outcomes: a BOREAS-TCM study. Heart Vessels 30:789–797CrossRefPubMedGoogle Scholar

Copyright information

© Springer Japan KK 2017

Authors and Affiliations

  1. 1.Department of Clinical Epidemiology and Health Economics, School of Public HealthThe University of TokyoTokyoJapan
  2. 2.Department of CardiologyTokyo Metropolitan Tama Medical CenterTokyoJapan
  3. 3.Department of Health Policy and Informatics, Graduate School of MedicineTokyo Medical and Dental UniversityTokyoJapan

Personalised recommendations