Prognostic value of cardiac magnetic resonance T2 mapping in patients with Takotsubo syndrome

Background: Myocardial edema is a hallmark of Takotsubo syndrome (TTS) (1). Cardiac magnetic resonance (CMR) tissue mapping enables the quantitative assessment of myocardial edema (2); however, its prognostic relevance in TTS remains uncertain. We evaluated the association between CMR-derived myocardial T1 and T2 and clinical outcomes in patients with TTS.

Methods: At a tertiary care center, we retrospectively identified consecutive patients with TTS from January 2020 to January 2025 who underwent CMR with tissue mapping at 1.5 T. Imaging data was re-analyzed for biventricular volumes and function, regional wall motion abnormalities, myocardial T1, T2, and extracellular volume fraction by an experienced reader blinded to outcomes. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), inclusive of all-cause death, heart failure hospitalization, recurrent TTS, stroke, or transient ischemic attack. Time-dependent receiver operating characteristic analysis identified the optimal T2 threshold, and prognostic associations were examined using multivariable Cox regression.

Results: After excluding patients with significant delays to CMR (N=22) and lack of analyzable tissue mapping (N=14), the study cohort comprised 113 patients, median age 68 years; 89% female. The median time from admission to CMR was 4 days (IQR 2–6). The median left ventricular ejection fraction, T1, and T2 values were 47 % (IQR 38–58), 1,101 ms (IQR 1,055–1,150), and 56 ms (IQR 53–60), respectively. During a median follow-up of 664 days (IQR 426–1,280), 17 patients (15.0%) experienced MACCE. A global T2 threshold ≥63 ms predicted 1-year MACCE, AUC 0.636; sensitivity 51%; specificity 90% (Figure 1), and T2 ≥63 ms was associated with higher event rates on Kaplan-Meier survival analysis (log-rank p=0.031). In multivariable analysis, global T2 was independently associated with MACCE (adjusted HR 1.075 per ms; 95% CI 1.007–1.148; p=0.030) (Figure 2).

Conclusion: CMR-derived T2 mapping provides independent prognostic information in patients with TTS, supporting its integration into routine CMR assessment to improve risk stratification.

Figure 1. Kaplan-Meier curve stratified by T2 value on CMR for predicting MACCE
Figure 2. Multivariable Cox models for predicting MACCE