Decreasing myocardial edema correlates with functional recovery in Takotsubo syndrome

Thursday, February 5, 2026

3:52 PM - 3:59 PM

Location: Galapagos / Aruba / Ilhabela (2nd Lower Level)

Presenting Author(s)

RS

Rebecka Steffen Johansson, MD

MD, PhD student
Karolinska Institutet
Stockholm, Stockholms Lan, Sweden

Primary Author(s)

RS

Rebecka Steffen Johansson, MD

MD, PhD student
Karolinska Institutet
Stockholm, Stockholms Lan, Sweden

Co-Author(s)

CE

Christina Ekenbäck, MD

Karolinska Institutet Danderyds Sjukhus, Sweden
EB

Elin B. Brolin, MD, PhD

Karolinska Institutet, Sweden
JJ

Jens Jensen, MD, PhD

MD, Associate Professor
Karolinska Institute, Sweden
MS

Martin G. Sundqvist, MD, PhD

MD, PhD
Karolinska Institute, Sweden
SY

Shams Y-Hassan, MD

MD
Karolinska Institute, Sweden
LH

Loghman Henareh, MD, PhD

MD, Associate Professor
Karolinska Institute, Sweden
KC

Kenneth Caidahl, MD, PhD

Professor
Karolinska Institutet
Stockholm, Stockholms Lan, Sweden
JS

Jonas Spaak, MD, PhD

MD, Professor
Karolinska Institutet
Stockholm, Stockholms Lan, Sweden
AS

Andreas Sigfridsson, PhD

Associate Professor
Karolinska Institute, Sweden
PK

Peter Kellman, PhD

Dr.
National Institutes of Health, Maryland, United States
Martin Ugander, MD, PhD

Professor of Cardiac Imaging
Kolling Institute, Royal North Shore Hospital and University of Sydney/ Karolinska University Hospital and Karolinska Institutet
Sydney, New South Wales, Australia
PT

Per Tornvall, MD, PhD

Karolinska Institute, Stockholms Lan, Sweden
PS

Peder Sörensson, MD, PhD

Associate professor
Karolinska Institute, Stockholms Lan, Sweden
Jannike Nickander, MD, PhD

MD, PhD
Karolinska Institutet
Stockholm, Stockholms Lan, Sweden

Background: Takotsubo syndrome (TTS) mimics myocardial infarction, presenting with acute chest pain, electrocardiographic abnormalities and elevated cardiac biomarkers, but routine coronary angiography (CAG) typically reveals unobstructed coronary arteries and left ventricular (LV) ballooning. Cardiovascular magnetic resonance imaging (CMR) shows myocardial edema at presentation, but the relationship between the resolution of myocardial edema and recovery of LV function remains unclear. Therefore, the aim of this study was to examine the relationship of native T1 compared to extracellular volume (ECV) with functional recovery at 6-months follow-up.

Methods: A total of 42 patients with TTS, aged 60 [55-66] years, 39 (93%) female, from the SMINC-2 study (1) underwent CMR exams on 1.5T scanners (MAGNETOM Aera/Sola, Siemens Healthineers, Forchheim, Germany) at hospitalization (baseline) and 6 months follow-up. LV edema and function were assessed using global and regional native T1 and ECV (using a research sequence (2)), longitudinal and circumferential strain (LS, CS), LV mass and volumes. Initial CAG and left ventriculography, cardiac biomarkers and cardiac risk factors were recorded. Data between presentation and follow-up were compared with the paired t-test or Wilcoxon signed rank test. Correlations between change in native T1 or ECV and CS and LS were explored using Spearman’s rank correlation coefficient (r_s).

Results: Admission CAG was normal in all but 5 patients (12%), which had minimal atherosclerosis. Left ventriculogram was performed in 36 (86%) patients of which 28 (78%) had TTS ballooning. Initial cardiac biomarkers, TTS pattern on baseline CMR and cardiac risk factors are presented in Table 1. Global native T1 and ECV were elevated at baseline and normalized to follow-up (native T1 1102 [1072-1142] vs 1015 [995-1040] ms, ECV 31 [30-34] vs 28 [26-30] %, both p< 0.001). LV ejection fraction (55 [51-58] vs 59 [55-63] %, p</em>< 0.001), global LS and CS (GLS -16 [-17-(-13)] vs -20 [-20-(-18)] %, GCS -14 [-17-(-11)] vs -20 [-22-(-18)] %, both p< 0.001) improved to follow-up. Native T1, ECV, LS and CS were progressively worse from base to apex at presentation, all improved to follow-up. There were moderate correlations between global native T1 and GLS (r_s=0.39, p=0.01) as well as GCS (r_s=0.47, p=0.002), basal native T1 and LS (r_s=0.48, p=0.001), midventricular native T1 and CS (r_s=0.65, p< 0.001), apical native T1 and LS as well as CS (r_s=0.41, p=0.007, and r_s=0.36, p</em>=0.02), Figure 1. There were no correlations between global, basal, midventricular or apical ECV and CS or LS (p>0.05 for all), Figure 2.

Conclusion: Patients with TTS exhibit global and regional LV myocardial edema and dysfunction at baseline, with overall improvements at 6-months follow-up. There is a correlation between the resolution of myocardial edema and improvement in LV function, primarily as detected by native T1, warranting further studies into the relationship between intra- and extracellular edema in TTS.

Table 1. Clinical characteristics and CMR findings
Clinical characteristics
Index (n=42)
Follow-up (n=42)
Change, p</em>
Age (years)
60 [55-66]
61 [55-66]
< 0.001
Height (cm)
167 [162-172]
167 [161-171]
0.38
Weight (kg)
70 [62-80]
70 [61-80]
0.65
BSA (m²)
1.8 [1.7-1.9]
1.8 [1.7-1.9]
0.81
Initial Troponin T (ng/L)
55 [36-126]

Maximal Troponin T (ng/L)
254 [115-438]

NT-proBNP (ng/L)
795 [437-1670]

Hypertension
9 (21%)

Hyperlipidemia
6 (14%)

Diabetes mellitus
3 (7%)

Smoking currently
8 (19%)

Smoking previously
14 (33%)

TTS ballooning pattern on initial CMR
Midventricular
32 (76%)

Mid-lateral
2 (5%)

Midventricular and apical
1 (2%)

Apical
7 (17%)

CMR findings
LVEDV (ml)
146 [131-155]
139 [126-156]
Δ -5%, p=0.80
LVEDVi (ml/m²)
81 [73-88]
81 [73-86]
Δ 0%, p=0.70
LVESV (ml)
65 [50-73]
59 [51-67]
Δ -9%, p=0.008
LVESVi (ml/m²)
35 [32-42]
33 [28-38]
Δ -6%, p=0.005
LVSV (ml)
79 [68-87]
81 [75-94]
Δ 3%, p=0.002†
LVSVi (ml/m²)
44 [40-49]
47 [43-52]
Δ 7%, p=0.002†
LVEF (%)
55 [51-58]
59 [55-63]
Δ 7%, p< 0.001
LVM (g)
112 [103-133]
110 [101-121]
Δ -2%, p=0.22
LVMi (g/m²)
64 [58-71]
63 [57-67]
Δ -2%, p=0.18
Native T1 (ms)
1102 [1072-1142]
1015 [995-1040]
Δ -8%, p< 0.001†
ECV (%)
31 [30-34]
28 [26-30]
Δ -10%, p< 0.001
GLS (%)
-16 [-17-(-13)]
-20 [-20-(-18)]
Δ 25%, p< 0.001
GCS (%)
-14 [-17-(-11)]
-20 [-22-(-18)]
Δ 43%, p< 0.001
Data presented as median [interquartile range] or n (%), change denoted Δ represents median percent change, p-values denotes the Wilcoxon signed-rank test and p-values marked with † denotes the paired t-test. Abbreviations: CMR = cardiovascular magnetic resonance imaging; BSA = body surface area; LVEDV = left ventricular end diastolic volume; LVESV = left ventricular end systolic volume; LVSV = left ventricular stroke volume; LVEF = ejection fraction, LVM = left ventricular mass, ECV = extracellular volume; GLS = global longitudinal strain; GCS = global circumferential strain; NT-proBNP = N-terminal pro–B-type natriuretic peptide; i signifies indexed to BSA.

Figure 1. Scatterplots of native T1 vs LS and CS. The scatterplots show change of global, basal, midventricular, and apical native T1 vs LS and CS, with Spearman’s rank correlation coefficient rs and p-values. Abbreviations: LS = longitudinal strain; CS = circumferential strain.
Figure 2. Scatterplots of ECV vs LS and CS. The scatterplots show change of global, basal, midventricular, and apical ECV vs LS and CS, with Spearman’s rank correlation coefficient rs and p-values. Abbreviations: ECV = extracellular volume; LS = longitudinal strain; CS = circumferential strain.