Response to: Correspondence on ‘Beta-blockers are associated with better long-term survival in patients with Takotsubo syndrome’ by John E Madias

To the Editor I enjoyed reading the article by Silverio et al, pertaining to the longterm (median followup of 24.0 months) effects of β-blocker therapy in patients with takotsubo syndrome (TTS). The authors employed a consecutive patient database of 825, studied over a 12year period, mostly female in their early 60s to late 70s from the Takotsubo Italian Network (TIN) registry, about 60% of whom were discharged on β-blockers, while the balance of patients did not receive such therapy, focusing on allcause mortality, TTS recurrence, and cardiac and noncardiac mortality as outcomes. While β-blockers did not influence TTS recurrence or cardiac mortality, they led to a reduction of allcause mortality, particularly for patients with hypertension and those who developed cardiogenic shock during the acute phase of TTS. The results reinforce the current belief that β-blockers do not have a specific effect in patients who have suffered TTS, in terms of prevention of its recurrence; also, it is not surprising that there was a beneficial effect of β-blockers in patients with hypertension and cardiogenic shock, considering the established indications for β-blocker therapy for patients with history of hypertension, coronary artery disease and heart failure. Considering the interest among Italian and other investigators on the effect of ACE inhibitors/ angiotensin receptor blockers, alone or in combination with β-blockers, on mortality and the recurrence of TTS, I would like to ask the authors if they have any information on the above for the patients in the TIN registry, and whether they recommend the use of ACE inhibitors/angiotensin receptor blockers, with or without β-blockers, for patients discharged after an index admission with TTS, as done by others. Also, since the TIN registry constitutes a multicentre (16 Italian hospitals) study of consecutive patients with TTS prospectively collected, fairly representative of the Italian population, it would be of interest to compare the observed prevalence of diabetes mellitus (DM) (11.9%) noted in the TIN registry with the prevalence of DM in the general Italian population, particularly in women in their early 60s to late 70s, considering previous work showing a low prevalence of DM in patients with TTS.