CMR findings across disease phases in Takotsubo syndrome: insights from the multicenter EVOLUTION registry

Takotsubo syndrome (TS) is characterized by transient left ventricular dysfunction accompanied by dynamic changes in myocardial tissue; however, differences in cardiac magnetic resonance (CMR) findings across disease phases remain incompletely characterized, particularly in large multicenter cohorts. This retrospective analysis from the multicenter EVOLUTION registry included 439 consecutive patients with TS (400 females; mean age 70.01 ± 11.59 years), stratified according to the time from symptom onset to CMR into acute (1-72 hours), subacute (4-21 days), and late (≥22 days) acquisition groups. Among these, 146 (33%) were classified as acute, 266 (60%) as subacute, and 27 (6%) as late. Biventricular systolic function was higher in patients imaged at later time points (both p = 0.001). Myocardial edema and late gadolinium enhancement (LGE) were more prevalent and extensive in patients imaged earlier and less evident in those imaged later. In multivariable analysis, T2-mapping Z-score and LGE extent were independently associated with earlier timing of CMR. T2-mapping Z-score decreased by approximately 0.22 units per day, corresponding to an average relative decline of 3-4% per day. In conclusion, cross-sectional CMR assessment in TS demonstrates that patients imaged at later time points exhibit more preserved systolic function and lower prevalence of myocardial edema and LGE, supporting the dynamic and reversible nature of myocardial injury in this condition; however, longitudinal studies with serial imaging are needed to confirm these findings.