To the Editor

We have read the article by Silverio et al 1 regarding beta-blockers reducing all-cause mortality in patients with Takotsubo syndrome (TTS). The beneficial effect of beta-blockers particularly applies to TTS patients with hypertension or cardiogenic shock. While this exciting finding validates an important risk reduction strategy in TTS survivors at long-term follow-up, Silverio et al’s1 results also bring up a seemingly paradoxical therapeutic dilemma in TTS patients with cardiogenic shock.

Dynamic left ventricular outflow tract (LVOT) obstruction and worsening mitral regurgitation (MR) play important roles in TTS-associated cardiogenic shock.2 3 Preceding myocardial structural abnormalities (hypertensive heart disease and basal septal hypertrophy, …