The Authors’ reply

We appreciate the interest of Dr Chang and Dr Liu in our study.1 Cardiogenic shock (CS) complicates the in-hospital course of patients with takotsubo syndrome (TTS) in 6%–20% of cases and is the main cause of in-hospital mortality.2

Treatment of CS in TTS is a clinical challenge and, due to the complexity of investigating this subject in dedicated randomised controlled trials, current evidence is limited to case reports or retrospective observational studies.

The use of catecholamines in TTS complicated by CS is still debated since the administration of exogenous catecholamines might re-exacerbate the acute phase and increase the risk of in-hospital adverse events. In this scenario, previous case series have suggested the use of the Ca2+ sensitiser levosimendan as a safe and feasible non-adrenergic alternative to common inotropic agents in TTS.3

Owing to the key role of catecholamine overstimulation in TTS pathophysiology, the use of beta-blockers has been proposed to mitigate the sympathetic drive and the effects of further catecholamine surges during the acute phase. In a monkey model of epinephrine-induced TTS, metoprolol improved left ventricular dysfunction, diminished the catecholamine-induced …