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Letter to the Editor / Rev Esp Cardiol.
2021;74(2):199–204 201
4. Isogai T, Matsui H, Tanaka H, Fushimi K, Yasunaga H. Early b-blocker use and in-
https://doi.org/10.1016/j.rec.2020.09.002
hospital mortality in patients with Takotsubo cardiomyopathy. Heart. 2016;102:
1029–1035. 1885-5857/
C 2020 Sociedad Española de Cardiologı́a. Published by Elsevier España, S.L.U. All
5. Kim H, Senecal C, Lewis B, et al. Natural history and predictors of mortality of
patients with Takotsubo syndrome. Int J Cardiol. 2018;267:22–27. rights reserved.
Neurohormonal treatment in tako-tsubo recommended treatment. The only treatment with evidence on
cardiomyopathy precipitated by COVID-19. Response survival in COVID-19 is corticosteroids3 (dexamethasone),
possibly due to its effect on the inflammatory cascade that
Tratamiento neurohormonal en miocardiopatıá de tako-tsubo occurs in this disease. Bearing in mind that the systemic
precipitada por COVID-19. Respuesta inflammatory status could contribute to the development of
tako-tsubo cardiomyopathy, treatment with dexamethasone
To the Editor, may affect its onset and outcome, although specific studies are
needed to assess this.
The neurohormonal treatment received by our patient com-
prised a beta-blocker, bisoprolol, and an angiotensin-converting
enzyme inhibitor (ACE-I), enalapril. At 3 months of follow-up, he Loreto Oyarzabal,a,* Joan Antoni Gómez-Hospital,a,b
had no further episodes of chest pain or signs of heart failure.
and Josep Comı́n-Coleta
As mentioned in the Letter, although treatment with beta-
blockers may slow the effect of catecholamine release thought to a
Servicio de Cardiologıá, Hospital Universitario de Bellvitge-IDIBELL,
be the pathophysiological mechanism behind tako-tsubo cardio- L’Hospitalet de Llobregat, Barcelona, Spain
myopathy, clinical benefits have not been demonstrated. However, b
Centro de Investigación Biomédica en Red de Enfermedades
treatment with ACE-I, which has shown improved survival in a Cardiovasculares (CIBERCV), Spain
registry, could contribute to ventricular remodeling.
In the case of coronavirus disease 2019 (COVID-19), * Corresponding author:
treatment with ACE-I has generated controversy. When the
E-mail address: [email protected] (L. Oyarzabal).
disease first emerged, animal studies1 demonstrated that
coronavirus uses angiotensin-converting enzyme 2 (ACE-2), Available online 8 November 2020
an aminopeptidase with abundant expression in the lungs and
heart, as a receptor for cell entry. Treatment with ACE-I increases REFERENCES
the expression of ACE-2, leading to the hypothesis that it may
affect susceptibility to the infection or its virulence. Later, a case- 1. Paul M, Poyan Mehr A, Kreutz R. Physiology of local renin-angiotensin systems.
control study2 with more than 6000 patients found no evidence Physiol Rev. 2006;86:747–803.
2. Mancia G, Rea F, Ludergnani M, Apolone G, Corrao G. Renin-angiotensin-aldosterone
of an association between these drugs and COVID-19; current
system blockers and the risk of COVID-19. N Engl J Med. 2020. http://dx.doi.org/
protocols therefore recommend continuing treatment with ACE- 10.1056/NEJMoa2006923.
I in patients with SARS-CoV-2 infection in the absence of other 3. The RECOVERY Collaborative Group. Dexamethasone in hospitalized patients with
contraindications. COVID-19 — preliminary report. N Engl J Med. 2020. https://doi.org/10.1056/
NEJMoa2021436.
As tako-tsubo cardiomyopathy is a rare complication of SARS-
CoV-2 infection, to date there are no specific studies on the
https://doi.org/10.1016/j.rec.2020.09.024
1885-5857/
SEE RELATED CONTENT: C 2020 Sociedad Española de Cardiologı́a. Published by Elsevier España, S.L.U. All
https://doi.org/10.1016/j.rec.2020.09.002 rights reserved.
Clinical management indicators for the cardiovascular (CU) (services, clinical management units, institutes, etc) to assess
area. A note for the debate their management results. The focus of the proposal and the
111 indicators it contains deserve joint reflection by those
Indicadores de gestión clı́nica en el área cardiovascular. responsible for CUs, which could be promoted by the Spanish
Un apunte para el debate Society of Cardiology (SEC). The following points are offered in
relation to this proposal:
To the Editor,
The editorial by González-Juanatey et al.1 is of great interest and ‘‘Measure outcomes. Add value’’. In line with Porter’s strategy of
stimulates the debate on the metrics to be used by cardiology units ‘‘adding value’’,2 the authors suggest that health outcome
indicators should be prioritized. Although this approach is
correct, only a third of the proposed indicators—many of which
overlap—are outcome indicators (mortality, readmissions, com-
SEE RELATED CONTENT:
https://doi.org/10.1016/j.rec.2020.05.043 plications). It is also difficult to understand the rationale
https://doi.org/10.1016/j.rec.2020.09.026 underlying some of the process or activity indicators (does

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