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      We thank Madias for his interest in our study
      • Pelliccia F.
      • Parodi G.
      • Greco C.
      • et al.
      Comorbidities frequency in Takotsubo syndrome: an international collaborative systematic review including 1109 patients.
      that was recently published in The American Journal Medicine and for giving us the opportunity to better address the diabetes mellitus prevalence in patients with Takotsubo syndrome. The COmorbidity freqUency iN Takotsubo Syndrome (COUNTS) study highlights that comorbidities are highly prevalent in patients with Takotsubo syndrome. In regard to cardiovascular risk factors (in particular, hypertension, hypercholesterolemia, and smoking), there is now a general consensus that the not negligible prevalence presented overall by patients with Takotsubo syndrome may account for potential premorbid endothelial dysfunction that may represent a predisposing factor for the syndrome.
      • Pelliccia F.
      • Greco C.
      • Vitale C.
      • Rosano G.
      • Gaudio C.
      • Kaski J.C.
      Takotsubo syndrome (stress cardiomyopathy): an intriguing clinical condition in search of its identity.
      Indeed, we should consider that the syndrome occurs most commonly in postmenopausal women,
      • Patel S.M.
      • Chokka R.G.
      • Prasad K.
      • Prasad A.
      Distinctive clinical characteristics according to age and gender in apical ballooning syndrome (takotsubo/stress cardiomyopathy): an analysis focusing on men and young women.
      and therefore a high prevalence of cardiovascular risk factors in patients with Takotsubo syndrome should be considered a common finding of the syndrome with relevant pathophysiologic consequences. Nevertheless, we agree that among risk factors, diabetes mellitus generally is observed less frequently in patients with Takotsubo syndrome compared with those with acute myocardial infarction, as previously described in studies directly comparing the 2 diseases.
      • Parodi G.
      • Del Pace S.
      • Carrabba N.
      • et al.
      Incidence, clinical findings, and outcome of women with left ventricular apical ballooning syndrome.
      • Madias J.E.
      Low prevalence of diabetes mellitus in patients with Takotsubo syndrome: a plausible ‘protective’ effect with pathophysiologic connotations.
      However, further studies are needed to elucidate whether this phenomenon has any pathogenetic significance.

      References

        • Pelliccia F.
        • Parodi G.
        • Greco C.
        • et al.
        Comorbidities frequency in Takotsubo syndrome: an international collaborative systematic review including 1109 patients.
        Am J Med. 2015; 128: 654.e11-654.e19
        • Pelliccia F.
        • Greco C.
        • Vitale C.
        • Rosano G.
        • Gaudio C.
        • Kaski J.C.
        Takotsubo syndrome (stress cardiomyopathy): an intriguing clinical condition in search of its identity.
        Am J Med. 2014; 127: 699-704
        • Patel S.M.
        • Chokka R.G.
        • Prasad K.
        • Prasad A.
        Distinctive clinical characteristics according to age and gender in apical ballooning syndrome (takotsubo/stress cardiomyopathy): an analysis focusing on men and young women.
        J Card Fail. 2013; 19: 306-310
        • Parodi G.
        • Del Pace S.
        • Carrabba N.
        • et al.
        Incidence, clinical findings, and outcome of women with left ventricular apical ballooning syndrome.
        Am J Cardiol. 2007; 99: 182-185
        • Madias J.E.
        Low prevalence of diabetes mellitus in patients with Takotsubo syndrome: a plausible ‘protective’ effect with pathophysiologic connotations.
        Eur Heart J Acute Cardiovasc Care. February 11, 2015; ([Epub ahead of print])

      Linked Article

      • Prevalence of Comorbidities in Patients with Takotsubo Syndrome
        The American Journal of MedicineVol. 128Issue 8
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          The report by Pelliccia et al,1 published in June issue, in The American Journal of Medicine, about the prevalence of comorbidities in 1109 patients with Takotsubo syndrome, deriving from 19 studies via an international collaborative effort (COUNTS study), deserves careful reading by all clinicians and investigators working in the field. The authors refer to the clinical characteristics and comorbidities as “predisposing factors” for the emergence of Takotsubo syndrome, although these factors may not be related pathophysiologically to Takotsubo syndrome.
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