Recovery beyond ejection fraction after takotsubo syndrome: a multidimensional framework for risk-enriched follow-up

Takotsubo syndrome (TTS) is defined by transient regional ventricular dysfunction, and normalization of left ventricular ejection fraction (LVEF) remains the conventional marker of recovery. This endpoint is clinically useful but does not capture the tempo or full clinical breadth of convalescence. Registry and multimodality studies indicate that ventricular recovery may be delayed or asynchronous; some survivors report persistent symptoms or functional limitation, whereas others have subclinical abnormalities in myocardial deformation, tissue characteristics, energetics, microvascular function, or inflammation. The clinical meaning and causal attribution of many subclinical findings remain uncertain. This State-of-the-Art Review examines how LVEF became the default recovery endpoint and synthesizes evidence across mechanical, clinical/functional, and biological/subclinical domains. We propose a staged framework in which recovery trajectory, persistent symptoms, and severe cardiovascular complications identify unresolved cardiovascular recovery concerns, whereas malignancy, neurological disease, physical triggers, and major systemic comorbidity primarily indicate competing risk and a need for coordinated care. Strain imaging, cardiovascular magnetic resonance, cardiopulmonary exercise testing, and structured patient-reported outcomes should be selected only when they address a defined clinical question. Management remains indication-driven, with complication surveillance and targeted rehabilitation or psychological care when limitations persist. The framework organizes clinical reasoning and trial design but is not a validated risk score or management algorithm. Prospective studies should define temporal recovery stages, establish a pragmatic core recovery set, and test whether adjunctive assessments or recovery-directed interventions improve clinically meaningful outcomes.