{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T09:00:24Z","timestamp":1790240424272,"version":"4.1.0"},"reference-count":58,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T00:00:00Z","timestamp":1790208000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Cardiovasc. Med."],"abstract":"<jats:p>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.<\/jats:p>","DOI":"10.3389\/fcvm.2026.1960498","type":"journal-article","created":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T08:09:15Z","timestamp":1790237355000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Recovery beyond ejection fraction after takotsubo syndrome: a multidimensional framework for risk-enriched follow-up"],"prefix":"10.3389","volume":"13","author":[{"given":"Shuxia","family":"Liang","sequence":"first","affiliation":[{"name":"Emergency Department, The Second Hospital of Hebei Medical University","place":["Shijiazhuang, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lu","family":"Xu","sequence":"additional","affiliation":[{"name":"Department of Cardiology, The Second Hospital of Hebei Medical University","place":["Shijiazhuang, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zheng","family":"Hu","sequence":"additional","affiliation":[{"name":"Department of Cardiology, The Second Hospital of Hebei Medical University","place":["Shijiazhuang, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,24]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"2032","DOI":"10.1093\/eurheartj\/ehy076","article-title":"International expert consensus document on Takotsubo syndrome (part I): clinical characteristics, diagnostic criteria, and pathophysiology","volume":"39","author":"Ghadri","year":"2018","journal-title":"Eur Heart J"},{"key":"B2","doi-asserted-by":"publisher","first-page":"929","DOI":"10.1056\/NEJMoa1406761","article-title":"Clinical features and outcomes of Takotsubo (stress) cardiomyopathy","volume":"373","author":"Templin","year":"2015","journal-title":"N Engl J Med"},{"key":"B3","doi-asserted-by":"publisher","first-page":"1178","DOI":"10.1016\/j.jacc.2024.05.076","article-title":"Temporal trends in Takotsubo syndrome: results from the international Takotsubo registry","volume":"84","author":"Schweiger","year":"2024","journal-title":"J Am Coll Cardiol"},{"key":"B4","doi-asserted-by":"publisher","first-page":"e017290","DOI":"10.1161\/JAHA.119.017290","article-title":"Short- and long-term clinical outcomes for patients with Takotsubo syndrome and patients with myocardial infarction: a report from the Swedish coronary angiography and angioplasty registry","volume":"10","author":"Redfors","year":"2021","journal-title":"J Am Heart Assoc"},{"key":"B5","doi-asserted-by":"publisher","first-page":"1163","DOI":"10.1016\/j.jacc.2024.05.075","article-title":"Recovery of left ventricular function and long-term outcomes in patients with Takotsubo syndrome","volume":"84","author":"Almendro-Delia","year":"2024","journal-title":"J Am Coll Cardiol"},{"key":"B6","doi-asserted-by":"publisher","first-page":"1039","DOI":"10.1161\/CIRCULATIONAHA.117.031841","article-title":"Persistent long-term structural, functional, and metabolic changes after stress-induced (Takotsubo) cardiomyopathy","volume":"137","author":"Scally","year":"2018","journal-title":"Circulation"},{"key":"B7","doi-asserted-by":"publisher","first-page":"1002","DOI":"10.1161\/CIRCULATIONAHA.121.055854","article-title":"Takotsubo syndrome: pathophysiology, emerging concepts, and clinical implications","volume":"145","author":"Singh","year":"2022","journal-title":"Circulation"},{"key":"B8","doi-asserted-by":"publisher","first-page":"902","DOI":"10.1016\/j.jacc.2020.10.060","article-title":"Pathophysiology of Takotsubo syndrome: jACC state-of-the-art review","volume":"77","author":"Lyon","year":"2021","journal-title":"J Am Coll Cardiol"},{"key":"B9","doi-asserted-by":"publisher","first-page":"239","DOI":"10.1038\/s41569-025-01211-5","article-title":"Takotsubo syndrome: pathophysiological insights and innovations in patient care","volume":"23","author":"Omerovic","year":"2026","journal-title":"Nat Rev Cardiol"},{"key":"B10","first-page":"203","article-title":"Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases","volume":"21","author":"Dote","year":"1991","journal-title":"J Cardiol"},{"key":"B11","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1016\/S0735-1097(01)01316-X","article-title":"Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. 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