Can COVID-19 Promote Takotsubo Syndrome? Perhaps Not Directly

Megan Brooks

July 13, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

The incidence of stress cardiomyopathy, also known as Takotsubo syndrome, may have gone up during the COVID-19 crisis, compared with earlier times, in patients presenting with acute coronary syndromes (ACS), according to a new analysis.

None of the study's patients with stress cardiomyopathy, almost 8% of those presenting with ACS in March and April of this year, were positive for SARS-CoV-2, suggesting that the cardiomyopathy stemmed from pandemic-related stressors and apparently exonerating the virus as the culprit.

"The psychosocioeconomic stress of the pandemic has directly affected the incidence of stress cardiomyopathy, an objective measure of stress in people's lives," investigator Ankur Kalra, MD, Cleveland Clinic, told theheart.org | Medscape Cardiology. He is a coauthor on the analysis published July 9 in JAMA Network Open.

"It's a toll of worrying about a virus that there is no treatment for and its psychological duress. This invisible pathogen is now causing stress-induced weakening of the heart, mimicking a heart attack," offered Guy L. Mintz, MD, North Shore University Hospital, Manhasset, New York.

"Clinicians must be aware of this association and recognize it early in its clinical presentation. There is also a cardiac price to pay for social distancing, isolation, and economic distress," Mintz, not involved in the study, told theheart.org | Medscape Cardiology.

Kalra and his colleagues reviewed the incidence of stress cardiomyopathy in 258 patients presenting with apparent ACS at two affiliated northeast Ohio hospitals during 2 months of the COVID-19 pandemic. They compared them with 1656 such patients who presented in four preceding 2-month periods from 2018 to 2020. The two groups were predominantly male and similar in age.

Twenty of 258 patients (7.75%) in the COVID-19 period were diagnosed with stress cardiomyopathy by interTAK criteria, compared with five to 12 patients (1.5% to 1.8%) in the different prepandemic periods (rate ratio, 4.58; 95% CI, 4.11 - 5.11; P < .001).

Mortality and 30-day rehospitalization rates were similar for patients seen in the pandemic and prepandemic periods. But patients with stress cardiomyopathy during the pandemic had significantly longer median hospital stays (8 vs 4–5 days).

Those differences, plus the finding that COVID-19 test results were negative in all patients diagnosed with stress cardiomyopathy in the pandemic period, suggests that "the psychological, social, and economic distress accompanying the pandemic, rather than direct viral involvement and sequelae of the infection, are more likely factors associated with the increase in stress cardiomyopathy cases," the authors write.

Kalra said it's more important than ever to address self-care and do "inner work — take care of the body, mind, and spirit; train the body (exercise); master the mind (meditate); and enrich the spirit (pray)."

The current study is "an important reminder" that mechanisms for myocardial injury in COVID-19 are varied, and one must look at all potential causes of cardiac injury, said Matthew W. Martinez, MD, who codirects the Chanin T. Mast Center for Hypertrophic Cardiomyopathy, Morristown Medical Center, New Jersey.

Cardiac manifestations, including elevated troponin levels, are common in hospitalized COVID-19 patients and can be caused by stress cardiomyopathy or a variety of other cardiac disorders, Martinez told theheart.org | Medscape Cardiology.

"Once other causes, such as myocarditis and myocardial infarction, are eliminated, consider stress cardiomyopathy as an etiology. However, given we know that COVID-19 has a severe inflammatory component and higher risk of thrombosis and its downstream sequelae, this should remain a diagnosis of exclusion."

Treatment for stress cardiomyopathy consists of "supportive care and optimal medical management," Mintz said. "Mild cases may resolve with time — weeks to months. More severe cases are associated with heart failure and the need for mechanical support. In some patients, the syndrome is recurrent."

Kalra, Mintz, and Martinez declared no relevant conflicts of interest.

JAMA Netw Open. 2020;3:e2014780. Full text

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