Stress Cardiomyopathy/Takotsubo Syndrome and COVID-19: An Important Link to Understand

Sir,

It is now well known that patients with COVID-19 infection along with comorbid noncommunicable diseases such as hypertension, malignancy, past history of coronary heart disease/cardiovascular diseases, diabetes mellitus, stroke, chronic obstructive pulmonary disease, and so on have poorer outcomes and increased mortality rates. ¹ COVID-19 has also been shown to have cardiovascular presentations in the form of myocarditis, acute coronary syndrome, arrythmias, heart failure, and cardiogenic shock. ² As the experience with COVID-19 has accumulated, another entity known as stress cardiomyopathy/takotsubo syndrome/broken heart syndrome has been reported. ³

Stress cardiomyopathy/takotsubo syndrome can be understood as a manifestation of acute stress, which has an acute presentation and reversible course. ⁴ In the context of the ongoing pandemic, psychosocial stress (lockdown, migrant crisis, economic downfall, unemployment, etc) or being found positive for COVID-19 is known to precipitate acute stress. Additionally, earlier data suggest an association of this type of cardiomyopathy with depression, illness in a close person or death of near ones, hospitalization, moving to another city, loss of job, bankruptcy, and so on. All these have been regarded as some of the common emotional triggers which have been linked with the development of stress cardiomyopathy in healthy individuals. ⁴ Clinically, this entity mimics other cardiac conditions and the patient mainly presents with chest pain and dyspnea and has a favorable outcome with immediate treatment. It is usually seen that patients present with cardiac issues with no remarkable past medical history. In the context of the ongoing pandemic, there is evidence to suggest increased prevalence/incidence of mental health problems (depression, anxiety, insomnia, self-harm attempts, etc), and these can be possible contributing factors for development of stress cardiomyopathy/takotsubo syndrome. Further, patients admitted in COVID wards/isolation centers and intensive care units go through a difficult stressful period with varying degrees of anxiety, stress, and depressive symptoms, ⁵ and hence are more vulnerable to develop stress cardiomyopathy.

In this regard, whenever a patient positive with COVID-19 infection presents with signs and symptoms suggestive of cardiomyopathy, with new electrocardiogram changes (ST-elevation and T-wave inversion), a small increase in the cardiac biomarkers such as cardiac troponin and brain natriuretic peptide and lack of evidence of blockage in the coronary arteries and presence of a ballooning of the left ventricle, a possibility of stress cardiomyopathy must be considered as a differential diagnosis. During the systolic phase, the ballooning of the heart looks like a takotsubo, which is the shape of the pot used by Japanese fishermen to trap octopuses. ⁴

In such a patient, detailed mental state examination needs to be conducted to understand stress, depression, and anxiety. Getting infected with nSARs-CoV-2 and subsequent hospitalization or isolation from family is a stressful life event which can be considered as a severe emotional trigger in the background of COVID-19 infection to predispose an individual to stress cardiomyopathy.

To conclude, while the mechanism of myocardial injury in patients with COVID-19 still remains to be unexplainable, a working hypothesis of stress-induced cardiomyopathy needs to be considered in new-onset cardiac issues in patients with COVID-19 infection, which can help prevent adverse outcomes with prompt management of both physical and mental health aspects. Mental health aspect needs to be among significant priorities in this regard to promote positive mental health.