Reference: JAMA Netw Open. 2020 Jul 1;3(7)
The sequelae of the COVID-19 pandemic will take decades to sort out, but cardiologists at the Cleveland Clinic have recently noticed a spike in Takotsubo Syndrome (TS, sometimes called “stress” or “broken heart cardiomyopathy”). Although COVID infection has been linked to myocarditis, these authors assessed people who presented during the pandemic with acute coronary syndrome but who did not have COVID. It has been established that psychological stress may lead to brain-body interactions that cause temporary malfunction of the left ventricular muscle and TS.
The authors of this study retrospectively reviewed 278 patients who had a heart catheterization for acute coronary syndrome (ACS) at two affiliated hospitals in March and April 2020, and found that 20 of these patients had TS. The researchers then looked at four other comparable two-month periods (March/April 2019, January/February 2020, etc.) between 2018-2020 at the same hospital and found 28 patients diagnosed with TS out of 1,656 catheterized for ACS. The two populations were similar but not identical at baseline. Both had an average age of 67; however, the COVID-19 era group had a higher rate of hypertension and lower rates of asthma or previously recognized coronary disease. All of the patients in the March/April 2020 group had negative COVID PCR testing and none had fever or cough. Antibody testing was not performed. In both groups with TS, the clinical findings and baseline characteristics were similar. The groups had similar troponin, proBNP levels, and ejection fractions as well as very low 30-day rehospitalization or mortality rates.
The big difference was the higher incidence rate of TS during the first two months of the US COVID-19 pandemic (7.8%) vs. pre-COVID times (1.7%) (rate ratio 4.58, 95% CI 4.11-5.11). Similar results were found for the four comparison subgroups. However, while there were only 258 patients catheterized for ACS during the two-month COVID-19 period, a mean of 414 patients/period (range 278-679) were catheterized during the 2-month comparison periods..
There were early case reports of TS in the pandemic but this is the first large study showing an association with TS in individuals not infected with COVID-19. As the authors note, the incidence discussed in this study is the incidence of TS in people who received catheterization for ACS. We might assume it represents an approximation of the incidence in the population at large since the diagnosis of TS depends on cardiac catheterization data and we assume the catchment area of the two hospitals in question didn’t significantly change over the five 2018-2020 time periods studied. What does the lower rate of presentation for ACS mean? There have been widespread reports of patients being reluctant to go to the hospital, even for chest pain, due to fears of contracting COVID-19. If fewer patients were getting catheterized, perhaps TS patients were over-represented among those being catheterized because TS symptoms are harder to ignore. This would explain the increased percentage of TS among those presenting for ACS, but would not cause an increase in the absolute rate. An increased rate of Takotsubo Syndrome appears to be one more example of collateral damage from the COVID-19 pandemic.
For more information, see the topic Takotsubo Syndrome in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Dan Randall, MD, Deputy Editor for Internal Medicine at DynaMed. Edited by Alan Ehrlich, MD, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School, and Katharine DeGeorge, MD, MS, Associate Professor of Family Medicine at the University of Virginia and Clinical Editor at DynaMed.