EBM Focus: Collateral Damage of COVID-19 Pandemic Stress

Medical | Dan Randall, MD| October 01, 2020

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In this EBM Focus article, DynaMed editors examine a study finding a significant increase in Takotsubo syndrome (stress cardiomyopathy) during the COVID-19 pandemic.

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 (sometimes called “stress” or “broken heart” cardiomyopathy). Although COVID-19 has been linked to myocarditis, these authors assessed people who presented during the pandemic with acute coronary syndrome but who did not have COVID-19. It has been established that psychological stress may lead to brain-body interactions that cause temporary malfunction of the left ventricular muscle and Takotsubo syndrome.

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 Takotsubo syndrome. The researchers then looked at four other comparable two-month periods between 2018 and 2020 at the same hospital and found 28 patients diagnosed with Takotsubo syndrome out of 1,656 catheterized for ACS. Patients evaluated during the COVID-19 pandemic were similar but not identical at baseline to patients in the pre-COVID period. Both had an average age of 67, however, the COVID-19 era group had a higher rate of hypertension and lower rates of asthma and previously recognized coronary disease. All 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 Takotsubo syndrome, 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 Takotsubo syndrome during the first two months of the U.S. COVID-19 pandemic (7.8 percent) compared to the pre-COVID period (1.7 percent) (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 two month comparison periods.

There were early case reports of Takotsubo syndrome in the pandemic but this is the first large study showing an association with Takotsubo syndrome in individuals not infected with SARS-CoV-2. As the authors note, the incidence discussed in this study is the incidence of Takotsubo syndrome 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 Takotsubo syndrome 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 Takotsubo syndrome patients were over-represented among those being catheterized because Takotsubo syndrome symptoms are harder to ignore. This would explain the increased percentage of Takotsubo syndrome 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, log in to view the Takotsubo Syndrome topic in DynaMed.

EBM Focus articles provide concise summaries of clinical trials most likely to inform clinical practice curated by the DynaMed editorial team.

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Dan Randall, MD
Deputy Editor for Internal Medicine at DynaMed

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, Clinical Editor at DynaMed and Associate Professor of Family Medicine at the University of Virginia.

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