Stress-Induced Cardiomyopathy—Considerations for Diagnosis and Management during the COVID-19 Pandemic

Abstract

The novel coronavirus disease 2019 (COVID-19) is associated with several cardiovascular manifestations including myocardial injury, myocarditis, arrhythmia, and pulmonary embolism. Rare cases of stress-induced cardiomyopathy, or takotsubo syndrome have also been reported during the acute infection, and secondary to stress following lockdown and self-isolation. Diagnosis in the setting of the acute infection is challenging since conventional imaging modalities such as transthoracic echocardiography and coronary angiography should be restricted to minimize physician-patient contact until the patients is tested negative for COVID-19. The use of point of care hand-held ultrasound is appropriate for this purpose. The overall course of the disease seems to be similar to takotsubo in the general population. Physicians should be familiar with the clinical presentation, possible complications, and management of takotsubo during COVID-19 outbreak. Here, we review the special considerations in the diagnosis and management of takotsubo syndrome during the current pandemic.

Early Postoperative Pulmonary Edema Attributable to Reverse Stress-Induced Cardiomyopathy in a Recently Infected COVID-19 Patient: A Case Report

“…Last, COVID-19 infection also activates the hypothalamic-pituitaryadrenal axis, inducing hypercortisolism and suppressing corticotropin release. Cortisol excess and adrenal deficiency have been reported in SICMP cases [8].…”

COVID-19 With Stress Cardiomyopathy Mortality and Outcomes Among Patients Hospitalized in the United States: A Propensity Matched Analysis Using the National Inpatient Sample Database

“…Treatment of underlying COVID-19 infection with novel therapeutics, most of which have become available after the interval of our dataset, have since shown benefit in reducing the severity of COVID-19 infection 32 ; it remains to be seen if antivirals such as remdesivir or glucocorticoids have any specific benefit for preventing or treating stress cardiomyopathy. Additionally, Stress cardiomyopathy has a 1% to 2% annual recurrence rate and it is controversial if beta-blockers, ACE inhibitors, or other interventions help reduce recurrence 7 , 33 . Further investigation is warranted to determine if long COVID plays a role in the incidence of recurrent takotsubo syndrome given a reported 57% of patients experience persistent cardiac symptoms at a median follow-up of 329 days (IQR 274–383 days) 34 .…”

“…We hypothesize that mRNA vaccinations against COVID-19 will be beneficial in reducing the overall incidence of stress cardiomyopathy among COVID-19 patients. Two theoretical vaccine-mediated mechanisms of stress cardiomyopathy reduction among COVID-19 patients include the overall prevention of severe COVID-19 infection and accompanying acute physiologic stress by modulating host immunity and secondly, reducing emotional and mental stress by providing a sense of protection 33 , 37 . Moreover, emergency use authorization for the Pfizer–BioNTech BNT162b2, COVID-19 mRNA vaccine was granted at the end of 2020 (December 11, 2020), and the next iteration of the NIS database in 2021 presents an opportunity to analyze the effect of the vaccine on stress cardiomyopathy incidence.…”

The Cardiovascular Manifestations of COVID-19

“… 55 Documented complications of stress-induced cardiomyopathy include LV dysfunction, cardiogenic shock, LV thrombus, dynamic LV outflow tract obstruction, QT prolongation, atrial and ventricular arrhythmias, pericardial effusions, and death. 56 …”