COVID-19-associated stress cardiomyopathy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] José Eduardo Riceto Loyola Junior, M.D.[3]

Synonyms and Keywords: Takotsubo syndrome, TTS, Takotsubo cardiomyopathy, broken heart syndrome, Stress cardiomyopathy, left ventricular outflow obstruction ( LVOTO)

Overview

COVID-19-associated stress cardiomyopathy was first described by Elena Roca, an Italian physician, in April 2020. This disorder is the result of extreme sympathetic stimulation due to the abnormal release of catecholamines and cortisol leading to rapid, severe, reversible cardiac dysfunction, as well as, wall motion abnormality of the left ventricle subtending more than one coronary artery territory, without evidence of significant obstructive coronary artery disease. Few cases of stress cardiomyopathy reported in literature due to direct consequences of covid-19 on the myocardium. However, due to increased psychological, social, economical distress during covid-19 pandemic, the incidence of stress cardiomyopathy in non-covid-19 patients increased significantly compared with prepandemic periods. In general, stress cardiomyopathy may develope in the setting of emotional stress or secondary to infections such as covid-19. The latter may have worse prognosis in terms of mortality compared with emotional trigger.

Historical Perspective

Classification




Apical type Midventricular type Basal type Focal type
Common type (>80%), hypokinesia or dyskinesia of midventricular and apical parts of anterior, septal, inferior and lateral walls of left ventricle associated with hyperkinesia of basal segments Hypokinesia or dyskinesia of midventricular segments, like a cuff in most cases, with normokinesia or hyperkinesia of basal and apical segments Inverse takotsubo cardiomyopathy, wall motion abnormality is reciprocal to apical type, hypokinesia or dyskinesia of basal segments, normokinesia or hyperkinesia of midventricular, anterior, antroseptal, and antroapikal segments of left ventricle Focal hypkinesia or dyskinesia of any segments of the left ventricle , commonly antroseptal wall

Pathophysiology



 
 
 
 
 
 
 
 
 
 
 
 
 
Stress Induced Cardiomyopathy
 
 
 
 
 
 
 
 
 
 
 
Microvascular/Thrombotic Injury
 
 
 
 
 
 
 
 
Cytokine Storm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pre-existing cardiovascular Disease
 
 
 
 
 
Acute Myocardial Injury Characterized by Abnormal Troponin
 
 
 
 
 
Viral Myocarditis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypoxemia
 
 
 
 
 
 
 
 
Hypotension +/- Shock
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ventricular or atrial arrhythmias
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Causes

Common causes of stress cardiomyopathy include:

Differentiating COVID-19-associated stress cardiomyopathy from other Diseases

  • For further information about the differential diagnosis, click here.
  • To view the differential diagnosis of COVID-19, click here.
Differentiating diagnosis Takotsubo cardiomyopathy STEMI
Stressful trigger Prominent stressful event (79%) 8%
Elevated troponin on admission 91% 37%
LVEF<40% Higher incidence of decreased LVEF at presentation (80%) 31%
Symptoms Chest pain (73%) Higher rate of chest pain (100%)
Sex Female Male
Age Older age (66 years old) Mean age 60 years old
Risk factors Lower incidence of HLP, smoking, diabetes mellitus HLP, smoking, diabetes mellitus
Coronary angiography Lower incidence of stenosis> 50% (15%) Stenosis> 50% in 100%
In-hospital mortality 1.3% 3.6%

Epidemiology and Demographics

Age

Gender

Race

Risk Factors




Screening

Natural History, Complications, and Prognosis

Diagnosis


Diagnostic Study of Choice

History and Symptoms

Symptoms of stress cardiomyopathy can mimic acute coronary syndrome. The most common presenting symptoms are:[12][16][13][18][23][17]

Physical Examination

Organ System Findings Suggestive Of
General appearance Patient may be anxious, ill-appearing or diaphoretic
Vital signs Cardiogenic shock
Cardiac Murmurs, S3, gallop rhythm, Displaced point of maximal impulse (PMI) Heart failure
Respiratory Rales, crackles Pulmonary edema

Laboratory Findings

Electrocardiogram

The ECG findings are largely the same of the regular stress cardiomyopathy, and are often confused with those of an acute anterior wall myocardial infarction.[12][18] Findings on ECG include:[12][16][13][14][18][23][17]

X-ray

Takotsubo refers to a ceramic pot used to trap octopuses in the Japanese language. The typical chest x-ray findings in patients with stress cardiomyopathy include a takotsubo-shaped heart, in which there is apical ballooning and narrowing of the proximal portion near the great vessels.

Echocardiography or Ultrasound

The following echocardiographic findings may be seen in patients with stress cardiomyopathy:[16][13][14][17]

CT scan

A cardiac CT scan can also help differentiate between stress cardiomyopathy and acute MI. Regional abnormalities in the wall motion of the heart, along with absence of coronary atherosclerosis support the diagnosis of stress cardiomyopathy over an acute MI.[17]

Chest CT scan may also show findings associated with COVID-19 and they can include:

  • Unilateral or bilateral pneumonia[27][28][29]
  • Mottling and ground-glass opacity
  • Focal or multifocal opacities
  • Consolidation
  • Septal thickening
  • Subpleural and lower lobe involvement more likely

MRI

Other findings on CMR include:[17][20]

Other Imaging Findings

Positron Emission Tomography (PET) Scan

In patients with stress cardiomyopathy, a PET scan may be done. Areas of hypokinesia or dyskinesia have reduced glucose utilization compared to normal regions.[38]

Coronary Angiography

Other Diagnostic Studies

Cardiac Catheterization

When patients with stress cardiomyopathy undergo cardiac catheterization, the following findings are usually reported:[16][18][14]

Myocardial Biopsy

Treatment

Medical Therapy

Surgery

  • Surgical intervention is not recommended for the management of COVID-19-associated stress cardiomyopathy.

Primary Prevention

  • There are no established measures for the primary prevention of COVID-19-associated stress cardiomyopathy.
  • Preventive measures should be taken to avoid COVID-19 infection.

Secondary Prevention

References

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  3. Tan T, Khoo B, Mills EG, Phylactou M, Patel B, Eng PC, Thurston L, Muzi B, Meeran K, Prevost AT, Comninos AN, Abbara A, Dhillo WS (August 2020). "Association between high serum total cortisol concentrations and mortality from COVID-19". Lancet Diabetes Endocrinol. 8 (8): 659–660. doi:10.1016/S2213-8587(20)30216-3. PMC 7302794 Check |pmc= value (help). PMID 32563278 Check |pmid= value (help).
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