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: José Eduardo Riceto Loyola Junior, M.D.[2]

Synonyms and Keywords:


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 causing epicardial coronary vasospasm. The incidence of COVID-19-associated stress cardiomyopathy is approximately 7.8% of all patients presenting acute coronary syndrome.

Historical Perspective



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


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.

Epidemiology and Demographics

Risk Factors


Natural History, Complications, and Prognosis

  • Provided that patients survive the initial insult without any complications, most patients recover and have a normalized cardiac function within a few weeks.[5][6][7]


  • Diagnostic findings are largely the same in comparison to stress cardiomyopathy, and these are listed below. There is however a need to show evidence of ongoing COVID-19 infection.

Diagnostic Study of Choice

History and Symptoms

Symptoms of stress cardiomyopathy can mimic acute coronary syndrome. The most common presenting symptoms are:[5][9][6][11][16][10]

When taking the history from a patient with suspected stress cardiomyopathy, it is important to ask about:[9][11]

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 PMI Heart failure
Respiratory Rales, crackles Pulmonary edema

Laboratory Findings


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.[5][11] Findings on ECG include:[5][9][6][7][11][16][10]


Takotsubo in Japanese language refer to a ceramic pot, which is used to trap octopus. 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:[9][6][7][10]

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.[10]

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

  • Unilateral or bilateral pneumonia[20][21][22]
  • Mottling and ground-glass opacity
  • Focal or multifocal opacities
  • Consolidation
  • Septal thickening
  • Subpleural and lower lobe involvement more likely


Other findings on CMR include:[10][13]

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.[31]

Coronary Angiography

Other Diagnostic Studies

Cardiac Catheterization

When patients with stress cardiomyopathy undergo cardiac catheterization, the following findings are usually reported:[9][11][7]

Myocardial Biopsy


Medical Therapy

Treatment of Complications

The following interventions are performed if their associated complications arise:[8][9][11]


  • 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 if a patient has acquired COVID-19 infection.
  • Preventive measures should be taken to avoid COVID-19 infection.

Secondary Prevention


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  2. Pasqualetto MC, Secco E, Nizzetto M, Scevola M, Altafini L, Cester A; et al. (2020). "Stress Cardiomyopathy in COVID-19 Disease". Eur J Case Rep Intern Med. 7 (6): 001718. doi:10.12890/2020_001718. PMC 7279910 Check |pmc= value (help). PMID 32523926 Check |pmid= value (help).
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