Heartbreak Could Occur from Stress of COVID-19

A recent increase in the number of patients presenting with stress cardiomyopathy (Takotsubo or broken heart syndrome) is associated with psychosocial stress from the coronavirus 2019 (COVID-19) pandemic, according to investigators who compared contemporaneous and prepandemic cardiac catheterization records.

Ankur Kalra, MD, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and colleagues conducted what they consider to be the first study to systematically investigate the association of the incidence of stress cardiomyopathy with the severe pressures people are experiencing in the COVID-19 pandemic.

"These cases were not because of direct viral infection; all patients were COVID negative," Kalra emphasized in comments with ContagionLive®.

"We postulated the uptick was due to the psychological, social and economic stress of the pandemic," she said.

Kalra and colleagues conducted a retrospective cohort study of patients presenting with acute coronary syndrome and undergoing coronary arteriography at 2 cardiac catheterization laboratories in the Cleveland Clinic health system in Northeastern Ohio during distinct time periods before and during the spread of COVID-19.

Records of 390, 309, 640, and 278 patients presenting in the pre-COVID-19 periods of March-April 2018, January-February 2019, March-April 2019 and January-February 2020 were compared to those of 258 patients presenting in March-April 2020 during the COVID-19 pandemic.

There were no significant differences between groups in median age, sex, or baseline characteristics, except for hypertension. Hypertension was the most frequent comorbidity in all groups, with the highest incidence in those in the COVID-19 period.

The stress cardiomyopathy diagnosis was made in accordance with the international Takotsubo syndrome criteria of 2014 (InterTAK diagnostic criteria). These include transient left ventricular dysfunction presenting as apical ballooning or midventricular, basal, or focal wall-motion anomalies. Although an emotional, physical, or combined trigger may precede the disease onset, it is not obligatory for the diagnosis. The investigators note, however, that the association between stress cardiomyopathy and increasing levels of stress and anxiety is well established.

The investigators found a significant increase in the incidence of stress cardiomyopathy during the COVID-19 period, with an incidence proportion of 7.8% compared to the 1.5-1.8% in the prepandemic timelines. The rate ratio comparing the COVID-19 pandemic period to the combined prepandemic period was 4.58 (95% CI 3.11-5.11; p,0.001).

In addition, Kalra and colleagues found that the patients presenting with stress cardiomyopathy during the COVID-19 pandemic had a longer median hospital length of stay compared with those hospitalized in the prepandemic period, with median 8 (6-9) days compared to median of 4 to 5 days in the prepandemic periods. There was no statistical difference between groups in rates of mortality, or in 30-day rehospitalization.

Investigators acknowledge that findings from the study sites that might not be applicable to other states or countries. In addition, they do not rule out the possibility of a pathogenic mechanism associated with COVID-19 causing Takotsubo syndrome-like cardiomyopathy. The absence of the infection in this cohort, however, supports their conclusion that the psychosocial stresses accompanying the pandemic are likely factors for the increase in cases of stress cardiomyopathy.

With this strong association, Kalra recommends that preventative measures should be taken during this pandemic, and for other times of personal stress. "Its important to focus on self care (in) body (with) daily exercise; mind (with) daily meditation; and spirit (with) daily prayer," she urged.