Pandemic Stressors Give Rise to 'Broken Heart' Syndrome

Stresses from the COVID-19 pandemic were linked to an uptick in stress cardiomyopathy, also known as Takotsubo syndrome, in people presenting with acute coronary syndrome (ACS), researchers reported.

A 7.8% incidence of stress cardiomyopathy was observed from March 1 to April 30 this year, a time during the COVID-19 period, whereas the incidence had been 1.5-1.8% for pre-pandemic cohorts. Thus, the risk was greater for the pandemic cohort than for historical periods combined (RR 4.58, 95% CI 4.11-5.11), according to Ankur Kalra, MD, of Cleveland Clinic, and colleagues.

"The association between stress cardiomyopathy and increasing levels of stress and anxiety has long been established. The psychological, social, and economic distress accompanying the pandemic, rather than direct viral involvement and sequelae of the infection, are more likely factors associated with the increase in stress cardiomyopathy cases," the investigators wrote in their study online in JAMA Network Open.

"This was further supported by negative COVID-19 testing results in all patients diagnosed with stress cardiomyopathy in the study group," the investigators continued.

Kalra's group conducted the retrospective cohort study using electronic medical record data from two hospitals in the Cleveland Clinic health system.

Patients with apparent ACS who underwent coronary arteriography during the COVID-19 pandemic (258 patients) were compared with historical controls from four distinct periods:

• March to April 2018 (390 patients)
• January to February 2019 (309 patients)
• March to April 2019 (679 patients)
• January to February 2020 (278 patients)

The median age of the patients in the cohort was 67, and roughly two-thirds were men. The distribution of age and sex was similar among groups.

Patients with stress cardiomyopathy during the pandemic had longer hospital stays compared with those hospitalized pre-pandemic (median 8 days vs 4-5 days for other periods, P=0.006). However, the COVID-19 period was not associated with either increased risk of mortality or 30-day rehospitalization.

The study's questionable generalizability to other populations and geographies was a major limitation, the researchers said, adding that sampling bias was also possible given that some ACS patients might have chosen not to go to the hospital during the pandemic.

Notably, all patients during the pandemic had negative polymerase chain reaction tests for COVID-19.

"There may still be an association of COVID-19 with Takotsubo-like cardiomyopathy," Kalra and co-authors wrote. "Few patients with Takotsubo syndrome with underlying COVID-19 have been reported in the literature. The mechanism behind this type of myocardial injury in patients with COVID-19 remains to be elucidated."

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