Takotsubo Cardiomyopathy as a Cardiovascular Manifestation of COVID-19: A Case Report and Literature Review.

Coronavirus disease 2019 (COVID-19) has a wide range of clinical manifestations, affecting multiple organ systems. Cardiovascular manifestations of COVID-19 that have been reported include arrhythmias, myocarditis, and an increased predisposition to acute myocardial infarction. Takotsubo cardiomyopathy (TCM), which is characterized by apical ballooning of the heart leading to acute left ventricular dysfunction, is scarcely seen in COVID-19 patients. We present a case of COVID-19-associated TCM in a 68-year-old man.  A 68-year-old man with no significant past medical history presented with sudden-onset midsternal pressure-like chest pain at rest, associated with diaphoresis and shortness of breath. This occurred ten days after diagnosis of COVID-19 with mild symptoms, with no other recent physical or emotional stressors. At presentation, he was afebrile (98.5 °F), hypertensive (177/108 mmHg), tachycardic (HR 118 bpm), and saturating 100% on room air. Labs were significant for leukocytosis with 15.1 × 103 WBCs/mcL, elevated creatinine (1.46 g/dL), brain natriuretic peptide (BNP) of 156, troponin of 4 ng/mL that peaked at 16.28 ng/mL. The rapid COVID-19 test was positive. EKG showed anterolateral ST elevation and QTc interval of 446 ms. Echo showed severe hypokinesis of mid and apical segments and severely decreased left ventricular ejection fraction (LVEF)of <30%. Emergent left heart catheterization showed 75% mid left anterior descending coronary artery (LAD) stenosis and moderate right coronary artery (RCA) disease, while the ventriculogram showed a left ventricular ejection fraction of 35% with anteroapical and inferoapical akinesia suggestive of Takotsubo cardiomyopathy. The patient was placed on aspirin, ticagrelor, and atorvastatin, carvedilol, and lisinopril. EKG the next day showed a prolonged QTc of 526 ms with T-wave inversion and no ST elevations. The patient had no findings consistent with myocarditis or pheochromocytoma. He was discharged two days later. Within the next few weeks, his symptoms improved, and a follow-up echo confirmed normalization of left ventricular function.  There has been an increased incidence of Takotsubo cardiomyopathy during the COVID-19 pandemic compared to the pre-pandemic period. There is only a slight female preponderance in COVID-19-induced TCM, possibly because males are predominantly affected by COVID-19. Our patient satisfied all four Mayo Clinic criteria required for the diagnosis of TCM. Pathophysiology of TCM in COVID-19 is linked with cytokine storm and consequent catecholamine surge. Most patients improve within succeeding weeks or months. Nonetheless, the case fatality rate is high 36.5%, which is significantly higher compared to TCM patients without COVID-19. COVID-19 has a multisystem involvement with various clinical presentations. New cardiomyopathy in COVID-19 patients should raise suspicion among clinicians regarding stress-induced cardiomyopathy.

Global reports of takotsubo (stress) cardiomyopathy following COVID-19 vaccination: A systematic review and meta-analysis.

Concerns have been raised recently about takotsubo cardiomyopathy (TCM) after receiving COVID-19 vaccines, particularly the messenger RNA (mRNA) vaccines. The goal of this study was to compile case reports to provide a comprehensive overview of takotsubo cardiomyopathy (TCM) associated with COVID-19 vaccines. A systematic literature search was conducted in PubMed, Scopus, Embase, Web of Science, and Google Scholar between 2020 and June 1, 2022. The study included individuals who developed cardiac takotsubo cardiomyopathy from receiving COVID-19 vaccinations. Ten studies, including 10 cases, participated in the current systematic review. The mean age was 61.8 years; 90 % were female, while 10 % were male. 80 % of the patients received the mRNA COVID-19 vaccine, while 20 % received other types. In addition, takotsubo cardiomyopathy (TCM) occurred in 50 % of patients receiving the first dose and another 40 % after the second dose of COVID-19 vaccines. Moreover, the mean number of days to the onset of symptoms was 2.62 days. All cases had an elevated troponin test and abnormal ECG findings. The left ventricular ejection fraction (LVEF) was lower than 50 % in 90 % of patients. In terms of the average length of hospital stay, 50 % stayed for 10.2 days, and all cases recovered from their symptoms. In conclusion, takotsubo (stress) cardiomyopathy (TCM) complications associated with COVID-19 vaccination are rare but can be life-threatening. Chest pain should be considered an alarming symptom, especially in those who have received the first and second doses of the COVID-19 vaccine.

Long COVID Syndrome and Takotsubo Cardiomyopathy: An Unwelcome Combination.

Since the report of the first case from China in late 2019, the coronavirus disease (COVID-19) has spread very rapidly through the countries and regions leaving a trail of devastation in its path, everywhere. Although COVID-19 is primarily a respiratory illness mainly affecting the lungs; involvement of other organs including the cardiovascular system has been widely recognized. Whilst COVID-19 is an acute illness for a majority of cases; some of the debilitating virus-related symptoms can last for weeks and months, and are collectively termed as long COVID syndrome. Several published reports have described an association between acute COVID-19 illness and cardiac complications such as myocarditis and Takotsubo cardiomyopathy. However, little is known about any link between long COVID syndrome and the cardiac disease. We describe the case of a middle-aged woman with long COVID syndrome who presented with central chest pain and breathlessness. Her initial investigations showed an elevated cardiac troponin I and ischemic changes on 12 lead ECG. She was initially treated for non-ST elevation myocardial infarction. A subsequent coronary angiogram showed unobstructed coronary vessels and left ventricle (LV) gram demonstrated apical LV ballooning. She was managed conservatively and was discharged home following her clinical improvement. This case highlights the importance of holistic assessment of patients presenting with chest pain with the background of long COVID syndrome. It also outlines an emergent need to better understand pathophysiological mechanisms that underpin the development of cardiac complications in those with COVID-19 and long COVID syndrome.

Takotsubo Syndrome a Rare Entity in COVID-19: a Systemic Review-Focus on Biomarkers, Imaging, Treatment, and Outcome.

Takotsubo syndrome(TTS) is attributed to catecholamine surge, which is also observed in COVID-19 disease due to the cytokine storm. We performed a systematic literature search using PubMed, Embase, and the Cochrane Central Register of Controlled Trials retrospectively to identify COVID-19-associated TTS case reports and evaluated patient-level demographics, laboratory markers clinical attributes, treatment given, and outcomes. There are 27 cases reported of TTS associated with COVID-19 infection of which 44.5% were male. Reported median age was 57 years (IQR: 39-65) and 62.95 years (IQR: 50.5-73.5) in case series and individual patients' cases in database, respectively. The time interval from the symptom onset to TTS diagnosis was median 6.5 days (IQR: 1.0-8.0) in case series and 6.7 days (IQR: 4-10) in individual patients' database. The median LVEF was 36% (IQR: 35-37) and 38.15%(IQR: 30-42.5%-[male: 40.33% (IQR: 33-44.2)] and female [37.15% (IQR: 30-40)] in case series and individual-patients' database, respectively. Troponin was elevated in all patients except one patient. 77.2% patients of TTS with COVID-19 had an elevated C-reactive protein and/or D-dimer. Twelve out of 22 (54.5%) patients developed cardiac complication such as cardiogenic-shock, atrial fibrillation, acute heart failure, supraventricular tachycardia, and biventricular heart failure. Nineteen out of 26 (73.07%) patients were discharged, and three were hospitalized due to acute respiratory distress syndrome and needed extracorporeal membrane oxygenation or ongoing maternal age. There were 4 (14.8%) mortality. There was no major gender difference observed in development of TTS in COVID-19 unlike COVID-19 per se. Older median age group for TTS in COVID-19 patients irrespective of cardiovascular comorbidities and gender probably reflects age as an independent risk factor. Patients who developed TTS had higher mortality rate especially if they developed cardiogenic shock.

Takotsubo Syndrome in Patients with COVID-19: a Systematic Review of Published Cases.

Takotsubo syndrome (TTS) is caused by catecholamine surge, which is also observed in COVID-19 disease due to the cytokine storm. We performed a systematic literature search using PubMed/Medline, SCOPUS, Web of Science, and Google Scholar databases to identify COVID-19-associated TTS case reports and evaluated patient-level demographics, clinical attributes, and outcomes. There are 12 cases reported of TTS associated with COVID-19 infection with mean age of 70.8 ± 15.2 years (range 43-87 years) with elderly (66.6% > 60 years) female (66.6%) majority. The time interval from the first symptom to TTS was 8.3 ± 3.6 days (range 3-14 days). Out of 12 cases, 7 reported apical ballooning, 4 reported basal segment hypo/akinesia, and 1 reported median TTS. Out of 12 cases, during hospitalization, data on left ventricular ejection fraction (LVEF) was reported in only 9 of the cases. The mean LVEF was 40.6 ± 9.9% (male, 46.7 ± 5.7%, and female, 37.7 ± 10.6%). Troponin was measured in all 12 cases and was elevated in 11 (91.6%) without stenosis on coronary angiography except one. Out of 11 cases, 6 developed cardiac complications with 1 case each of cardiac tamponade, heart failure, myocarditis, hypertensive crisis, and cardiogenic shock in 2. Five patients required intubation, 1 patient required continuous positive airway pressure, and 1 patient required venovenous extracorporeal membrane oxygenation. The outcome was reported in terms of recovery in 11 (91.6%) out of 12 cases, and a successful recovery was noted in 10 (90.9%) cases. COVID-19-related TTS has a higher prevalence in older women. Despite a lower prevalence of cardiac comorbidities in COVID-19 patients, direct myocardial injury, inflammation, and stress may contribute to TTS with a high complication rate.