The Stressed Heart: A Case Report of Takotsubo Cardiomyopathy in a Patient With Known Coronary Artery Disease.

Takotsubo cardiomyopathy and acute coronary syndrome are often clinically indistinguishable, making their differentiation challenging for physicians. We present a case of a 65-year-old female who presented with acute chest pain, shortness of breath, and a recent psychosocial stressor. This is a unique case in which our patient, with known history of coronary artery disease and recent percutaneous intervention, favored a misleading initial diagnosis of non-ST elevation myocardial infarction.

Takotsubo Cardiomyopathy and COVID-19: A Case Report and Literature Review.

Bckground: Takotsubo cardiomyopathy is characterized by transient regional ventricular abnormalities in the absence of coronary artery disease and is reported as a complication of COVID-19. Case Representation: It can have a diverse clinical presentation, occasionally resembling an acute coronary syndrome, and progress to acute heart failure and cardiogenic shock with an adverse effect on patients' prognosis. A high index of suspicion and a thorough diagnostic approach supported by ancillary studies like echocardiography and coronary angiography is key for an accurate diagnosis and correct medical treatment. Herein, we report a patient with severe COVID-19 who developed Takotsubo cardiomyopathy. Conclusion: We also present a detailed review of the available literature regarding the relationship between COVID-19 and Takotsubo cardiomyopathy.

Takotsubo Syndrome and Sudden Cardiac Death.

Takotsubo syndrome (TTS), triggered by intense emotional or physical stress, occurring most commonly in post-menopausal women, presents as an ST-elevation myocardial infarction (MI). Cardiovascular complications occur in almost half the patients with TTS, and the inpatient mortality is comparable to MI (4-5%) owing to cardiogenic shock, myocardial rupture, or life-threatening arrhythmias. Thus, its prognosis is not as benign as previously thought, as it may cause mechanical complications (cardiac rupture) and potentially lethal arrhythmias and sudden cardiac death (SCD). Similar to MI, some patients may perish before reaching the hospital due to out-of-hospital cardiac arrest; this may lead to underestimation of the actual SCD risk. Furthermore, after discharge, some patients may develop late SCD and/or TTS recurrence that may result in SCD. There are risk factors for SCD in TTS patients, such as severe/persistent QT-interval prolongation inciting torsade-de-pointes, other ECG abnormalities (diffuse giant negative T-waves, widened QRS-complex), bradyarrhythmias, comorbidities, concurrent obstructive coronary artery disease or vasospasm, male gender, older age, severe left ventricular dysfunction, and use of sympathomimetic drugs. All these issues are herein reviewed, case reports/series and data from large cohort studies and meta-analyses are analyzed, risk factors are tabulated, and proarrhythmic effects and management strategies are discussed and pictorially illustrated.

Impact of COVID-19 in patients hospitalized with stress cardiomyopathy: A nationwide analysis.

Stress cardiomyopathy was noted to occur at a higher incidence during coronavirus disease of 2019 (COVID-19) pandemic. This database analysis has been done to compare the in-hospital outcomes in patients with stress cardiomyopathy and concurrent COVID-19 infection with those without COVID-19 infection. The National Inpatient Sample database for the year 2020 was queried to identify all admissions diagnosed with stress cardiomyopathy. These patients were then stratified based on whether they had concomitant COVID-19 infection or not. A 1:1 propensity score matching was performed. Multivariate logistic regression analysis was done to identify predictors of mortality. We identified 41,290 hospitalizations for stress cardiomyopathy, including 1665 patients with concurrent diagnosis of COVID-19. The female preponderance was significantly lower in patients with stress cardiomyopathy and COVID-19. Patients with concomitant COVID-19 were more likely to be African American, diabetic and have chronic kidney disease. After propensity matching, the incidence of complications, including acute kidney injury (AKI), AKI requiring dialysis, coagulopathy, sepsis, cardiogenic shock, cases with prolonged intubation of >24 h, requirement of vasopressor and inpatient mortality, were noted to be significantly higher in patients with COVID-19. Concomitant COVID-19 infection was independently associated with worse outcomes and increased mortality in patients hospitalized with stress cardiomyopathy.

Takotsubo syndrome and COVID-19: A systematic review.

Background and Aims: Takotsubo syndrome (TTS), also known as stress cardiomyopathy, is characterized by acute and transient left ventricular dysfunction and has increased during the COVID-19 pandemic. Herein, we aim to review studies on TTS that were associated with COVID-19 infection, vaccine, and other COVID-19-related etiologies including psychosocial stressors. Methods: We systematically searched PubMed, EMBASE, and Scopus up to May 12, 2022. We included case reports, case series, and original articles that reported at least one TTS case associated with COVID-19, or TTS cases after receiving COVID-19 vaccines, or TTS cases secondary to psychological stress due to the COVID-19 pandemic. The quality assessment was conducted using the Joanna Briggs Institute checklist. Results: Sixty-seven articles including 102 cases were included. Hypertension was the most frequently accompanying comorbidity (N = 67 [65.6%]) and the mean left ventricular ejection fraction was 36.5%. Among COVID-19 patients, the in-hospital mortality rate was 33.3%. On the other hand, only one COVID-19-negative individual expired (2.3%). The most common presenting clinical symptom was dyspnea in 42 (73.6%) patients. the mean time interval from the first symptom to admission was 7.2 days. The most common chest imaging finding was ground-glass opacity which was reported in 14 (31.1%) participants. The most common abnormalities were T-wave inversion in 35 (43.2%) and ST-segment elevation in 30 (37%). Brain natriuretic peptide and troponin were elevated in 94.7% and 95.9% of participants, respectively. Conclusion: The TTS in patients with COVID-19 is almost rare, whereas it could lead to a great mortality and morbidity. An individual with COVID-19, especially an elderly woman, presented with dyspnea in addition to a rise in brain natriuretic peptide and troponin should be evaluated for TTS.

Apical Takotsubo Cardiomyopathy in a COVID-19 Patient Presenting with Stroke: A Case Report and Pathophysiologic Insights.

COVID-19 is a pandemic that started in Wuhan city, Hubei province in China in December 2019 and is associated with high morbidity and mortality. It is characterized by a heightened inflammatory and prothrombotic state that are known to cause various cardiovascular manifestations such as thromboembolism, acute coronary syndrome and stroke. We here present a 72-year-old woman with multiple cardiovascular risk factors and COVI 19 pneumonia who presented with acute ischemic stroke. She was also noted to have ST segment elevation myocardial infarction (STEMI) on the electrocardiogram however the imaging and clinical presentation was consistent with apical takotsubo cardiomyopathy. We here discuss the various pathophysiologic mechanisms by which COVID-19 can result in acute stroke. The patient likely developed takotsubo cardiomyopathy because of stroke and acute COVID-19 induced sympathetic stimulation and catecholamine surge. To the best of our knowledge this is the first case of apical variant of takotsubo cardiomyopathy in a COVID-19 report.

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.

Takotsubo Syndrome in the Emergency Room - Diagnostic Challenges and Suggested Algorithm

Takotsubo syndrome is an important condition to consider among patients with acute chest pain in the emergency room. It often mimics acute coronary syndrome since chest pain and ECG changes are key features in both conditions. The hallmark of takotsubo syndrome is transient left ventricular dysfunction (characterized by apical ballooning) followed by complete echocardiographic recovery in most cases. Although most patients exhibit a benign course, lethal complications may occur. The use of hand-held point-of-care focused cardiac ultrasound may be helpful for early identification of takotsubo syndrome and distinguishing it from acute coronary syndrome and other cardiovascular emergencies. Emergency room physicians should be familiar with typical and atypical presentations of takotsubo syndrome and its key electrocardiographic changes. The approach in the emergency room should be based on a combination the clinical presentation, ECG, and handheld echocardiography device findings, rather than a single electrocardiographic algorithm.

Simultaneous occurrence of a Takotsubo syndrome and paranoia delirium, related to Covid-19 pandemic: A case report.

Some psychosomatic diseases, like Tako-tsubo cardiomyopathy, may occur because of exposure to a stressful event like COVID-19. The simultaneous development of psychosis and Tako-tsubo cardiomyopathy suggests a field of vulnerability. Specific measures need to be taken to help vulnerable people to manage these stressful events.

Cardiotoxicity of Immune Checkpoint Inhibitors.

PURPOSE OF REVIEW: Immune checkpoint inhibitors (ICIs) have improved the survival of several cancers. However, they may cause a wide range of immune-related adverse events (irAEs). While most irAEs are manageable with temporary cessation of ICI and immunosuppression, cardiovascular toxicity can be associated with high rates of morbidity and mortality. As ICIs evolve to include high-risk patients with preexisting cardiovascular risk factors and disease, the risk and relevance of ICI-associated cardiotoxicity may be even higher. RECENT FINDINGS: Several cardiovascular toxicities such as myocarditis, stress cardiomyopathy, and pericardial disease have been reported in association with ICIs. Recent findings also suggest an increased risk of atherosclerosis with ICI use. ICI-associated myocarditis usually occurs early after initiation and can be fulminant. A high index of suspicion is required for timely diagnosis. Prompt treatment with high-dose corticosteroids is shown to improve outcomes. Although the overall incidence is rare, ICI cardiotoxicity, particularly myocarditis, is associated with significant morbidity and mortality, making it a major therapy-limiting adverse event. Early recognition and prompt treatment with the cessation of ICI therapy and initiation of high-dose corticosteroids are crucial to improve outcomes. Cardio-oncologists will need to play an important role not just in the management of acute cardiotoxicity but also to reduce the risk of long-term sequelae.

Myocarditis and Other Cardiovascular Complications of the mRNA-Based COVID-19 Vaccines.

Cardiovascular complications following the receipt of mRNA-based (Pfizer-BioNTech and Moderna) coronavirus disease 2019 (COVID-19) vaccines have not yet been described. In this case series, we describe two patients with clinically suspected myocarditis, one patient with stress cardiomyopathy, and two patients with pericarditis after receiving an mRNA-based COVID-19 vaccine. The two patients with clinically suspected myocarditis were otherwise healthy young men who presented with acute substernal chest pressure and/or dyspnea after receiving the second dose of the vaccine and were found to have diffuse ST elevations on electrocardiogram (ECG), elevated cardiac biomarkers and inflammatory markers, and mildly reduced left ventricular (LV) function on echocardiography. Both patients met the modified Lake Louise Criteria for acute myocarditis by cardiac magnetic resonance imaging. We subsequently discuss a case of a 60-year-old woman with known coronary artery disease (CAD) and previously normal LV function, who presented with new exertional symptoms, ECG changes, and apical akinesis following the second dose of the vaccine, and was diagnosed with a stress cardiomyopathy. Finally, we describe two patients with pericarditis who presented with chest pain, elevated inflammatory markers, and pericardial effusions after receiving the vaccine. Overall, this case series describes the first reported cases of myocarditis, stress cardiomyopathy, and pericarditis after receiving an mRNA-based COVID-19 vaccine.

Cardiac manifestation of corona virus disease 2019: a preliminary report.

BACKGROUND: Corona virus disease 2019 (COVID-19) is a multi-systemic illness that can present with cardiac complications. This report describes the preliminary findings of cardiac manifestations seen in patients managed in three centres in Lagos, Nigeria. METHODS: Ten patients, part of an ongoing study of patients admitted in three centres in Lagos, Nigeria, with COVID-19 diagnosed with reverse transcriptase polymerase chain reaction (RT-PCR) or serology were retrospectively studied for cardiac manifestations. RESULTS: The mean (SD) age was 52.5 ± 18.79 years (with a minimum of 17 years and maximum of 79 years). Six patients were female and four were male. Hypertension was seen in 70%, diabetes in 50% and obesity in 60% of patients. All had elevated inflammatory markers. Only four patients had bilateral pneumonia. The rest had only cardiac manifestations. Six patients presented with de novo heart failure and one had decompensated heart failure. A set of three patients had individually fulminant myocarditis, probable pulmonary embolism and stress cardiomyopathy, respectively. CONCLUSIONS: This study shows that co-morbidities are common in patients with COVID-19 and cardiac complications. The array of cardiac complications is large, with the commonest being heart failure.

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.

Clinical and Angiographic Features in Three COVID-19 Patients with Takotsubo Cardiomyopathy. Case Report.

While coronavirus disease 2019 (COVID-19), caused by severe acute respiratory coronavirus 2 (SARS-CoV-2), has often been perceived as a predominantly respiratory condition, it is characterized by complications in multiple organ systems. Especially the involvement of the cardiovascular system, along with the possibly severe pulmonary injury, is crucial for prognosis. We identified three COVID-19 patients with takotsubo (TT) cardiomyopathy at our infectious diseases treatment center and present their clinical, laboratory, echocardiographic, electrocardiographic, and angiographic features. All patients were female (median age, 67 years); disease severity regarding COVID-19 ranged from asymptomatic to ARDS (adult respiratory syndrome) necessitating mechanical ventilation for 22 days. Angiography revealed normal coronary arteries in patient 1, severe three-vessel coronary artery disease (CAD) in patient 2, and insignificant bystander CAD in patient 3. All patients showed classic apical hypokinesia with basal hyperkinesia. In patient 3, TT cardiomyopathy resulted in transient cardiogenic shock. Twenty-eight-day mortality was 0% in this case series. In conclusion, takotsubo cardiomyopathy may be yet another clinical entity associated with SARS-CoV-2 infection.

Takotsubo cardiomyopathy caused by emotional stressors in the coronavirus disease 2019 (COVID-19) pandemic era.

The COVID-19 pandemic has had far-reaching consequences beyond the disease itself, including economic, social, political, religious, and psychological implications. This novel coronavirus has been shown to have cardiovascular manifestations in the form of arrhythmias, conduction disturbances, myocarditis, stress cardiomyopathy, myocardial injury and myocardial ischemia or infarction from increased microvascular and/or macrovascular coagulopathy. However, in addition to these direct effects, we are now starting to recognize indirect cardiovascular effects of COVID-19 in the form of increased incidence of Takutsobo cardiomyopathy in patients without any evidence of coronavirus infection presumably due to the increased psychological stress of social isolation and societal turbulence. In this case series, we present two post-menopausal women, presenting with chest pain and acute coronary syndrome, who are finally diagnosed with stress cardiomyopathy, triggered by increased emotional stress-related to the pandemic. There is data from a retrospective cohort analysis showing a fourfold increase in the incidence of acute coronary syndrome resulting from stress cardiomyopathy during the pandemic period compared to similar times periods before the pandemic. Hence, health care providers need to be cognizant of the emotional ramifications of the ongoing pandemic in the form of increased risk of Takotsubo cardiomyopathy. Moreover, urgent measures need to be taken to help the at-risk population cope with the ongoing stressors to help decrease the incidence of this cardiomyopathy.

Fatal Takotsubo syndrome in critical COVID-19 related pneumonia.

COVID-19 can involve several organs and systems, often with indirect and poorly clarified mechanisms. Different presentations of myocardial injury have been reported, with variable degrees of severity, often impacting on the prognosis of COVID-19 patients. The pathogenic mechanisms underlying cardiac damage in SARS-CoV-2 infection are under active investigation. We report the clinical and autopsy findings of a fatal case of Takotsubo Syndrome occurring in an 83-year-old patient with COVID-19 pneumonia. The patient was admitted to Emergency Department with dyspnea, fever and diarrhea. A naso-pharyngeal swab test for SARS-CoV-2 was positive. In the following week his conditions worsened, requiring intubation and deep sedation. While in the ICU, the patient suddenly showed ST segment elevation. Left ventricular angiography showed decreased with hypercontractile ventricular bases and mid-apical ballooning, consistent with diagnosis of Takotsubo syndrome. Shortly after the patient was pulseless. After extensive resuscitation maneuvers, the patient was declared dead. Autopsy revealed a subepicardial hematoma, in absence of myocardial rupture. On histology, the myocardium showed diffuse edema, multiple foci of contraction band necrosis in both ventricles and occasional coagulative necrosis of single cardiac myocytes. Abundant macrophages CD68+ were detected in the myocardial interstitium. The finding of diffuse contraction band necrosis supports the pathogenic role of increased catecholamine levels; the presence of a significant interstitial inflammatory infiltrate, made up by macrophages, remains of uncertain significance.

Takotsubo cardiomyopathy in COVID-19: a case report. Haemodynamic and therapeutic considerations.

BACKGROUND: Cardiovascular complications are increasingly recognized during the current coronavirus disease 2019 (COVID-19) pandemic. Myocardial injury is most commonly described and its underlying mechanism is believed to be multifactorial. Next to Type 2 ischaemia, COVID-19 may lead to (peri)myocarditis or Takotsubo (or stress) cardiomyopathy. CASE SUMMARY: A 72-year-old woman was admitted to the intensive care unit for mechanical ventilation because of respiratory insufficiency secondary to COVID-19 viral pneumonia. Seven days after admission, she developed new negative T-waves and a prolonged QTc interval on electrocardiography (ECG). Troponin levels were mildly elevated. Echocardiography showed a poor left ventricular systolic function with apical ballooning consistent with the diagnosis Takotsubo cardiomyopathy. Seven days afterwards, the ECG and troponin levels normalized. Echocardiography showed improvement of left ventricular systolic function, however with persistent hypokinesia of the apical segments. Coronary artery disease was excluded using coronary computed tomography angiography. The patient was discharged home and follow-up echocardiography after 3 months showed normal contractility of the apical myocardial segments, with normalization of the left ventricular systolic function, as expected in Takotsubo cardiomyopathy. DISCUSSION: COVID-19 caregivers should be aware of Takotsubo cardiomyopathy as complication of COVID-19, since regular use of QT-prolonging drugs combined with prolongation of the QTc interval in Takotsubo cardiomyopathy may lead to life-threatening arrhythmias. Furthermore, Takotsubo cardiomyopathy may lead to acute heart failure and even cardiogenic shock. Frequent ECG monitoring of COVID-19 patients therefore is of paramount importance and timely echocardiography should be obtained when ECG abnormalities or haemodynamical problems occur.