Takotsubo cardiomyopathy – “Breaking hearts” linked to Covid

Priasha Dutta, Amity University Kolkata

Cardiovascular complications in patients with COVID-19 require attention. Patients having comorbidities like acute cardiac injury, arrhythmia hypertension, and coronary artery disease have been associated with increased mortality. The novel coronavirus, conversely, increases the risk of developing cardiovascular pathologies like cardiomyopathy, acute coronary syndrome, myocarditis, thromboembolism, and various arrhythmias. In several cases, the virus is also capable of causing myocardial infarction. Hydroxychloroquine and azithromycin are medications used to treat infected patients, which can lead to cardiac complications as well.

TAKOTSUBO SYNDROME:

Better known as the “broken-heart syndrome”, Takotsubo cardiomyopathy or Takotsubo syndrome (TTS) is a cardiovascular condition that occurs more commonly in menopausal females. It is defined by an acute dysfunction or weakening of the segmental left ventricle. TTS commonly occurs as a reaction to severe physical or emotional stress that would metaphorically cause a broken heart, and can further cause clinical problems. Thus, this condition is also referred to as “stress-induced cardiomyopathy”.

The associated stressors of Takotsubo cardiomyopathy are:

• A serious illness or medical procedure (e.g., cardiac stress test)
• Events like domestic violence, fierce argument, asthma attack, financial loss
• Receiving bad news of an unexpected loss, illness, injury, or an accident
• Intense fear, public speaking, a sudden surprise

Patients have similar symptoms as that of an acute coronary syndrome, for instance, shortness of breath and chest pain. Echocardiography readings give the same results for both Takotsubo cardiomyopathy and heart attack. However, if a coronary angiography shows the absence of blockages in the coronary arteries; it confirms that the heart is suffering TTS and not myocardial infarction.  Another specific abnormality is the ballooning of the lower part of the apex of the left ventricle. This is called “apical ballooning” and it is detected in ventriculography. During systole, the bulging ventricle looks similar to a “tako-tsubo”, a pot used by Japanese fishermen to trap octopuses, thus giving this condition its unique name.

Left ventricular dysfunction from Takotsubo cardiomyopathy usually resolves in weeks, with most patients fully recovering within 2 months. In severe cases, the patients may suffer a heart attack. Although there is no permanent treatment, Angiotensin-converting enzyme(ACE) inhibitors, beta-blockers, and diuretics are used as temporary solutions. Long-term solutions involve the use of beta-blockers as they lessen the impact of stress hormones. Patients can also go through psychotherapy to reduce emotional stress.

Takotsubo cardiomyopathy seems to be more prominent in the COVID-19 era, whether it’s due to cardiovascular complications caused directly or indirectly by the virus; or because the pandemic has taken a toll on the mental health of the masses. The impact of coronavirus on the cardiovascular system is important to understand and provide the best care for patients and to prevent hostile outcomes during this developing global crisis.

REASON BEHIND THE SUDDEN INCIDENCE OF “BROKEN HEARTS” DURING THE PANDEMIC:

During the early days of the pandemic, between 1.5% and 2% of the infected people were diagnosed with Takotsubo cardiomyopathy. On the other hand, around 10% of patients with acute coronary syndrome were diagnosed with stress-induced cardiomyopathy. Alongside this increase in TTS cases within the uninfected population, larger studies have implied there is a surge in TTS diagnoses within the infected ones. COVID-19 positive patients with echocardiography have determined potential cardiovascular implications of the virus.

Pathophysiological Connections Between Stress-Induced Cardiomyopathy and COVID-19:

Although the direct connections are not completely understood, three factors suggest the association of the virus and the syndrome: sympathetic nervous system surge, an overactive immune response from “cytokine storm” and developing microvascular dysfunction.

A “cytokine storm” is an increased release of pro-inflammatory cytokines and chemokines, such as tumor necrosis factor-α, interleukin-6, and interleukin-1β into the bloodstream. The release of these agents is triggered by the apoptosis of epithelial and endothelial cell and vascular leakage, which occur due to viral replication in the early phase. When the pro-inflammatory agents are released, cardiac function can be impacted, usually causing myocardial injury and then leading to Takotsubo cardiomyopathy. A COVID-positive patient was diagnosed with stress-induced cardiomyopathy after observing hemodynamic instability and ST-segment elevations on ECG readings. The diagnosis also showed nonobstructive coronary angiogram and “apical ballooning” on ventriculography. A hyperinflammatory state was seen, proving the possibility of the “cytokine storm”. The patient was subjected to suitable treatment and showed hemodynamic improvement. This suggests a potential relationship between the cytokine response and Takotsubo cardiomyopathy.

Hyperactivity of the sympathetic nervous system causes catecholamine-induced myocardial stunning, leading to the development of stress-induced cardiomyopathy. Microvascular dysfunction has also been associated with stress-induced cardiomyopathy. In COVID-19 patients, microvascular dysfunction can occur due to a systemic inflammatory response, or the formation of microthrombi during the condition of hypercoagulability. 

Psychosocial Effects of the Global Pandemic:

Fear, anger, anxiety, and grief are the major triggers of Takotsubo cardiomyopathy. During the pandemic, we have witnessed an increase in economic hardships and emotional distress because of ending relationships, deaths, and sudden disruption of social interaction. This is accompanied by deteriorated anxiety, depression, and panic levels in the masses during quarantine. The adverse effects on mental health may also occur due to inability to cope with the new way of life, fear of contracting the virus, anxiety for loved ones, etc. Such effects may be responsible for the sudden surge in stress-induced cardiomyopathy among the masses. An incidence of TTS has been seen before in groups for people who have witnessed or been impacted together in a major event such as a widespread violent act or a natural calamity like an earthquake.

Conclusion:

The association between stress-induced cardiomyopathy and COVID-19 is prevalent in the general population suffering from the adverse psychosocial effects of the pandemic; as well as in COVID-19 patients. By studying the physiological connections between the two conditions, optimal therapies can be formulated, such as immunosuppressive therapy for “cytokine storm” or anticoagulation for microvascular dysfunction. Since we have to live in the “new normal” for quite some time, it is important to treat COVID-19 as a systemic condition instead of just a respiratory one. Further studies should be conducted on larger cohort sizes to investigate the causes of a sudden overall increase of Takotsubo cardiomyopathy. Such research may suggest a need for methods to protect the emotional health of society during such widespread disasters. Moving beyond the pandemic, it is important to learn from this disaster to improve the response to future cases of “broken hearts”.

Also read: How do the more advanced life forms sexually reproduce?

References:

1. Shah, R. M., Shah, M., Shah, S., Li, A., & Jauhar, S. (2021). Takotsubo Syndrome and COVID-19: Associations and Implications. Current problems in cardiology, 46(3), 100763. https://doi.org/10.1016/j.cpcardiol.2020.100763
2. Singh, S., Desai, R., Gandhi, Z., Fong, H. K., Doreswamy, S., Desai, V., Chockalingam, A., Mehta, P. K., Sachdeva, R., & Kumar, G. (2020). Takotsubo Syndrome in Patients with COVID-19: a Systematic Review of Published Cases. SN comprehensive clinical medicine, 1–7. Advance online publication. https://doi.org/10.1007/s42399-020-00557-w
3. Okura H. (2021). Update of Takotsubo syndrome in the era of COVID-19. Journal of cardiology, 77(5), 553. https://doi.org/10.1016/j.jjcc.2021.01.014

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