key: cord-0770598-imiaa09z
authors: Rallidis, Loukianos S.; Iordanidis, Dimitrios; Kosmas, Nikolaos; Varounis, Christos; Filippatos, Gerasimos
title: Rising trends in Takostubo syndrome during the COVID-19 pandemic: a single center experience
date: 2022-03-23
journal: Hellenic J Cardiol
DOI: 10.1016/j.hjc.2022.03.007
sha: 3dad5263a11c8e18f8df4646ee02002eba271e9e
doc_id: 770598
cord_uid: imiaa09z

nan

Takotsubo syndrome (TTS) is a major psychosomatic cardiovascular disease (CVD) and it has been estimated that it represents 1-3% of patients presenting with suspected acute coronary syndrome (ACS) [1] . Although initially considered to be a benign condition, there are reports suggesting that TTS is associated with increased long-term morbidity and mortality [1, 2] . TTS is characterized by acute reversible left ventricular (LV) dysfunction, typically affecting LV apex with hypercontractile basal segments, in the setting of unobstructed or obstructed coronary arteries not corresponding to the pattern of LV dysfunction. Although the precise pathophysiological mechanisms remain unknown it has been proposed that a catecholamine surge, precipitated by physical or emotional stress, plays a principal role [1] .

The ongoing coronavirus disease 2019 (COVID-19) pandemic has brought major consequences to physical and psychological health of the population. It has been suggested that in the current pandemic COVID-19 era, the psychological and physical consequences of the restrictive measures taken to combat the pandemic, is likely to make individuals more vulnerable to TTS [3] . In our study, we investigated whether TTS incidence, as a percentage of ACS admitted to a major tertiary hospital, has increased during the COVID-19 era. Failure Association of the European Society of Cardiology criteria were applied [4] . Table 1 shows the characteristics of TTS patients. There was a significant increase in the incidence of TTS during the 16 months COVID-19 period (6.3%, i.e., 20 TTS among 316 ACS patients) compared with the corresponding incidence of TTS 16 months prior COVID-19 pandemic (2.6%, i.e., 9 TTS among 342 ACS patients)

[ Figure 1 ]. The incidence rate ratio comparing the TTS cases of COVID-19 pandemic period to the pre-pandemic period was 2.22 (95%CI: 0.97-5.54, p=0.021). Among the 20 TTS patients presented during the pandemic period, 2 (10%) had normal ECG at admission, 9 (45%) had T wave inversion, 5 (25%) had ST-segment elevation and 4 (20%) had ST-segment depression. There was no any difference in the type of ECG changes between the TTS cases presented prior compared to those presented during the pandemic (p >0.05).

Although there are several reports of TTS among COVID-19 patients [6] suggesting a direct "detrimental" triggering role of new coronavirus in the development of TTS, there are few and conflicting data on the impact of COVID-19 pandemic in the incidence of TTS among "non-COVID-19" patients [6, 7] . In line with our results, Jabri et al., reported a significant increase in the incidence of TTS among ACS patients presented during the COVID-19 pandemic compared with the incidence in the prepandemic period [6] . On the contrary, Delmas et al. did not find an increase in TTS cases admitted to their institution between March 1 st and April 15 th 2020 compared with the same period of previous years [7] . The difference in the results between the J o u r n a l P r e -p r o o f studies may be due to different quarantine policies and diverse levels of pandemic severity of the studied populations, and the length of the study period [8] .

The current pandemic has renewed interest in TTS, as one of the most characteristic psychosomatic manifestations of CVD. Quarantine and self-isolation can elicit feelings of social deprivation, anxiety, fear of infection, economic catastrophe and depression, which in turn may lead to severe emotional stress, activating the hypothalamus-pituitary-adrenal axis and provoking increased catecholamines secretion, which is a pathophysiological cornerstone of TTS development [1, 3] . Therefore, TTS increase among "non-COVID-19" individuals maybe secondary to the additional psychological overload imposed by the COVID-19 pandemic.

In conclusion, we found that COVID-19 pandemic was associated with a significant increase in incidence of TTS probably due to the additional psychological burden imposed by the pandemic. However, there is need for larger studies to confirm the association of TTS with the COVID-19 pandemic.

J o u r n a l P r e -p r o o f 

Pathophysiology of Takotsubo Syndrome: JACC State-of-the-Art Review

Persistent Long-Term Structural, Functional, and Metabolic Changes After Stress-Induced (Takotsubo) Cardiomyopathy

Takotsubo syndrome in COVID-19 era: Is psychological distress the key?

Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of

Takotsubo Cardiomyopathy in COVID-19

Incidence of Stress Cardiomyopathy During the Coronavirus Disease

COVID-19 pandemic : no increase of takotsubo syndrome occurrence despite high-stress conditions

Takotsubo syndrome during the COVID-19 pandemic, stateof -the-art review