717 A case of takotsubo cardiomyopathy due to… fear of COVID

Abstract

Takotsubo syndrome (TTS), also known as ‘stress cardiomyopathy’ or ‘broken heart syndrome’, is a frequent cause of transient ST-segment elevation, characterized by typically reversible abnormalities of segmental kinetics of the left ventricle, triggered by emotional or physical stress, with not critical stenosis at coronarography. This cardiomyopathy mainly affects women (about 90% of cases), especially in the post-menopausal age, and owes its names to the typical shape of the left ventricle in telesystole to ventriculography (‘takotsubo’ is a Japanese term for a vessel used as an octopus trap, with a thin neck and rounded tip). The incidence of Takotsubo cardiomyopathy showed a marked increase during the COVID-19 pandemic. On the other hand, a marked worsening of anxiety and depressive symptoms in the general population was recorded during the lockdown. In April 2020, an 86-year-old woman was admitted to the Coronary Intensive Care Unit of our hospital. Her remote medical history shows: arterial hypertension, previous breast cancer, operated and treated with adjuvant radiotherapy and hormone therapy, and cervical cancer, subjected to radical hysterectomy and subsequent pelvic radiotherapy. Upon entering the ward, the patient was in a state of shock (BP 75/50 mmHg, HR 105/m') and there was marked hypothermia (34 °C). The relatives reported that the patient did not leave home since the beginning of the Sars-CoV-2 pandemic due to the high fear of contracting the infection and in the day before admission she had a feverish rise (39 °C), which regressed spontaneously. ECG showed sinus tachycardia with ST-segment elevation V2–V6, in I and aVL and under level in III and aVR (Figure 1) with elongated QT interval. Echocardiogram revealed akinesia of the mid-apical segments, with kinetics preserved in the basal segments, severe left ventricular systolic dysfunction (ejection fraction: 25%), moderate dual-jet mitral insufficiency due to symmetrical tethering of the flaps and a mild infero-lateral pericardial effusion. The indices of myocardionecrosis and inflammation were high. The patient was asymptomatic for chest pain and equivalents and expressed an excessive fear of having contracted COVID-19. Nasal swab for SARS-CoV-2 was performed, which was negative. The interTAK score was 68 (Takotsubo probability: 82.4%). Emergency coronary angiography was performed, which showed no critical coronary stenosis. Ventriculography revealed apical dyskinesia with hyperkinesis of the basal segments (Figure 2). At the end of the procedure due to hemodynamic instability an intra-aortic balloon pump (IABP) was placed and inotropic and vasopressor therapy was undertaken. Over the next 48 h there were numerous episodes of non-sustained ventricular tachycardia and amiodarone was applied for the onset of atrial fibrillation, with prompt restoration of the sinus rhythm. The patient was progressively weaned from the mechanical and pharmacological support of the circulation and she was discharged in optimal medical therapy, with indication for echocardiographic follow-up, still in progress.