Coronavirus Disease 2019 (COVID-19) and Cardiac Injury

To the Editor The article by Shi et al¹ studied the clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) and associated myocardial injury that was present in almost 20% of cases. The authors should be commended for undertaking the largest analysis so far exploring the association of myocardial injury with mortality in patients with COVID-19. However, one question still remains: what is the cause of myocardial injury in this context? Sepsis, hypoxemia with or without underlying coronary artery disease, and myocarditis have all been proposed.² In our view, takotsubo syndrome (TTS) should also be considered in the differential diagnosis of myocardial injury during the COVID-19 pandemic.

After the first reported case in Switzerland on February 25, 2020, the COVID-19 epidemic has spread rapidly in our country, reaching in March the highest cumulative prevalence per inhabitants in the world. The Geneva canton is particularly hit and has decided to centralize all patients with COVID-19 at the University Hospital of Geneva. As of April 3, 2020, 404 patients with confirmed COVID-19 are hospitalized in this center, of whom 62 are intubated in the intensive care unit. Since the beginning of the COVID-19 outbreak, we have noticed an intriguing high number of TTS diagnoses, with an average rate of 1 case per week instead of a usual approximate rate of 1 case per month.

Takotsubo syndrome, also named broken heart syndrome or stress cardiomyopathy, usually presents like an acute coronary syndrome with chest pain, dyspnea, dynamic changes on electrocardiography, and elevated cardiac biomarkers.³ Its etiology is not well understood but may be related to coronary microvascular constriction.⁴ Obstructive coronary artery disease may occasionally be present concomitantly but is not an underlying cause for TTS. Characteristically, patients show transient left ventricular wall motion abnormalities, of which 4 different patterns can be differentiated.⁵ In two-thirds of cases, an emotional or a physical trigger is typically found.³

During the COVID-19 pandemic, the huge emotional stress at the population level exacerbated by generalized lockdown and tragic stories involving relatives represent potential triggers of TTS. In addition, severe acute respiratory syndrome coronavirus 2 causes respiratory tract infections, severe pneumonia, sepsis, and hypoxemia, which are also well-known physical triggers of TTS.³ Therefore, comprehensive cardiovascular examinations, such as electrocardiography, echocardiography, coronary angiography, and cardiac magnetic resonance imaging, should be maintained during the pandemic to better understand the underlying mechanisms of myocardial injury in patients with COVID-19.

Corresponding Author: Philippe Meyer, MD, Cardiology Service, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland (philippe.meyer@hcuge.ch).

Published Online: July 8, 2020. doi:10.1001/jamacardio.2020.2453

Conflict of Interest Disclosures: None reported.