How Patients With Stress Cardiomyopathy Have Fared During the Pandemic

Stress cardiomyopathy (aka broken heart syndrome), which can lead to congestive heart failure if untreated, has presented in more patients with acute coronary syndrome (ACS) during the coronavirus disease 2019 (COVID-19) pandemic compared with several measured periods before the pandemic, according to study results in JAMA Network Open, but the reasons for this remain unclear.

“This observation warrants further investigation,” the authors noted, “due to the associated psychological, social, and economic stress with imposed quarantine, lack of social interaction, strict physical distancing rules, and its economic consequences in people’s lives.”

They conducted a retrospective analysis of medical records for 1914 patients with ACS admitted to 2 Cleveland Clinic hospitals for coronary arteriography, with the study group (n = 258) presenting at the start of the COVID-19 epidemic in the United States (March-April 2020) compared with patients from 4 periods (the control group) before the pandemic:

• March to April 2018 (n = 390)
• January to February 2019 (n = 309)
• March to April 2019 (n = 679)
• January to February 2020 (n = 278)

Patients in the study and control groups were of similar age, at a median 67 years each but with slightly different interquartile ranges (IQRs): 57 to 75 and 59 to 74 years, respectively.

Results show that 7.8% of the study group was admitted with stress cardiomyopathy during the pandemic, compared with 1.5% to 1.8% of patients from the control groups, for a rate ratio of 4.58 (95% CI, 4.11-5.11; P < .001), but that none had positive antibody results for the virus as determined by reverse transcription—polymerase chain reaction following nasopharyngeal and throat swabs.

These patients also had longer median hospital stays compared with the patients admitted in the 4 prepandemic periods: 8 (IQR, 6-9) days vs 4 (IQR, 3-4), 5 (IQR, 3-6), 4 (IQR, 4-8), and 5 (IQR, 4-5) days, respectively. In addition, the study group had the highest rate of hypertension (89.9%) and the second highest rate of hyperlipidemia (77.1%), which was second only to the January to February 2020 period (79.5%).

Mortality and 30-day rehospitalization rates, however, were equivalent for the COVID-19 and pre—COVID-19 groups, respectively:

• Mortality: 5.0% vs 3.6% (P = .81)
• 30-day rehospitalization: 22.2% vs 21.4% (P = .90)

Additional results show the study patients had significantly lower median initial and peak troponin levels—0.18 (IQR, 0.03-0.50; P < .001) and 0.7 (0.15-2.10; P < .001) ng/mL, respectively—compared with the control groups:

• March to April 2018: 0.28 (IQR, 0.01-0.90) and 2.42 (IQR, 0.75-6.27) ng/mL
• January to February 2019: 0.21 (IQR, 0.01-1.01) and 1.48 (IQR, 0.10-4.15) ng/mL
• March to April 2019: 0.40 (IQR, 0.04-1.40) and 1.8 (IQR, 0.21-6.95) ng/mL
• January to February 2020: 0.40 (IQR, 0.07-1.38) and 3.10 (IQR, 0.60-8.10) ng/mL

“The psychological, social, and economic distress accompanying the pandemic, rather than direct viral involvement and sequelae of the infection, are more likely factors associated with the increase in stress cardiomyopathy cases,” the authors concluded. “This was further supported by negative COVID-19 testing results in all patients diagnosed with stress cardiomyopathy in the study group.”

Further study is warranted on links between stress cardiomyopathy and COVID-19, especially regarding temporal and regional rate differences, chiefly because the authors’ rates may have been underreported due to sampling bias from patients with ACS avoiding hospitals during the pandemic.

Reference

Jabri A, Kalra A, Kumar A, et al. Incidence of stress cardiomyopathy during the coronavirus disease 2019 pandemic. JAMA Network Open. Published online July 9, 2020. doi:10.1001/jamanetworkopen.2020.14780