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Cardiology

Incidence of Stress Cardiomyopathy During the Coronavirus Disease 2019 Pandemic

Educational Objective
To understand how stress associated with COVID-19 is affecting the rate of stress cardiomyopathy incidences

1 Credit CME

JAMA Network Open

Published Online: July 9, 2020

Original Investigation

Article Information and Disclosures

Ahmad Jabri, MD¹;

Ankur Kalra, MD^2,3;

Ashish Kumar, MBBS⁴;

Anas Alameh, MD¹;

Shubham Adroja, MBBS¹;

Hanad Bashir, MD¹;

Amy S. Nowacki, PhD⁵;

Rohan Shah, MD²;

Shameer Khubber, MD⁶;

Anmar Kanaa’N, MD³;

David P. Hedrick, MD, PhD^2,3;

Khaled M. Sleik, MD^2,3;

Neil Mehta, MBBS⁷;

Mina K. Chung, MD²;

Umesh N. Khot, MD²;

Samir R. Kapadia, MD²;

Rishi Puri, MBBS, PhD²;

Grant W. Reed, MD, MSc²

Author Affiliations

¹Department of Internal Medicine, Cleveland Clinic Akron General, Akron, Ohio
²Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
³Heart, Vascular and Thoracic Department, Cleveland Clinic Akron General, Akron, Ohio
⁴Department of Critical Care Medicine, St John’s Medical College Hospital, Bengaluru, India
⁵Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
⁶Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio
⁷Lerner College of Medicine, Cleveland Clinic, Department of Medicine, Case Western Reserve University, Cleveland, Ohio

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Key Points

Question Is psychological, social, and economic stress associated with coronavirus disease 2019 (COVID-19) associated with the incidence of stress cardiomyopathy?

Findings This cohort study included 1914 patients with acute coronary syndrome to compare patients presenting during the COVID-19 pandemic with patients presenting across 4 timelines prior to the pandemic and found a significantly increased incidence of 7.8% of stress cardiomyopathy during the COVID-19 pandemic, compared with prepandemic incidences that ranged from 1.5% to 1.8%.

Meaning These findings suggest that psychological, social, and economic stress related to the COVID-19 pandemic was associated with an increased incidence of stress cardiomyopathy.

Abstract

Importance The coronavirus disease 2019 (COVID-19) pandemic has resulted in severe psychological, social, and economic stress in people’s lives. It is not known whether the stress of the pandemic is associated with an increase in the incidence of stress cardiomyopathy.

Objective To determine the incidence and outcomes of stress cardiomyopathy during the COVID-19 pandemic compared with before the pandemic.

Design, Setting, and Participants This retrospective cohort study at cardiac catheterization laboratories with primary percutaneous coronary intervention capability at 2 hospitals in the Cleveland Clinic health system in Northeast Ohio examined the incidence of stress cardiomyopathy (also known as Takotsubo syndrome) in patients presenting with acute coronary syndrome who underwent coronary arteriography. Patients presenting during the COVID-19 pandemic, between March 1 and April 30, 2020, were compared with 4 control groups of patients with acute coronary syndrome presenting prior to the pandemic across 4 distinct timelines: March to April 2018, January to February 2019, March to April 2019, and January to February 2020. Data were analyzed in May 2020.

Exposures Patients were divided into 5 groups based on the date of their clinical presentation in relation to the COVID-19 pandemic.

Main Outcomes and Measures Incidence of stress cardiomyopathy.

Results Among 1914 patient presenting with acute coronary syndrome, 1656 patients (median [interquartile range] age, 67 [59-74]; 1094 [66.1%] men) presented during the pre–COVID-19 period (390 patients in March-April 2018, 309 patients in January-February 2019, 679 patients in March-April 2019, and 278 patients in January-February 2020), and 258 patients (median [interquartile range] age, 67 [57-75]; 175 [67.8%] men) presented during the COVID-19 pandemic period (ie, March-April 2020). There was a significant increase in the incidence of stress cardiomyopathy during the COVID-19 period, with a total of 20 patients with stress cardiomyopathy (incidence proportion, 7.8%), compared with prepandemic timelines, which ranged from 5 to 12 patients with stress cardiomyopathy (incidence proportion range, 1.5%-1.8%). The rate ratio comparing the COVID-19 pandemic period to the combined prepandemic period was 4.58 (95% CI, 4.11-5.11; P < .001). All patients during the COVID-19 pandemic had negative reverse transcription–polymerase chain reaction test results for COVID-19. Patients with stress cardiomyopathy during the COVID-19 pandemic had a longer median (interquartile range) hospital length of stay compared with those hospitalized in the prepandemic period (COVID-19 period: 8 [6-9] days; March-April 2018: 4 [3-4] days; January-February 2019: 5 [3-6] days; March-April 2019: 4 [4-8] days; January-February: 5 [4-5] days; P = .006). There were no significant differences between the COVID-19 period and the overall pre–COVID-19 period in mortality (1 patient [5.0%] vs 1 patient [3.6%], respectively; P = .81) or 30-day rehospitalization (4 patients [22.2%] vs 6 patients [21.4%], respectively; P = .90).

Conclusions and Relevance This study found that there was a significant increase in the incidence of stress cardiomyopathy during the COVID-19 pandemic when compared with prepandemic periods.

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Article Information

Accepted for Publication: June 11, 2020.

Published: July 9, 2020. doi:10.1001/jamanetworkopen.2020.14780

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Jabri A et al. JAMA Network Open.

Corresponding Author: Ankur Kalra, MD, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 224 W Exchange St, Ste 225, Akron, Ohio 44302 (kalraa@ccf.org).

Author Contributions: Drs Jabri and Kalra had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Jabri and Kalra contributed equally to this work.

Concept and design: Jabri, Kalra, Alameh, Bashir, Khubber, Kanaa’N, Hedrick, Mehta, Puri, Reed.

Acquisition, analysis, or interpretation of data: Jabri, Kalra, Kumar, Alameh, Adroja, Nowacki, Shah, Kanaa’N, Hedrick, Sleik, Chung, Khot, Kapadia, Reed.

Drafting of the manuscript: Jabri, Kalra, Kumar, Alameh, Adroja, Bashir, Mehta, Reed.

Critical revision of the manuscript for important intellectual content: Jabri, Kalra, Alameh, Bashir, Nowacki, Shah, Khubber, Kanaa’N, Hedrick, Sleik, Mehta, Chung, Khot, Kapadia, Puri, Reed.

Statistical analysis: Kalra, Kumar, Alameh, Bashir, Nowacki, Reed.

Obtained funding: Kalra.

Administrative, technical, or material support: Jabri, Kalra, Adroja, Bashir, Shah, Kanaa’N, Hedrick, Khot, Reed.

Supervision: Jabri, Kalra, Mehta, Khot, Kapadia, Puri, Reed.

Conflict of Interest Disclosures: None reported.

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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

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