Social distancing/isolation is vital for infection control but can adversely impact on mental health. As the spread of COVID-19 is contained, mental health issues will surface with particular concerns for elderly, isolated populations. We present a case of Takotsubo cardiomyopathy related to lockdown anxiety.
An 81-year-old woman presented to our cardiac centre with acute onset ischaemic sounding chest pain during week 4 of the first COVID-19 lockdown in the UK. She reported increasing anxiety since the start of isolation. The onset of chest pain was related to a package dropped off by her family and occurred within an hour of receiving it. Although welcome, this caused her a mixed extreme of emotions as it both heightened her sense of loneliness and anxiety, while at the same time caused her pleasure from family contact. Her past medical history included permanent atrial fibrillation (AF), hypertension, hypercholesterolaemia and iron deficiency anaemia. She displayed no infective symptoms related to COVID-19. A 12-lead electrocardiogram (ECG) revealed AF with a ventricular rate of 50 beats per minute and dynamic T-wave inversion in the anterolateral leads (figure 1A). Troponin T at 0 hours was 334 ng/L increasing at maximum to 858 ng/L at six hours post-onset of the chest pain. A d-dimer level was, unfortunately, not measured. Initial differential diagnoses considered included: an acute coronary syndrome due to a ruptured plaque in the left anterior descending (LAD), coronary embolism (given the background of AF), coronary spasm, hypertensive cardiomyopathy and COVID-19 cardiomyopathy mimicking Takotsubo cardiomyopathy (TCM).
Owing to ongoing symptoms and a low index of suspicion for COVID-19, we decided to proceed with urgent coronary angiography. Interestingly, this revealed unobstructed coronaries but antero-apical wall hypokinesis on left ventriculography consistent with Takotsubo cardiomyopathy (TCM) (figures 1B–E). Transthoracic echocardiography (TTE) demonstrated significant regional wall motion abnormalities (mid to apical dysfunction with preserved basal contraction), which resolved on repeat echocardiography at three weeks post-admission. Importantly, TTE excluded intracardiac thrombus. The patient remains asymptomatic at follow-up.
TCM is a diagnosis of exclusion but several diagnostic tests have either been unavailable or in limited availability during the height of the COVID pandemic. We, therefore, discuss the possible differential diagnoses and the difficulties encountered in making a diagnosis of TCM during this unprecedented time. Operators often consider intravascular imaging in such cases to rule out a ruptured plaque event. However, this option was not available to us, as this case occurred during the height of the pandemic. Similarly, most centres would routinely arrange cardiac magnetic resonance imaging (MRI) to confirm the diagnosis of TCM and distinguish it from other pathologies, including acute coronary syndrome. Likewise, the cardiac MRI service was limited at the height of the pandemic, and on risk-benefit discussion with the patient and classical findings of TCM on echo, this was not pursued. COVID-19 pharyngeal PCR (polymerase chain reaction) result was found to be negative, ruling out a COVID-related myocarditis.
TCM, also known as broken heart or stress-induced cardiomyopathy, is often seen in women of post-menopausal age. Most cases result from a physical event or emotional stress (sad as well as happy), although in some, there are no apparent triggers.1 The International Expert Consensus Document published in 2018 defines TCM as transient left ventricular dysfunction (hypokinesia, akinesia, or dyskinesia) presenting as apical ballooning or mid-ventricular, basal, or rarely focal wall motion abnormalities with or without right ventricular involvement. Other commonly used diagnostic criteria include that of the Mayo clinic,2 which differ only in the exclusion of co-existing coronary artery disease for TCM diagnosis in the latter.
Lockdown-related emotional stress has now been linked with and reported in the literature as a trigger for TCM.1,2 Many countries adopted lockdown and social distancing as a measure to contain the rapid spread of this disease. Nevertheless, anxiety, depression and self-harm are on the rise as communities have never experienced such isolation measures in their lifetime. Studies support a secure link between anxiety, depression and social isolation; especially in elderly, vulnerable, age groups. Despite a relaxation of lockdown measures, it is unclear when lockdown will officially become redundant. Therefore, it is prudent that we involve our psychiatry and psychology colleagues for their input as to how this can be achieved safely and effectively with minimal impact on mental health.3-5 Otherwise, we risk going from a COVID-19 pandemic to a loneliness pandemic and a vaccine for the latter may prove more difficult.
- Takotsubo cardiomyopathy (TCM), also known as broken heart or stress-induced cardiomyopathy, is often seen in women of post-menopausal age
- Most cases result from a physical event or emotional stress. Lockdown-related emotional stress is an unusual cause of TCM, but has now been reported as a precipitant
- Lockdown measures are essential for infection control but strongly linked to anxiety and depression, especially in elderly populations
- Healthcare workers in general hospital or community settings lack the skills to manage mental health illness. Therefore, a multi-disciplinary approach is crucial in combating this and achieving the best outcomes for patients
Conflicts of interest
The patient provided verbal and written informed consent.
Please also see the article by Díaz-Navarro on pages 30–4 (https://bjcardio.co.uk/2021/03/takotsubo-syndrome-the-broken-heart-syndrome/), and the case report by Matthews et al. pages 37–8 of this issue (https://bjcardio.co.uk/2021/03/takotsubo-syndrome-a-predominantly-female-cv-disorder-from-the-perspective-of-primary-care/).
1. Ghadri J-R, Wittstein S, Prasad A et al. International Expert Consensus Document on Takotsubo syndrome (part I): clinical characteristics, diagnostic criteria, and pathophysiology. Eur Heart J 2018;39:2032–46. https://doi.org/10.1093/eurheartj/ehy076
2. Madhavan M, Prasad A. Proposed Mayo clinic criteria for the diagnosis of Tako-Tsubo cardiomyopathy and long-term prognosis. Herz 2010;35:240–3. https://doi.org/10.1007/s00059-010-3339-x
3. Santini Z, Jose P, Cornwell E et al. Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): a longitudinal mediation analysis. Lancet Public Health 2020;5:e62–e70. https://doi.org/10.1016/S2468-2667(19)30230-0
4. Lima C, Carvalho P. The emotional impact of Coronavirus 2019-nCoV (new Coronavirus disease). Psychiatr Res 2020;287:112915. https://doi.org/10.1016/j.psychres.2020.112915
5. Banerjee D. The COVID-19 outbreak: crucial role the psychiatrists can play. Asian J Psychiatr 2020;50:102014. https://doi.org/10.1016/j.ajp.2020.102014