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CASE REPORT
CLINICAL CASE
Takotsubo Syndrome in the Setting of
COVID-19
Anum S. Minhas, MD,a,b
Paul Scheel, MD,a
Brian Garibaldi, MD,c
Gigi Liu, MD, MS,d
Maureen Horton, MD,c
Mark Jennings, MD, MHS,c
Steven R. Jones, MD,a
Erin D. Michos, MD, MHS,a,b
Allison G. Hays, MDa
ABSTRACT
A 58-year-old woman was admitted with symptoms of coronavirus disease 2019. She subsequently developed mixed
shock, and an echocardiogram showed mid-distal left ventricular hypokinesis and apical ballooning, findings typical of
stress, or takotsubo, cardiomyopathy. Over the next few days her left ventricular function improved, the further supporting the
reversibility of acute stress cardiomyopathy. (Level of Difficulty: Beginner.) (J Am Coll Cardiol Case Rep 2020;-:-–-)
© 2020 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
HISTORY OF PRESENTATION
A 58-year-old woman presented with productive
cough, fatigue, fever, and diarrhea for the previous
5 days. Physical examination was notable for diffuse
rhonchi. Initial vital signs were as follows: blood
pressure, 156/95 mm Hg; heart rate, 130 beats/min;
oxygen saturation, 82% on a 5-l nasal cannula; res-
piratory rate, 24 breaths/min; and temperature,
38.7
C. The chest radiograph showed lower lobe–
predominant bilateral infiltrates. Shortly thereafter
she was intubated for hypoxic respiratory failure and
likely acute respiratory distress syndrome. The
electrocardiogram (ECG) showed sinus tachycardia
and 1-mm upsloping ST-segment elevations in leads
I and aVL, mild diffuse PR interval depressions, and
diffuse ST-T wave changes (Figure 1). Her initial
troponin I level was negative but eventually peaked
at 11.02 ng/ml. Notably there was leukopenia (abso-
lute lymphocyte count of 1.04 K/mm3
). Severe acute
respiratory syndrome-coronavirus-2 (SARS-CoV-2),
or coronavirus disease-2019 (COVID-19), RNA detec-
ted by polymerase chain reaction returned a positive
result.
PAST MEDICAL HISTORY
The patient had a medical history of diabetes mellitus
type 2, hypertension, and dyslipidemia. She denied
LEARNING OBJECTIVES
 To recognize cardiovascular complications
among COVID-19 patients.
 To demonstrate the presence of stress
(takotsubo) cardiomyopathy in COVID-19.
 To manage stress cardiomyopathy in infected
patients.
ISSN 2666-0849 https://doi.org/10.1016/j.jaccas.2020.04.023
From the a
Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; b
Department of
Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; c
Division of Pulmonary and
Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; and the d
Department of Med-
icine, Johns Hopkins University, Baltimore, Maryland. Dr. Minhas has received support from National Heart, Lung and Blood
Institute (training grant T32HL007024); and has received a preeclampsia and prematurity grant from AMAG Pharmaceuticals. Dr.
Jennings has consulted for Hill-Rom and Savara. All other authors have reported that they have no relationships relevant to the
contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ in-
stitutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit
the JACC: Case Reports author instructions page.
Manuscript received April 16, 2020; accepted April 17, 2020.
J A C C : C A S E R E P O R T S V O L . - , N O . - , 2 0 2 0
ª 2 0 2 0 T H E A U T H O R S . P U B L I S H E D B Y E L S E V I E R O N B E H A L F O F T H E A M E R I C A N
C O L L E G E O F C A R D I O L O G Y F O U N D A T I O N . T H I S I S A N O P E N A C C E S S A R T I C L E U N D E R
T H E C C B Y - N C - N D L I C E N S E ( h t t p : / / c r e a t i v e c o m m o n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 / ) .
travel but noted that her father was ill with
similar symptoms.
DIFFERENTIAL DIAGNOSIS
Given the initial presentation, ECG findings,
and troponin elevation, the differential
diagnosis included ST-segment elevation
myocardial infarction (STEMI), stress cardio-
myopathy, and myopericarditis.
INVESTIGATIONS
A transthoracic echocardiogram demonstrated aki-
netic middle to distal anterior, anteroseptal, antero-
lateral, and apical segments, moderately hypokinetic
middle and distal inferolateral segments, and hyper-
dynamic basal segments. Apical ballooning was also
noted. Left ventricular (LV) ejection fraction was
20%. The distal third or apical right ventricular (RV)
free wall was akinetic, with hyperdynamic RV basal
wall motion. RV function was mildly reduced
(Figure 2, Video 1).
MANAGEMENT
The patient was admitted to the intensive care unit.
Her echocardiographic findings were classic for
takotsubo syndrome, or stress cardiomyopathy, and
the distribution of wall motion abnormalities being
out of proportion to ECG findings or troponin eleva-
tion made STEMI unlikely. Given her active COVID-
19, the decision was again made to defer coronary
angiography for the time. However, she was started
conservatively on medical therapy for acute coronary
syndrome with dual antiplatelet therapy and anti-
coagulation with continuous intravenous heparin.
For COVID-19, hydroxychloroquine therapy was
initially started but was subsequently discontinued
after echocardiography, given the possible risk of
worsening cardiomyopathy and further prolonging
the QT interval; a course of azithromycin was
completed.
Clinically the patient also developed shock, likely
cardiogenic or septic shock, with central venous ox-
ygen saturation of 42%, and she required dobut-
amine. Over the following days, cardiogenic shock
improved, with central venous oxygen saturation of
65% and a de-escalating need for dobutamine. An
echocardiogram was repeated 6 days later, with
improvement noted in overall wall motion and an LV
ejection fraction of 55% (Figure 3, Video 2). Given the
rapid improvement in function on the repeat echo-
cardiogram, her cardiac presentation was believed to
be most consistent with stress cardiomyopathy in the
FIGURE 1 Initial Electrocardiogram
A B B R E V I A T I O N S
A N D A C R O N Y M S
COVID-19 = coronavirus
disease-2019
ECG = electrocardiogram
LV = left ventricular
RV = right ventricular
STEMI = ST-segment elevation
myocardial infarction
Minhas et al. J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0
Takotsubo Syndrome in COVID-19 - 2 0 2 0 : - – -
2
setting of COVID-19. This opinion was further sup-
ported by her ECG, which demonstrated no evidence
of Q-wave myocardial infarction (Figure 4).
DISCUSSION
Cardiovascular complications of viral infections can
include arrhythmias, myocarditis, pericarditis, heart
failure, myocardial ischemia, and type 1 and type 2
myocardial infarction. The recent COVID-19
pandemic is precipitously affecting large pop-
ulations in the global community. Currently pub-
lished data suggest that many individuals with
COVID-19 develop cardiovascular complications:
7.2% of patients have had acute cardiac injury, 16.7%
have had arrhythmia, and 23% have had heart failure
(1,2). Whether heart failure in COVID-19 patients is
primarily the result of exacerbation of underlying
undiagnosed cardiomyopathy, stress cardiomyopa-
thy, myocarditis, or new cardiomyopathy secondary
to a robust proinflammatory cytokine storm remains
an area of active research, although acute cardiogenic
shock in the setting of systemic inflammatory
response seems the most likely cause. A heightened
systemic inflammatory response and procoagulant
activity with COVID-19 can certainly increase the risk
of cardiac stunning or injury, acute myocardial
infarction, or coronary vasospasm. Limited reports
are suggesting that myopericarditis may also occur,
but this is likely rare (3). To date, no cases of stress
cardiomyopathy associated with COVID-19 have been
formally reported in the United States.
Stress, or takotsubo, cardiomyopathy occurs pri-
marily in women (w90% of cases), and it can be
preceded by emotional or physical triggers (4,5).
Compared with acute coronary syndrome, stress car-
diomyopathy is often associated with lower LV
function (4). A review of published reports suggests
that coronary artery vasospasm, coronary
FIGURE 2 Strain Imaging on Initial Echocardiogram
ANT ¼ anterior; APLAX ¼ apical long axis; AVC ¼ aortic valve closure; CH ¼ chamber; G ¼ global; GS ¼ global strain; HR ¼ heart rate;
INF ¼ inferior; LAT ¼ lateral; POST ¼ posterior; PSD ¼ peak systolic dispersion; SEPT ¼ septal; SL ¼ strain length.
FIGURE 3 Strain Imaging on Repeat Echocardiogram
Abbreviations as in Figure 2.
J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0 Minhas et al.
- 2 0 2 0 : - – - Takotsubo Syndrome in COVID-19
3
microvascular dysfunction, LV outflow tract obstruc-
tion, and catecholamine surge may be potential
mechanisms of development of stress cardiomyopa-
thy (6). Stress cardiomyopathy has also been reported
with viral infections (7). Histological studies have
shown mild inflammatory infiltration (8,9), and it is
possible that heightened inflammation with viral in-
fections, particularly that seen with COVID-19, may
contribute to development of stress cardiomyopathy.
Overall, the prognosis of stress cardiomyopathy is
favorable, with the majority of patients fully recov-
ering LV function by 2 months (4).
To our knowledge this is the first case of takotsubo
(stress) cardiomyopathy reported in association with
COVID-19 in the United States. The patient presented
with acute respiratory failure and an ECG mimicking
STEMI. However, echocardiogram was classic for
stress cardiomyopathy, and the patient’s marked LV
functional recovery without coronary intervention
further suggests that this was the more likely under-
lying etiology of heart failure.
FOLLOW-UP
Unfortunately, the patient has continued to have
acute respiratory distress syndrome and has started to
undergo venovenous extracorporeal membrane
oxygenation. Because her LV function had improved
from admission, she did not require venoarterial
extracorporeal membrane oxygenation. Her ECG re-
mains free of evidence of active ischemia or infarction.
At this time, given the improvement in the patient’s
cardiovascular status, urgent coronary evaluation is
not warranted, and precautions are being taken to
limit unnecessary testing to reduce exposure to health
care workers. However, pending improvement in
clinical status, future coronary evaluation with either
coronary angiography or coronary computed tomog-
raphy angiography is recommended.
CONCLUSIONS
COVID-19 has been reported to be associated with a
variety of cardiovascular complications, including
acute cardiac dysfunction. To date, this is first case of
stress cardiomyopathy with COVID-19 in the United
States. It is anticipated that as the number of COVID-
19 cases rises worldwide, there will be an increase in
the number of associated cardiovascular complica-
tions. Clinicians should be aware of the diversity of
cardiovascular complications and should strategize
appropriately for diagnosing and managing them.
ADDRESS FOR CORRESPONDENCE: Dr. Anum S.
Minhas, Division of Cardiology, Johns Hopkins Uni-
versity, 600 North Wolfe Street, Halsted 500, Balti-
more, Maryland 21287. E-mail: aminhas2@jh.edu.
Twitter: DrAnumMinhas.
FIGURE 4 Follow-up Electrocardiogram
Minhas et al. J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0
Takotsubo Syndrome in COVID-19 - 2 0 2 0 : - – -
4
R E F E R E N C E S
1. Zhou F, Yu T, Du R, et al. Clinical course and
risk factors for mortality of adult
inpatients with COVID-19 in Wuhan, China: a
retrospective cohort study. Lancet 2020;395:
1054–62.
2. Wang D, Hu B, Hu C, et al. Clinical characteris-
tics of 138 hospitalized patients with 2019 novel
coronavirus–infected pneumonia in Wuhan, China.
JAMA 2020;323:1061.
3. Inciardi RM, Lupi L, Zaccone G, et al. Cardiac
involvement in a patient with coronavirus disease
2019 (COVID-19). JAMA Cardiol 2020 Mar 27 [E-
pub ahead of print].
4. Templin C, Ghadri JR, Diekmann J, et al.
Clinical features and outcomes of takotsubo
(stress) cardiomyopathy. N Engl J Med 2015;373:
929–38.
5. Minhas AS, Hughey AB, Kolias TJ. Nationwide
trends in reported incidence of takotsubo cardio-
myopathy from 2006 to 2012. Am J Cardiol 2015;
116:1128–31.
6. De Giorgi A, Fabbian F, Pala M, et al. Takotsubo
cardiomyopathy and acute infectious diseases: a
mini-review of case reports. Angiology 2015;66:
257–61.
7. Nef HM, Möllmann H, Akashi YJ, Hamm CW.
Mechanisms of stress (takotsubo) cardiomyopa-
thy. Nat Rev Cardiol 2010;7:187–93.
8. Sachdeva J, Dai W, Kloner RA. Functional and
histological assessment of an experimental model
of takotsubo’s cardiomyopathy. J Am Heart Assoc
2014;3:e000921.
9. Nef HM, Mollmann H, Kostin S, et al. Tako-
tsubo cardiomyopathy: intraindividual
structural analysis in the acute phase and after
functional recovery. Eur Heart J 2007;28:
2456–64.
KEY WORDS acute cardiac dysfunction,
COVID-19, stress cardiomyopathy, takotsubo
APPENDIX For supplemental
videos, please see the online version of this
paper.
J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0 Minhas et al.
- 2 0 2 0 : - – - Takotsubo Syndrome in COVID-19
5

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Takotsubo y covid

  • 1. CASE REPORT CLINICAL CASE Takotsubo Syndrome in the Setting of COVID-19 Anum S. Minhas, MD,a,b Paul Scheel, MD,a Brian Garibaldi, MD,c Gigi Liu, MD, MS,d Maureen Horton, MD,c Mark Jennings, MD, MHS,c Steven R. Jones, MD,a Erin D. Michos, MD, MHS,a,b Allison G. Hays, MDa ABSTRACT A 58-year-old woman was admitted with symptoms of coronavirus disease 2019. She subsequently developed mixed shock, and an echocardiogram showed mid-distal left ventricular hypokinesis and apical ballooning, findings typical of stress, or takotsubo, cardiomyopathy. Over the next few days her left ventricular function improved, the further supporting the reversibility of acute stress cardiomyopathy. (Level of Difficulty: Beginner.) (J Am Coll Cardiol Case Rep 2020;-:-–-) © 2020 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). HISTORY OF PRESENTATION A 58-year-old woman presented with productive cough, fatigue, fever, and diarrhea for the previous 5 days. Physical examination was notable for diffuse rhonchi. Initial vital signs were as follows: blood pressure, 156/95 mm Hg; heart rate, 130 beats/min; oxygen saturation, 82% on a 5-l nasal cannula; res- piratory rate, 24 breaths/min; and temperature, 38.7 C. The chest radiograph showed lower lobe– predominant bilateral infiltrates. Shortly thereafter she was intubated for hypoxic respiratory failure and likely acute respiratory distress syndrome. The electrocardiogram (ECG) showed sinus tachycardia and 1-mm upsloping ST-segment elevations in leads I and aVL, mild diffuse PR interval depressions, and diffuse ST-T wave changes (Figure 1). Her initial troponin I level was negative but eventually peaked at 11.02 ng/ml. Notably there was leukopenia (abso- lute lymphocyte count of 1.04 K/mm3 ). Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), or coronavirus disease-2019 (COVID-19), RNA detec- ted by polymerase chain reaction returned a positive result. PAST MEDICAL HISTORY The patient had a medical history of diabetes mellitus type 2, hypertension, and dyslipidemia. She denied LEARNING OBJECTIVES To recognize cardiovascular complications among COVID-19 patients. To demonstrate the presence of stress (takotsubo) cardiomyopathy in COVID-19. To manage stress cardiomyopathy in infected patients. ISSN 2666-0849 https://doi.org/10.1016/j.jaccas.2020.04.023 From the a Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; b Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; c Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; and the d Department of Med- icine, Johns Hopkins University, Baltimore, Maryland. Dr. Minhas has received support from National Heart, Lung and Blood Institute (training grant T32HL007024); and has received a preeclampsia and prematurity grant from AMAG Pharmaceuticals. Dr. Jennings has consulted for Hill-Rom and Savara. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ in- stitutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Case Reports author instructions page. Manuscript received April 16, 2020; accepted April 17, 2020. J A C C : C A S E R E P O R T S V O L . - , N O . - , 2 0 2 0 ª 2 0 2 0 T H E A U T H O R S . P U B L I S H E D B Y E L S E V I E R O N B E H A L F O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y F O U N D A T I O N . T H I S I S A N O P E N A C C E S S A R T I C L E U N D E R T H E C C B Y - N C - N D L I C E N S E ( h t t p : / / c r e a t i v e c o m m o n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 / ) .
  • 2. travel but noted that her father was ill with similar symptoms. DIFFERENTIAL DIAGNOSIS Given the initial presentation, ECG findings, and troponin elevation, the differential diagnosis included ST-segment elevation myocardial infarction (STEMI), stress cardio- myopathy, and myopericarditis. INVESTIGATIONS A transthoracic echocardiogram demonstrated aki- netic middle to distal anterior, anteroseptal, antero- lateral, and apical segments, moderately hypokinetic middle and distal inferolateral segments, and hyper- dynamic basal segments. Apical ballooning was also noted. Left ventricular (LV) ejection fraction was 20%. The distal third or apical right ventricular (RV) free wall was akinetic, with hyperdynamic RV basal wall motion. RV function was mildly reduced (Figure 2, Video 1). MANAGEMENT The patient was admitted to the intensive care unit. Her echocardiographic findings were classic for takotsubo syndrome, or stress cardiomyopathy, and the distribution of wall motion abnormalities being out of proportion to ECG findings or troponin eleva- tion made STEMI unlikely. Given her active COVID- 19, the decision was again made to defer coronary angiography for the time. However, she was started conservatively on medical therapy for acute coronary syndrome with dual antiplatelet therapy and anti- coagulation with continuous intravenous heparin. For COVID-19, hydroxychloroquine therapy was initially started but was subsequently discontinued after echocardiography, given the possible risk of worsening cardiomyopathy and further prolonging the QT interval; a course of azithromycin was completed. Clinically the patient also developed shock, likely cardiogenic or septic shock, with central venous ox- ygen saturation of 42%, and she required dobut- amine. Over the following days, cardiogenic shock improved, with central venous oxygen saturation of 65% and a de-escalating need for dobutamine. An echocardiogram was repeated 6 days later, with improvement noted in overall wall motion and an LV ejection fraction of 55% (Figure 3, Video 2). Given the rapid improvement in function on the repeat echo- cardiogram, her cardiac presentation was believed to be most consistent with stress cardiomyopathy in the FIGURE 1 Initial Electrocardiogram A B B R E V I A T I O N S A N D A C R O N Y M S COVID-19 = coronavirus disease-2019 ECG = electrocardiogram LV = left ventricular RV = right ventricular STEMI = ST-segment elevation myocardial infarction Minhas et al. J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0 Takotsubo Syndrome in COVID-19 - 2 0 2 0 : - – - 2
  • 3. setting of COVID-19. This opinion was further sup- ported by her ECG, which demonstrated no evidence of Q-wave myocardial infarction (Figure 4). DISCUSSION Cardiovascular complications of viral infections can include arrhythmias, myocarditis, pericarditis, heart failure, myocardial ischemia, and type 1 and type 2 myocardial infarction. The recent COVID-19 pandemic is precipitously affecting large pop- ulations in the global community. Currently pub- lished data suggest that many individuals with COVID-19 develop cardiovascular complications: 7.2% of patients have had acute cardiac injury, 16.7% have had arrhythmia, and 23% have had heart failure (1,2). Whether heart failure in COVID-19 patients is primarily the result of exacerbation of underlying undiagnosed cardiomyopathy, stress cardiomyopa- thy, myocarditis, or new cardiomyopathy secondary to a robust proinflammatory cytokine storm remains an area of active research, although acute cardiogenic shock in the setting of systemic inflammatory response seems the most likely cause. A heightened systemic inflammatory response and procoagulant activity with COVID-19 can certainly increase the risk of cardiac stunning or injury, acute myocardial infarction, or coronary vasospasm. Limited reports are suggesting that myopericarditis may also occur, but this is likely rare (3). To date, no cases of stress cardiomyopathy associated with COVID-19 have been formally reported in the United States. Stress, or takotsubo, cardiomyopathy occurs pri- marily in women (w90% of cases), and it can be preceded by emotional or physical triggers (4,5). Compared with acute coronary syndrome, stress car- diomyopathy is often associated with lower LV function (4). A review of published reports suggests that coronary artery vasospasm, coronary FIGURE 2 Strain Imaging on Initial Echocardiogram ANT ¼ anterior; APLAX ¼ apical long axis; AVC ¼ aortic valve closure; CH ¼ chamber; G ¼ global; GS ¼ global strain; HR ¼ heart rate; INF ¼ inferior; LAT ¼ lateral; POST ¼ posterior; PSD ¼ peak systolic dispersion; SEPT ¼ septal; SL ¼ strain length. FIGURE 3 Strain Imaging on Repeat Echocardiogram Abbreviations as in Figure 2. J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0 Minhas et al. - 2 0 2 0 : - – - Takotsubo Syndrome in COVID-19 3
  • 4. microvascular dysfunction, LV outflow tract obstruc- tion, and catecholamine surge may be potential mechanisms of development of stress cardiomyopa- thy (6). Stress cardiomyopathy has also been reported with viral infections (7). Histological studies have shown mild inflammatory infiltration (8,9), and it is possible that heightened inflammation with viral in- fections, particularly that seen with COVID-19, may contribute to development of stress cardiomyopathy. Overall, the prognosis of stress cardiomyopathy is favorable, with the majority of patients fully recov- ering LV function by 2 months (4). To our knowledge this is the first case of takotsubo (stress) cardiomyopathy reported in association with COVID-19 in the United States. The patient presented with acute respiratory failure and an ECG mimicking STEMI. However, echocardiogram was classic for stress cardiomyopathy, and the patient’s marked LV functional recovery without coronary intervention further suggests that this was the more likely under- lying etiology of heart failure. FOLLOW-UP Unfortunately, the patient has continued to have acute respiratory distress syndrome and has started to undergo venovenous extracorporeal membrane oxygenation. Because her LV function had improved from admission, she did not require venoarterial extracorporeal membrane oxygenation. Her ECG re- mains free of evidence of active ischemia or infarction. At this time, given the improvement in the patient’s cardiovascular status, urgent coronary evaluation is not warranted, and precautions are being taken to limit unnecessary testing to reduce exposure to health care workers. However, pending improvement in clinical status, future coronary evaluation with either coronary angiography or coronary computed tomog- raphy angiography is recommended. CONCLUSIONS COVID-19 has been reported to be associated with a variety of cardiovascular complications, including acute cardiac dysfunction. To date, this is first case of stress cardiomyopathy with COVID-19 in the United States. It is anticipated that as the number of COVID- 19 cases rises worldwide, there will be an increase in the number of associated cardiovascular complica- tions. Clinicians should be aware of the diversity of cardiovascular complications and should strategize appropriately for diagnosing and managing them. ADDRESS FOR CORRESPONDENCE: Dr. Anum S. Minhas, Division of Cardiology, Johns Hopkins Uni- versity, 600 North Wolfe Street, Halsted 500, Balti- more, Maryland 21287. E-mail: aminhas2@jh.edu. Twitter: DrAnumMinhas. FIGURE 4 Follow-up Electrocardiogram Minhas et al. J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0 Takotsubo Syndrome in COVID-19 - 2 0 2 0 : - – - 4
  • 5. R E F E R E N C E S 1. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020;395: 1054–62. 2. Wang D, Hu B, Hu C, et al. Clinical characteris- tics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA 2020;323:1061. 3. Inciardi RM, Lupi L, Zaccone G, et al. Cardiac involvement in a patient with coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020 Mar 27 [E- pub ahead of print]. 4. Templin C, Ghadri JR, Diekmann J, et al. Clinical features and outcomes of takotsubo (stress) cardiomyopathy. N Engl J Med 2015;373: 929–38. 5. Minhas AS, Hughey AB, Kolias TJ. Nationwide trends in reported incidence of takotsubo cardio- myopathy from 2006 to 2012. Am J Cardiol 2015; 116:1128–31. 6. De Giorgi A, Fabbian F, Pala M, et al. Takotsubo cardiomyopathy and acute infectious diseases: a mini-review of case reports. Angiology 2015;66: 257–61. 7. Nef HM, Möllmann H, Akashi YJ, Hamm CW. Mechanisms of stress (takotsubo) cardiomyopa- thy. Nat Rev Cardiol 2010;7:187–93. 8. Sachdeva J, Dai W, Kloner RA. Functional and histological assessment of an experimental model of takotsubo’s cardiomyopathy. J Am Heart Assoc 2014;3:e000921. 9. Nef HM, Mollmann H, Kostin S, et al. Tako- tsubo cardiomyopathy: intraindividual structural analysis in the acute phase and after functional recovery. Eur Heart J 2007;28: 2456–64. KEY WORDS acute cardiac dysfunction, COVID-19, stress cardiomyopathy, takotsubo APPENDIX For supplemental videos, please see the online version of this paper. J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0 Minhas et al. - 2 0 2 0 : - – - Takotsubo Syndrome in COVID-19 5