Takotsubo syndrome a rare entity in patients with COVID-19: An updated review of case-reports and case-series

Takotsubo syndrome a rare entity in patients with COVID-19: An updated review of case-reports and case-series Since December-2019 coronavirus disease 2019 (COVID-19) has swept the world.As of 19th July, it has affected 14,043,176 people and 5,97,583 death with CFR of 4.25 globally as per WHO Situation Report.COVID-19 infection has myriad cardiac manifestation with preceding coronavirus outbreaks such as SARS and MERS [1].Various Cardiovascular complication have been reported in previous published studies and can manifest as ACS, stress cardiomyopathy, myocarditis, myopericarditis, heart failure, arrhythmias, pericardial effusion, cardiac tamponade, thromboembolic complications, and cardiogenic shock amongst COVID-19 patients.[2].It is hypothesized that virus causes cardiac injury via direct cytotoxic effects or via immune-mediated mechanisms.Current evidence suggests that Sars-Cov-2 binds to ACE-2 receptor present on various tissues like lung, kidney, heart, vascular endothelium and downregulates expression of this enzymes, producing enhanced vasoconstriction and deleterious effects of unopposed reticuloendothelial system [1].Takotsubo syndrome (TTS) is a rare cardiac complication which might be misdiagnosed in high risk cardiac patients of COVID-19.However, there is limited data available on TTS in COVID-19.We aimed to perform a review of the published case reports and series and pertinent outcomes of TTS in COVID-19.Online databases including PubMed, Embase, Scopus were retrospectively searched.The search strategy followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)" guidelines by using MeSH and keywords like ''Takotsubo cardiomyopathy syndrome", ''COVID-19", ''SARS-COV-2".We exclusively selected case reports and/or case series.Irrelevant articles were excluded.Five articles were from USA [3][4][5][6][7] and four articles were from Italy [8-11] and one was from Switzerland [12].The search yielded a total of 16 patients with TTS in COVID-19 of which 11/16 patient's individual data were available, amongst whom 8/16 (50%) were male.Giustino G and colleagues reported 5 male patients of TTS with COVID-19 positive.Reported median age was 57 years (IQR: 39-65).The study reported that median time from symptoms onset to TTS diagnosis was 6.5 days (IQR: 1.0-8.0),troponin-1.4 ng/ml (IQR: 0.55-12.55),CK-MB-26.9ng/ ml, BNP-153 pg/ml, CRP-207 mg/dl, IL-6-56 pg/ml, Ejection fraction of 36% (IQR: 35%-37%).Four out 5(80%) patients suffered from acute kidney injury during hospitalization (Table 2).For other 11 individual patient's data, calculated median age was 67 years (IQR: 58-84).There were broad range of comorbidities reported amongst these patients, including hypertension (72.7%),Diabetes (45.5%), psychiatric illness (18.2%), malignancy (9.1%), dyslipidemia (9.1%) and one patient also had ischemic cardiomyopathy (9.1%).Four out of 11 (36.4%)patients had cardiac complications such as atrial fibrillation, pericardial effusion, car-