A review of the presentation and outcome of Takotsubo cardiomyopathy in COVID-19



  • Kevin John | kevinjohn619@gmail.com Department of Critical Care, Bangalore Baptist Hospital, Bellary Road, Hebbal, Bengaluru, Karnataka, India. https://orcid.org/0000-0003-3382-0294
  • Amol Lal Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester MN, United States. https://orcid.org/0000-0002-0021-2033
  • Ajay Kumar Mishra Department of Medicine, Saint Vincent Hospital, Worcester, MA, United States.


Although the most frequent presentation of the novel Coronavirus disease-2019 (COVID-19) is a respiratory syndrome, cardiac involvement is being increasingly recognized. One such entity is takotsubo cardiomyopathy. We sought to review the various cases of takotsubo cardiomyopathy reported during the COVID-19 pandemic and consolidate the information available on its clinical features, evaluation and treatment. We performed a PubMed search using the MeSH terms “Takotsubo Cardiomyopathy” or “Stress Cardiomyopathy” and “COVID-19”, and identified 16 case reports, two case series, and one retrospective cohort study. There was a total of 24 reported patients with COVID-19 infection, who developed takotsubo cardiomyopathy, and two patients without COVID-19 who developed takotsubo cardiomyopathy due to the emotional stress associated with the global pandemic. The mean age of the patients was 67.19 years (SD 15.83) and 16(59.3%) were women. Chest pain was reported in only ten patients (38.46 %) and ST-elevation was seen in 11 patients (42.3%). While most patients had typical takotsubo cardiomyopathy, four patients had inverted(reverse) takotsubo cardiomyopathy, two had bi-ventricular involvement, one had median takotsubo and another had global takotsubo with apical sparing variant. Most patients had a positive outcome with complete or near-complete reversal of cardiac dysfunction at the time of discharge. Five deaths (19.23%) were reported. Takotsubo cardiomyopathy is a rare, but increasingly reported reversible cardiomyopathy that can be seen in patients with COVID-19 infection and the diagnosis must be actively sought for in these patients.



PlumX Metrics


Download data is not yet available.


Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of Novel coronavirus–infected pneumonia. N Engl J Med 2020; 382:1199–207. DOI: https://doi.org/10.1056/NEJMoa2001316

Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020; 382:1708-1720 DOI: https://doi.org/10.1056/NEJMoa2002032

Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus disease 2019 case surveillance — United States, January 22–May 30, 2020. Morb Mortal Wkly Rep. 2020; 69:759–65. DOI: https://doi.org/10.15585/mmwr.mm6924e2

Akashi YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo cardiomyopathy. Circulation. 2008; 118:2754–62. DOI: https://doi.org/10.1161/CIRCULATIONAHA.108.767012

Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): A mimic of acute myocardial infarction. Am Heart J. 2008; 155:408–17. DOI: https://doi.org/10.1016/j.ahj.2007.11.008

Sato M, Fujita S, Saito A, et al. Increased incidence of transient left ventricular apical ballooning (so-called `Takotsubo’ cardiomyopathy) after the mid-niigata prefecture earthquake. Circ J. 2006; 70:947–53. DOI: https://doi.org/10.1253/circj.70.947

Chadha S. “COVID-19 pandemic” anxiety-induced Takotsubo cardiomyopathy. QJM Mon J Assoc Physicians. 2020; 113:488–90. DOI: https://doi.org/10.1093/qjmed/hcaa135

Rivers J, Ihle JF. COVID-19 social isolation-induced Takotsubo cardiomyopathy. Med J Aust. 2020; 213:336-336.e1. DOI: https://doi.org/10.5694/mja2.50770

Nguyen D, Nguyen T, De Bels D, Castro Rodriguez J. A case of Takotsubo cardiomyopathy with COVID-19. Eur Heart J Cardiovasc Imaging. 2020 Sep 1;21(9):1052. DOI: https://doi.org/10.1093/ehjci/jeaa152

Bhattacharyya PJ, Attri PK, Farooqui W. Takotsubo cardiomyopathy in early term pregnancy: A rare cardiac complication of SARS-CoV-2 infection. BMJ Case Rep. 2020; 13: e239104. DOI: https://doi.org/10.1136/bcr-2020-239104

Jabri A, Kalra A, Kumar A, et al. Incidence of stress cardiomyopathy during the coronavirus disease 2019 pandemic. JAMA Netw Open. 2020; 3:e2014780. DOI: https://doi.org/10.1001/jamanetworkopen.2020.14780

Tsao CW, Strom JB, Chang JD, Manning WJ. COVID-19-associated stress (Takotsubo) cardiomyopathy. Circ Cardiovasc Imaging. 2020; 13:e011222. DOI: https://doi.org/10.1161/CIRCIMAGING.120.011222

Dave S, Thibodeau JT, Styrvoky K, Bhatt SH. Takotsubo cardiomyopathy in a coronavirus disease-2019–positive patient: A case report. AA Pract. 2020; 14:e01304. DOI: https://doi.org/10.1213/XAA.0000000000001304

Solano-López J, Sánchez-Recalde A, Zamorano JL. SARS-CoV-2, a novel virus with an unusual cardiac feature: Inverted Takotsubo syndrome. Eur Heart J. 2020; 41:3106. DOI: https://doi.org/10.1093/eurheartj/ehaa390

Faqihi F, Alharthy A, Alshaya R, et al. Reverse Takotsubo cardiomyopathy in fulminant COVID-19 associated with cytokine release syndrome and resolution following therapeutic plasma exchange: A case-report. BMC Cardiovasc Disord. 2020 26; 20:389.

Hegde S, Khan R, Zordok M, Maysky M. Characteristics and outcome of patients with COVID-19 complicated by Takotsubo cardiomyopathy: Case series with literature review. Open Heart. 2020; 7:e001360. DOI: https://doi.org/10.1136/openhrt-2020-001360

Minhas AS, Scheel P, Garibaldi B, et al. Takotsubo syndrome in the setting of COVID-19. JACC Case Rep. 2020; 2:1321–5. DOI: https://doi.org/10.1016/j.jaccas.2020.04.023

Sala S, Peretto G, Gramegna M, et al. Acute myocarditis presenting as a reverse Tako-Tsubo syndrome in a patient with SARS-CoV-2 respiratory infection. Eur Heart J. 2020; 41:1861–2. DOI: https://doi.org/10.1093/eurheartj/ehaa286

Pasqualetto MC, Secco E, Nizzetto M, et al. Stress cardiomyopathy in COVID-19 disease. Eur J Case Rep Intern Med. 2020; 7: 001718.

Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA. 2020; 323:1061–9. DOI: https://doi.org/10.1001/jama.2020.1585

Mishra AK, Lal A, Sahu KK, et al. Quantifying and reporting cardiac findings in imaging of COVID-19 patients. Monaldi Arch Chest Dis. 2020; 90. DOI: https://doi.org/10.4081/monaldi.2020.1394

Veillet-Chowdhury M, Hassan SF, Stergiopoulos K. Takotsubo cardiomyopathy: A review. Acute Card Care. 2014; 16:15–22. DOI: https://doi.org/10.3109/17482941.2013.869346

Hoffmann M, Kleine-Weber H, Schroeder S, et al. SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor. Cell. 2020; 181:271-280.e8. DOI: https://doi.org/10.1016/j.cell.2020.02.052

Siripanthong B, Nazarian S, Muser D, et al. Recognizing COVID-19–related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management. Heart Rhythm. 2020; 17:1463–71. DOI: https://doi.org/10.1016/j.hrthm.2020.05.001

Papanikolaou J, Tsolaki V, Makris D, Zakynthinos E. Early levosimendan administration may improve outcome in patients with subarachnoid hemorrhage complicated by acute heart failure. Int J Cardiol. 2014; 176:1435–7. DOI: https://doi.org/10.1016/j.ijcard.2014.08.039

Mrozek S, Srairi M, Marhar F, et al. Successful treatment of inverted Takotsubo cardiomyopathy after severe traumatic brain injury with milrinone after dobutamine failure. Heart Lung J Crit Care. 2016; 45:406–8. DOI: https://doi.org/10.1016/j.hrtlng.2016.06.007

Santoro F, Ieva R, Ferraretti A, et al. Hemodynamic effects, safety, and feasibility of intravenous esmolol infusion during Takotsubo cardiomyopathy with left ventricular outflow tract obstruction: Results from a multicenter registry. Cardiovasc Ther. 2016; 34:161–6. DOI: https://doi.org/10.1111/1755-5922.12182

Isogai T, Matsui H, Tanaka H, et al. Early β-blocker use and in-hospital mortality in patients with Takotsubo cardiomyopathy. Heart Br Card Soc. 2016; 102:1029–35. DOI: https://doi.org/10.1136/heartjnl-2015-308712

Mishra AK, Lal A, Sahu KK, Sargent J. Cardiovascular factors predicting poor outcome in COVID-19 patients. Cardiovasc Pathol. 2020; 49:107246. DOI: https://doi.org/10.1016/j.carpath.2020.107246

Mishra AK, Sahu KK, George AA, Lal A. A review of cardiac manifestations and predictors of outcome in patients with COVID – 19. Heart Lung. 2020; 49:848–52. DOI: https://doi.org/10.1016/j.hrtlng.2020.04.019

Roca E, Lombardi C, Campana M, et al. Takotsubo syndrome associated with COVID-19. Eur J Case Rep Intern Med. 2020; 7(5): 001665. DOI: https://doi.org/10.12890/2020_001665

Meyer P, Degrauwe S, Van Delden C, et al. Typical Takotsubo syndrome triggered by SARS-CoV-2 infection. Eur Heart J. 2020;41:1860. DOI: https://doi.org/10.1093/eurheartj/ehaa306

Taza F, Zulty M, Kanwal A, Grove D. Takotsubo cardiomyopathy triggered by SARS-CoV-2 infection in a critically ill patient. BMJ Case Rep. 2020;13:e236561 . DOI: https://doi.org/10.1136/bcr-2020-236561

Moderato L, Monello A, Lazzeroni D, et al. [Takotsubo syndrome during SARS-CoV-2 pneumonia: a possible cardiovascular complication]. G Ital Cardiol (2006). 2020; 21:417–20.

Dabbagh MF, Aurora L, D’Souza P et al. Cardiac tamponade secondary to COVID-19. JACC Case Rep. 2020; 2:1326–30. DOI: https://doi.org/10.1016/j.jaccas.2020.04.009

Faqihi F, Alharthy A, Alshaya R, et al. Reverse takotsubo cardiomyopathy in fulminant COVID-19 associated with cytokine release syndrome and resolution following therapeutic plasma exchange: a case-report. BMC Cardiovasc Disord. 2020; 20:389. DOI: https://doi.org/10.1186/s12872-020-01665-0

Oyarzabal L, Gómez-Hospital JA, Comin-Colet J. Tako-tsubo syndrome associated with COVID-19. Rev Espanola Cardiol Engl Ed. 2020; 73:846. DOI: https://doi.org/10.1016/j.recesp.2020.06.022


COVID-19 - Collection of articles on the Coronavirus outbreak
COVID-19; Takotsubo cardiomyopathy; Cardiomyopathy
  • Abstract views: 260

  • PDF: 173
How to Cite
John, Kevin, Amos Lal, and Ajay Mishra. 2021. “A Review of the Presentation and Outcome of Takotsubo Cardiomyopathy in COVID-19”. Monaldi Archives for Chest Disease, March. https://doi.org/10.4081/monaldi.2021.1710.