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COVID-19 and Stress Cardiomyopathy: How to Detect Broken Heart Syndrome vs MI with ECG

New information regarding COVID-19 continues to emerge daily. This content was based on the sources available at the time of writing.

As millions of Americans confront economic, social, and emotional stressors tied to the COVID-19 pandemic, cardiologists are wondering what toll all of that stress is taking on patients' heart health—particularly regarding their risk of broken heart syndrome.

That was the question posed in a study published in JAMA Network Open that found patients were over five times more likely to be hospitalized for stress cardiomyopathy during the pandemic than they were during non-pandemic times. The study compared 258 patients admitted with ACS in March and April 2020 and 1,656 ACS patients admitted during four other two-month control periods before March 2020. Among the patients admitted in March and April 2020, stress cardiomyopathy rates were 7.8%, while the rates of pre-pandemic patients averaged between 1.5 and 1.8%, which comports with current literature, the study's authors added.

None of the patients with stress cardiomyopathy tested positive for COVID-19, which underscores the notion that the sharp increase in the pandemic-era rates was independent of ischemic damage associated with the coronavirus. And while the pandemic didn't seem to affect mortality or readmission associated with stress cardiomyopathy, it did prolong average length of stay to eight days, compared to a pre-pandemic average of four to five days.

These trends all point to the potential consequences of stress cardiomyopathy among patients during an especially stressful time, as well as the particular impact of prolonged length of stay on already overutilized and under-resourced hospital facilities.

Stress in the COVID-19 Era

As one author noted in an article from Cleveland Clinic, patients are stressed about getting sick or losing loved ones to the virus, feeling lonely due to social distancing, and handling economic concerns amid record-breaking unemployment.

These types of emotional and financial stressors have long been associated with stress cardiomyopathy, otherwise known as Takotsubo or broken heart syndrome. However, stress has been a sustained and nearly ever-present force in 2020—not just because of the pandemic but also due to other factors, such as racial justice issues and the political climate of an election year.

In an April/May survey from the American Psychological Association, respondents rated their stress tied to the pandemic versus general stress as 5.9 and 5.4, respectively, on a 10-point scale. In 2019, the latter number was only 4.9. The report adds that current stress rates may be especially high for certain populations, including working parents and people of color.

Stress being so ubiquitous emphasizes the importance of diligence among providers to diagnose and treat ACS concerns promptly. Thoroughness is particularly critical given the similarities between Takotsubo syndrome and MI, which can share symptoms, lab results, and even waveform abnormalities.

As an efficient, lightweight, and accessible technology, ECG is a vital tool for informing care pathways, including cath lab activations and other interventions. But how do you differentiate stress cardiomyopathy from MI when the two can seem so similar?

What to Look for on the ECG

Patients with stress cardiomyopathy and MI tend to report similar symptoms, including angina. They also demonstrate troponin elevations, as one study in the Journal of the American Heart Association (JAHA) notes. There are overlaps in ST abnormalities as well: ST elevation (STE) can present in anywhere from 11 to 100% of stress cardiomyopathy cases.

These similarities historically made it more challenging to differentiate between Takotsubo, STEMI, and NSTEMI, but the large-cohort study in JAHA helped to clarify certain ambiguities. By analyzing a retrospective registry of 200 MI and 200 stress cardiomyopathy patients, researchers created a quick-reference flow chart to help guide ACS patient diagnostics using ECG.

Following the flow chart yields a 95% diagnostic specificity, the authors note, and can help to differentiate between four diagnoses: STE stress cardiomyopathy, non-STE stress cardiomyopathy, STEMI, and NSTEMI. All diagnoses involve an assessment of where elevations and depressions occur in the 12 leads.

The chart suggests that the first step is to assess ST elevation. If there is elevation in the segment, a series of scenarios involving STE and ST depression (STD) in different leads can help to diagnose STE stress cardiomyopathy versus STEMI. If there is not STE, there are also STE and STD scenarios that can differentiate between non-STE stress cardiomyopathy and NSTEMI.

Do note, however, that the JAHA flow chart is from 2016. Because of SARS-CoV-2's potential impact on the heart, researchers have learned more about ECG abnormalities from studying COVID-19 patients. Other considerations such as PR-segment depression may need to be taken into account to differentiate STEMI from myocarditis in COVID-19 patients.


To learn more about the power of the ECG in today's clinical landscape, browse our Diagnostic ECG Clinical Insights Center.


Mending Broken Hearts with Faster Detection

Even among people spared from SARS-CoV-2 infection, the pandemic's many stressors may affect patient health and psychosocial well-being for months or years to come. Second- and third-wave lockdowns, business closures, and social distancing measures may exacerbate the isolation, financial strains, and resultant stress that patients are feeling.

As pandemic-related stressors continue to increase patient risk and healthcare costs, cardiologists should be particularly mindful of patients who may be facing additional stress, such as minorities, working parents, and anyone enduring serious emotional or financial challenges tied to the pandemic.

Given the overlaps in ACS concerns, diagnostic tools such as ECG that are available at the point of care can help providers accurately detect emergent cardiac issues and avoid incorrect diagnoses.