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Heart, Lung and Circulation

Letter to the Editor Regarding: What Triggers Takotsubo After a SARS-CoV-2 Vaccination? Heart Lung Circ. 2021;30(12):e119–20

Published:January 19, 2022DOI:https://doi.org/10.1016/j.hlc.2021.12.010

      Keywords

      To the Editor,
      We read with interest the case report by Boscolo Berto et al. about a 63-year-old female who developed the classical type of Takotsubo cardiomyopathy (TTS) one day after her first jab of the Moderna vaccine [
      • Boscolo Berto M.
      • Spano G.
      • Wagner B.
      • Bernhard B.
      • Häner J.
      • Huber A.T.
      • et al.
      Takotsubo cardiomyopathy after mRNA COVID-19 vaccination.
      ]. The patient completely recovered without any treatment [
      • Boscolo Berto M.
      • Spano G.
      • Wagner B.
      • Bernhard B.
      • Häner J.
      • Huber A.T.
      • et al.
      Takotsubo cardiomyopathy after mRNA COVID-19 vaccination.
      ]. The study is appealing but raises several comments and concerns.
      We do not agree with the statement that the index case represents the first case with SARS-CoV-2 vaccination-induced TTS [
      • Boscolo Berto M.
      • Spano G.
      • Wagner B.
      • Bernhard B.
      • Häner J.
      • Huber A.T.
      • et al.
      Takotsubo cardiomyopathy after mRNA COVID-19 vaccination.
      ]. SARS-CoV-2 vaccination-induced TTS has previously been reported in at least four other cases (Table 1) [
      • Crane P.
      • Wong C.
      • Mehta N.
      • Barlis P.
      Takotsubo (stress) cardiomyopathy after ChAdOx1 nCoV-19 vaccination.
      ,
      • Jani C.
      • Leavitt J.
      • Al Omari O.
      • Dimaso A.
      • Pond K.
      • Gannon S.
      • et al.
      COVID-19 vaccine-associated Takotsubo cardiomyopathy.
      ,
      • Toida R.
      • Uezono S.
      • Komatsu H.
      • Toida T.
      • Imamura A.
      • Fujimoto S.
      • et al.
      Takotsubo cardiomyopathy after vaccination for coronavirus disease 2019 in a patient on maintenance hemodialysis.
      ,
      • Fearon C.
      • Parwani P.
      • Gow-Lee B.
      • Abramov D.
      Takotsubo syndrome after receiving the COVID-19 vaccine.
      ].
      Table 1SARS-CoV-2 vaccination triggered TTS reported as per the end of November 2021.
      AgeSexBrandLAOTTTS TypeTreatmentOutcomeReference
      63F1. Moderna1 dClassicalNonenr[
      • Boscolo Berto M.
      • Spano G.
      • Wagner B.
      • Bernhard B.
      • Häner J.
      • Huber A.T.
      • et al.
      Takotsubo cardiomyopathy after mRNA COVID-19 vaccination.
      ]
      72M1. AZV4 dClassicalDual APTCR[
      • Crane P.
      • Wong C.
      • Mehta N.
      • Barlis P.
      Takotsubo (stress) cardiomyopathy after ChAdOx1 nCoV-19 vaccination.
      ]
      65F1. Moderna2 dClassicalAspirin, atorvastatin, lisinopril, metoprololIR[
      • Jani C.
      • Leavitt J.
      • Al Omari O.
      • Dimaso A.
      • Pond K.
      • Gannon S.
      • et al.
      COVID-19 vaccine-associated Takotsubo cardiomyopathy.
      ]
      80F1. Pfizer4 dClassicalNoneIR[
      • Toida R.
      • Uezono S.
      • Komatsu H.
      • Toida T.
      • Imamura A.
      • Fujimoto S.
      • et al.
      Takotsubo cardiomyopathy after vaccination for coronavirus disease 2019 in a patient on maintenance hemodialysis.
      ]
      73F1. ModernanrClassicalMetoprolol, losartanIR[
      • Fearon C.
      • Parwani P.
      • Gow-Lee B.
      • Abramov D.
      Takotsubo syndrome after receiving the COVID-19 vaccine.
      ]
      Abbreviations: APT, antiplatelet therapy; AZV, Astra Zeneca vaccine; CR, complete recovery; IR, incomplete recovery at last follow-up; LAOT, latency between vaccination and onset of TTS; nr, not reported.
      Since SARS-CoV-2 vaccinations of any brand are not free of side effects [
      • Finsterer J.
      Neurological side effects of SARS-CoV-2 vaccinations.
      ], it would be interesting to know if the index patient reported any complaints in addition to fever and dyspnoea. Since headache is the most frequent neurological side effect and since headache can trigger TTS, we would like to know if the patient complained of a headache. Since the third most frequent neurological side effect of SARS-CoV-2 vaccinations is venous sinus thrombosis (VST), and VST is compulsorily associated with headache, we would like to know if there were any indications for VST. Since Guillain Barre syndrome (GBS) is the second most frequent neurological side effect of SARS-CoV-2 vaccinations [
      • Finsterer J.
      Neurological side effects of SARS-CoV-2 vaccinations.
      ], and GBS can go along with dysautonomia either in association with motor or sensory deficits or without, we would like to know if pure dysautonomic GBS was appropriately excluded. The authors themselves consider a sympatho-vagal imbalance towards adrenergic predominance as a possible pathophysiological mechanism. Since TTS is triggered by emotional or physical stress in one third each, we would like to know if any potential emotional or physical trigger was excluded; even fear from the vaccination can trigger TTS [
      • Sakamoto T.
      • Kagawa Y.
      • Endo A.
      • Tanabe K.
      Intense emotional stress over potential coronavirus disease vaccination side effects leads to Takotsubo cardiomyopathy.
      ].
      Overall, this interesting report had some limitations, which challenge the results and their interpretation. Before attributing TTS after a SARS-CoV-2 vaccination to the stress from the vaccination, several differential triggers of TSS should be considered.

      Acknowledgements

      None.

      Statement of Ethics

      In accordance if ethical guidelines.

      Conflicts of Interest

      None.

      Funding Sources

      No funding was received.

      Author Contribution

      JF: design, literature search, discussion, first draft, critical comments, final approval; TA: literature search, discussion, critical comments, final approval.

      Informed Consent

      Not applicable.
      The study was approved by the institutional review board.

      References

        • Boscolo Berto M.
        • Spano G.
        • Wagner B.
        • Bernhard B.
        • Häner J.
        • Huber A.T.
        • et al.
        Takotsubo cardiomyopathy after mRNA COVID-19 vaccination.
        Heart Lung Circ. 2021; 30: e119-e120
        • Crane P.
        • Wong C.
        • Mehta N.
        • Barlis P.
        Takotsubo (stress) cardiomyopathy after ChAdOx1 nCoV-19 vaccination.
        BMJ Case Rep. 2021; 14: e246580
        • Jani C.
        • Leavitt J.
        • Al Omari O.
        • Dimaso A.
        • Pond K.
        • Gannon S.
        • et al.
        COVID-19 vaccine-associated Takotsubo cardiomyopathy.
        Am J Ther. 2021; 28: 361-364
        • Toida R.
        • Uezono S.
        • Komatsu H.
        • Toida T.
        • Imamura A.
        • Fujimoto S.
        • et al.
        Takotsubo cardiomyopathy after vaccination for coronavirus disease 2019 in a patient on maintenance hemodialysis.
        CEN Case Rep. 2021; : 1-5
        • Fearon C.
        • Parwani P.
        • Gow-Lee B.
        • Abramov D.
        Takotsubo syndrome after receiving the COVID-19 vaccine.
        J Cardiol Cases. 2021; 24: 223-226
        • Finsterer J.
        Neurological side effects of SARS-CoV-2 vaccinations.
        Acta Neurol Scand. 2022; 145: 5-9
        • Sakamoto T.
        • Kagawa Y.
        • Endo A.
        • Tanabe K.
        Intense emotional stress over potential coronavirus disease vaccination side effects leads to Takotsubo cardiomyopathy.
        Circ Rep. 2021; 3: 476-477

      Linked Article

      • Takotsubo Cardiomyopathy After mRNA COVID-19 Vaccination
        Heart, Lung and CirculationVol. 30Issue 12
        • Preview
          A healthy 63-year-old woman with no cardiovascular risk factors was admitted to the emergency room with new-onset dyspnoea and fever. The symptoms started 1 day after receiving the first of two mRNA-1273 (Moderna, Cambridge, MA, USA) COVID-19 vaccinations. She had no other prior complaints. A retronasal severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test was negative. Laboratory tests revealed normal results for creatinine, creatine kinase, and creatine kinase MB (myocardial type).
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