American Journal of Medical Case Reports
ISSN (Print): 2374-2151 ISSN (Online): 2374-216X Website: Editor-in-chief: Apply for this position
Open Access
Journal Browser
American Journal of Medical Case Reports. 2020, 8(10), 350-357
DOI: 10.12691/ajmcr-8-10-8
Open AccessArticle

Apical Takotsubo Cardiomyopathy in a COVID-19 Patient Presenting with Stroke: A Case Report and Pathophysiologic Insights

Pramod Theetha Kariyanna1, Harshith Priyan Chandrakumar1, Apoorva Jayarangaiah2, Abdullah Khan3, Volodymyr Vulkanov4, Michael Ashamalla1, Moro O. Salifu1 and Samy I. McFarlane1,

1Department of Internal Medicine, State University of New York- Downstate Medical Center, Brooklyn, New York, U.S.A-11203

2Division of Hematology and Oncology, Department of Internal Medicine, Albert Einstein College of medicine/Jacobi Medical Center, Bronx, N.Y., U.S.A 10461

3Divisions of Cardiology, Department of Internal Medicine, Brookdale University Hospital and Research Center, Brooklyn, New York, U.S.A-11212

4Neurology, Department of Internal Medicine, Brookdale University Hospital and Research Canter, Brooklyn, New York, U.S.A-11212

Pub. Date: July 03, 2020

Cite this paper:
Pramod Theetha Kariyanna, Harshith Priyan Chandrakumar, Apoorva Jayarangaiah, Abdullah Khan, Volodymyr Vulkanov, Michael Ashamalla, Moro O. Salifu and Samy I. McFarlane. Apical Takotsubo Cardiomyopathy in a COVID-19 Patient Presenting with Stroke: A Case Report and Pathophysiologic Insights. American Journal of Medical Case Reports. 2020; 8(10):350-357. doi: 10.12691/ajmcr-8-10-8


COVID-19 is a pandemic that started in Wuhan city, Hubei province in China in December 2019 and is associated with high morbidity and mortality. It is characterized by a heightened inflammatory and prothrombotic state that are known to cause various cardiovascular manifestations such as thromboembolism, acute coronary syndrome and stroke. We here present a 72-year-old woman with multiple cardiovascular risk factors and COVI 19 pneumonia who presented with acute ischemic stroke. She was also noted to have ST segment elevation myocardial infarction (STEMI) on the electrocardiogram however the imaging and clinical presentation was consistent with apical takotsubo cardiomyopathy. We here discuss the various pathophysiologic mechanisms by which COVID-19 can result in acute stroke. The patient likely developed takotsubo cardiomyopathy because of stroke and acute COVID-19 induced sympathetic stimulation and catecholamine surge. To the best of our knowledge this is the first case of apical variant of takotsubo cardiomyopathy in a COVID-19 report.

COVID-19 takotsubo cardiomyopathy stress cardiomyopathy STEMI stroke cerebrovascular accident

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit


[1]  Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, Huang B, Shi W, Lu R, Niu P, Zhan F, Ma X, Wang D, Xu W, Wu G, Gao GF, Tan W, China Novel Coronavirus I and Research T. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020; 382: 727-733.
[2]  World Health Organization WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020. Available online at opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020.
[3]  COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU) available online at
[4]  Clerkin KJ, Fried JA, Raikhelkar J, Sayer G, Griffin JM, Masoumi A, Jain SS, Burkhoff D, Kumaraiah D, Rabbani L, Schwartz A, Uriel N. Coronavirus disease 2019 (COVID-19) and cardiovascular disease. Circulation 2020 Mar 21.
[5]  Klok FA, Kruip MJHA, van der Meer NJM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19 [published online ahead of print, 2020 Apr 10]. Thromb Res. 2020; S0049-3848 (20) 30120-1.
[6]  Li, Yanan and Wang, Mengdie and Zhou, Yifan and Chang, Jiang and Xian, Ying and Mao, Ling and Hong, Candong and Chen, Shengcai and Wang, Yong and Wang, Hailing and Li, Man and Jin, Huijuan and Hu, Bo, Acute Cerebrovascular Disease Following COVID-19: A Single Center, Retrospective, Observational Study (3/3/2020). Available at SSRN:
[7]  Andersen KG, Rambaut A, Lipkin WI, Holmes EC and Garry RF. The proximal origin of SARS-CoV-2. Nat Med. March 17, 2020. Zhang T WQ, Zhang Z. Probable pangolin origin of SARS-CoV-2 associated with the COVID-19 outbreak. Curr Biol. March 13, 2020.
[8]  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; MD
[9]  Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020.
[10]  Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020; 18(4): 844-847.
[11]  Hongde Hu, Fenglian Ma, Xin Wei, Yuan Fang, Coronavirus fulminant myocarditis treated with glucocorticoid and human immunoglobulin, European Heart Journal, ehaa190.
[12]  Simone Sala, Giovanni Peretto, Mario Gramegna, Anna Palmisano, Andrea Villatore, Davide Vignale, Francesco De Cobelli, Moreno Tresoldi, Alberto Maria Cappelletti, Cristina Basso, Cosmo Godino, Antonio Esposito, Acute myocarditis presenting as a reverse Tako-Tsubo syndrome in a patient with SARS-CoV-2 respiratory infection, European Heart Journal, ehaa 286.
[13]  Fei Zhou, Ting Yu, Ronghui Du, Guohui Fan, Ying Liu, Zhibo Liu, Jie Xiang, Yeming Wang, Bin Song, Xiaoying Gu, Lulu Guan, Yuan Wei, Hui Li, Xudong Wu, Jiuyang Xu, Shengjin Tu, Yi Zhang, Hua Chen, Bin Cao, 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.
[14]  Goyal et al., Clinical charcteristics of Covid-19 in New York city (Letter to the editor), NEJM, April 17, 2020.
[15]  Tavazzi G, Pellegrini C, Maurelli M, et al. Myocardial localization of coronavirus in COVID-19 cardiogenic shock. Eur J Heart Fail. 2020.
[16]  Mao L, Jin H, Wang M, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. 2020’
[17]  Ghinai I, Woods S, Ritger KA, et al. Community Transmission of SARS-CoV-2 at Two family gatherings - Chicago, Illinois, February -March 2020. MMWR Morb Mortal Wkly Rep 2020; 69: 446-450’
[18]  Minodier L, Charrel RN, Ceccaldi PE, et al. Prevalence of gastrointestinal symptoms in patients with influenza, clinical significance, and pathophysiology of human influenza viruses in faecal samples: what do we know? Virol J. 2015; 12: 215. Published 2015 Dec 12.
[19]  Walls AC, Park YJ, Tortorici MA, Wall A, McGuire AT and Veesler D. Structure, Function, and Antigenicity of the SARS-CoV-2 Spike Glycoprotein. Cell. 2020 Mar 6.
[20]  Hoffmann M, Kleine-Weber H, Schroeder S, Kruger N, Herrler T, Erichsen S, Schiergens TS, Herrler G, Wu NH, Nitsche A, Muller MA, Drosten C and Pohlmann S. SARS-CoV-2 Cell Entry Depends on ACE2 and TMPRSS2 and Is Blocked by a Clinically Proven Protease Inhibitor. Cell. 2020 Mar 4.
[21]  Matsuyama S, Nao N, Shirato K, Kawase M, Saito S, Takayama I, Nagata N, Sekizuka T, Katoh H, Kato F, Sakata M, Tahara M, Kutsuna S, Ohmagari N, Kuroda M, Suzuki T, Kageyama T and Takeda M. Enhanced isolation of SARS-CoV-2 by TMPRSS2- expressing cells. Proc Natl Acad Sci U S A. 2020 Mar 12.
[22]  Liu PP et al, The science underlying covid-19: Implications for the Cardiovascular system, 2020 Apr 15.
[23]  South AM et al, Covid-19, ACE2 and the cardiovascular consequences, 2020 May 1; 318(5): H1084-H1090.
[24]  Vaduganathan M, Vardeny O, Michel T, McMurray JJV, Pfeffer MA, Solomon SD. Renin-Angiotensin-Aldosterone System Inhibitors in Patients with Covid-19. N Engl J Med. 2020; 382(17): 1653-1659.
[25]  Yang. M, Cell Pyroptosis, a potential pathogenic mechanism of 2019-nCoV infection.
[26]  Huang C, Wang Y, Li X, Ren L, Zhao J et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet (London, England) 2020; 395 (10223): 497-506
[27]  Qin C, Zhou L, Hu Z, Zhang S, Yang S et al. Dysregulation of immune response in patients with COVID-19 in Wuhan, China. Clinical Infectious Diseases:an official publication of the Infectious Diseases Society of America 2020.
[28]  Chen L, Liu HG, Liu W, Liu J, Liu K et al.Analysis of clinical features of 29 patients with 2019 novel coronavirus pneumonia, Chinese Journal of Tuberculosis and Respiratory Diseases 2020; 43 (3): 203-208 (in Chinese).
[29]  Lippi G, Lavie CJ, Sanchis-Gomar F. Cardiac troponin I in patients with coronavirus disease 2019 (COVID-19): Evidence from a meta-analysis [published online ahead of print, 2020 Mar 10]. Prog Cardiovasc Dis. 2020; S0033-0620 (20) 30055-4.
[30]  Zhang Y, Xiao M, Zhang S, et al. Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19. N Engl J Med. 2020; 382(17): e38.
[31]  Vetta F, Vetta G, Marinaccio L. Coronavirus Disease 2019 (COVID-19) and Cardiovascular Disease: A Vicious Circle. J Cardiol Cardiovasc Res. 2020; 1(2): 1-12.
[32]  Cui, S., Chen, S., Li, X., Liu, S., & Wang, F. (2020). Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia. Journal of Thrombosis and Haemostasis.
[33]  Sharkey SW, Windenburg DC, Lesser JR, et al. Natural history and expansive clinical profile of stress (tako-tsubo) cardiomyopathy. J Am Coll Cardiol 2010; 55: 333-341.
[34]  Medina de Chazal H, Del Buono MG, Keyser-Marcus L, et al. Stress Cardiomyopathy Diagnosis and Treatment: JACC State-of-the-Art Review. J Am Coll Cardiol. 2018; 72(16): 1955-1971.
[35]  Tornvall P, Collste O, Ehrenborg E, Järnbert-Petterson H. A Case-Control Study of Risk Markers and Mortality in Takotsubo Stress Cardiomyopathy. J Am Coll Cardiol. 2016; 67: 1931-1936.
[36]  Patel N, Shenoy A, Dous G, Kamran H, El-Sherif N. Sepsis-Induced Takotsubo Cardiomyopathy Leading to Torsades de Pointes. Case Rep Cardiol. 2016; 2016: 2384752.
[37]  Lee VH, Connolly HM, Fulgham JR, Manno EM, Brown RD Jr, Wijdicks EF. Tako-tsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage: an underappreciated ventricular dysfunction. J Neurosurg 2006; 105: 264-270.
[38]  Le Ven F, Pennec PY, Timsit S, Blanc JJ. Takotsubo syndrome associated with seizures: an underestimated cause of sudden death in epilepsy? Int J Cardiol 2011; 146: 475-479
[39]  Riera M, Llompart-Pou JA, Carrillo A, Blanco C. Head injury and inverted Takotsubo cardiomyopathy. J Trauma 2010; 68: E13-E15
[40]  Kariyanna PT, Borhanjoo P, Jayarangaiah A, et al. Takotsubo Cardiomyopathy and Chronic Kidney Disease: A Scoping Study. Scifed J Cardiol. 2018; 2(3): 20.
[41]  Kariyanna PT, Sutarjono B, Jayarangaiah A, et al. Defining Features of Patients who Develop Takotsubo Cardiomyopathy during Myasthenic Crisis: A Systematic Review of Case Studies. Am J Med Case Rep. 2019; 7(9): 203-209.
[42]  Pelliccia F, Parodi G, Greco C, et al. Comorbidities frequency in Takotsubo syndrome: an international collaborative systematic review including 1109 patients. Am J Med. 2015; 128(6): 654. e11-9.
[43]  Ding H, Huang R, Shi X, Wu B. Stress-induced cardiomyopathy following infection of the upper respiratory tract in an elderly female patient: A case report. Exp Ther Med. 2016; 12(5): 3083-3086.
[44]  Kurisu S, Sato H, Kawagoe T, Ishihara M, Shimatani Y. Tako-tsubo-like left ventricular dysfunction with ST segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction. Am Heart J. 2002; 143: 448-55.
[45]  Cheung RTF, Hachinski V. The Insula and Cerebrogenic Sudden Death. Arch Neurol. 2000; 57(12): 1685-1688.
[46]  Oppenheimer SM, Wilson JX, Guiraudon C, Cechetto DF. Insular cortex stimulation produces lethal cardiac arrhythmias: a mechanism of sudden death? Brain Research. 1991; 550; 115-121.
[47]  Oppenheimer SM, Gelb A, Girvin JP, Hachinski VC. Cardiovascular effects of human insular cortex stimulation. Neurology. 1992; 42; 1727-32.
[48]  Wang TD, We CC, Lee YT. Myocardial stunning after cerebral infarction. Int J Cardiol. 1997; 58; 308-311.
[49]  Nguyen H, Zaroff JG. Neurogenic stunned myocardium. Curr Neurol Neurosci Rep. 2009; 9; 486-91.
[50]  Lyon, A., Rees, P., Prasad, S. et al. Stress (Takotsubo) cardiomyopathy—a novel pathophysiological hypothesis to explain catecholamine-induced acute myocardial stunning. Nat Rev Cardiol 5, 22-29 (2008).
[51]  Samuels MA. The brain-heart connection. Circulation. 2007; 116: 77-84.
[52]  Kariyanna, Pramod Theetha, Naseem Hossain, Apoorva Jayarangaiah, Nimrah.A. Hossain, Jonathan Christopher Francois, Jonathan D. Marmur, Moro O. Salifu, and Samy. I. McFarlane. 'Pharmaco-invasive Therapy for STEMI in a Patient with COVID-19: A Case Report.' American Journal of Medical Case Reports 8, no. 7 (2020): 192-196.
[53]  Hua A, O’Gallagher K, Sado D, Byrne J. Life-threatening cardiac tamponade complicating myo-pericarditis in COVID-19. European Heart Journal. 2020 Mar 30.
[54]  Courand PY, Harbaoui B, Bonnet M, Lantelme P. Spontaneous Coronary Artery Dissection in a Patient with COVID-19. JACC: Cardiovascular Interventions. 2020 Apr 7.
[55]  Kariyanna PT, Hossain NA, Jayarangaiah A, Hossain NA, Uppin V, Hegde S, Capric V, Salifu MO and McFarlane SI. Thrombus in Transit and Impending Pulmonary Embolism Detected on POCUS in a Patient with COVID-19 Pneumonia. American Journal of Medical Case Reports. 2020; 8(8): 225-228.