key: cord-0712504-mx77sqfj
authors: Tedeschi, Andrea; Camilli, Massimiliano; Ianni, Umberto; Tavecchia, Giovanni; Palazzini, Matteo; Cartella, Iside; Gentile, Piero; Quattrocchi, Giuseppina; Maria Spanò, Francesca; Cipriani, Manlio; Garascia, Andrea; Ammirati, Enrico
title: Takotsubo Syndrome after BNT162b2 mRNA Covid-19 vaccine: emotional or causative relationship with vaccination?
date: 2022-03-21
journal: Int J Cardiol Heart Vasc
DOI: 10.1016/j.ijcha.2022.101002
sha: 27f63b43d3d12c4b2db13a27acab704152e5c858
doc_id: 712504
cord_uid: mx77sqfj

nan

severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), that has afflicted over two hundred million people in a worldwide pandemic. BNT162b2 Pfizer BioNTech mRNA-SarsCoV-2 vaccines are effective in preventing COVID-19 with an excellent safety profile [1] , even if cardiac adverse events have been rarely reported, especially acute myocarditis [2, 3] . Early acknowledge of other potential cardiac consequences associated with mRNA COVID-19 vaccines could help health providers to promptly identify and treat adverse events. Takotsubo Syndrome (TTS), also known as stress cardiomyopathy, is a disorder characterized by acute and transient wall motion abnormalities with left ventricular (LV) systolic (and diastolic) dysfunction, often associated with a stressful, emotional, or physical event. Particularly females, in their seventh or eighth decade of life, are more frequently affected [4] . Up to now, few cases of TTS occurred after SARS-CoV-2 vaccines administration have been reported even including different types of vaccines (mRNA-1273-SARS-CoV-2 [5] [6] [7] , mRNA-BNT162b2-SarsCoV-2 [8] , and ChAdOx1 nCoV-19 vaccine) [9] . The occurrence of TTS in patients affected by congenital Long QT Syndrome (LQTS) has rarely been described [10] [11] [12] .

We herein report the case of a 71-year-old female who was admitted to our emergency department (ED) for self-limiting typical chest pain associated with shortness of breath that occurred almost five hours after administration of the first dose of BNT162b2 vaccine and persisted with a worsening trend for ten days. The patient's previous history included congenital LQTS (mutation in KCHNQ 1 gene), catheter ablation for paroxysmal atrial fibrillation, and known mitral prolapse with mild mitral regurgitation and (Figure 2 A-E). At the time of discharge, the QTc interval returned to normal values (440 ms). To the best of our knowledge, this is the first case of a patient with congenital LQTS who developed TTS after receiving the BNT162b2 COVID-19 vaccination. The rare association between TTS and congenital LQTS represents a great insult to myocardial cells repolarization reserve, conferring to patients affected a high risk of life-threatening arrhythmias occurrence [13] . Pathogenetic mechanisms underlying TTS are poorly understood: enhanced sympathetic activity and an excessive catecholamine surge following an emotional or physical trigger seem to play a key role in causing coronary microvascular dysfunction and direct myocardial injury. Furthermore, TTS has been described during viral infections, including Sars-COV2 [14] . In this case, the temporal association between vaccination and the onset of symptoms suggests a close relationship between TTS and the administration of the BNT162b2 vaccine. However, the mechanisms by which COVID-19 vaccination may have induced the TTS phenomenon are not clear. We speculate that the main pathways involved are the intense inflammatory reaction following vaccine administration and an enhanced sympathovagal imbalance towards adrenergic predominance, as described in previous TTS reports after the influenza vaccine [15] .

At the same time, robust evidence has demonstrated that psychological factors can impair the immune system's response to vaccines and are implicated in the prevalence and severity of vaccine-related side effects. The stress of an ongoing pandemic and the uncertainties related to COVID-19 vaccination may therefore have contributed, in a susceptible patient, to TTS occurrence. This case also suggests that TTS should be considered in the differential diagnosis across the spectrum of myocardial injury in patients undergoing COVID19 vaccination. Careful pharmacovigilance programs remain fundamental for evaluating vaccine safety and improving patient outcomes. While the body of evidence related to the possible complications of vaccination is progressively growing, the community benefits of this prevention strategy extensively counterbalance its side effects. 

Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine

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