# Biological stress, self-rated stress, anxiety and depression in women with takotsubo syndrome

## TL;DR

Women with takotsubo syndrome show higher morning saliva cortisol levels six months after the event, suggesting biological stress, but no major psychological differences compared to controls.

## Contribution

This study provides new insights into biological stress markers in takotsubo syndrome patients six months post-event.

## Key findings

- Awakening saliva cortisol levels were significantly higher in takotsubo syndrome patients compared to controls.
- No significant differences in evening cortisol levels or depression scores were observed.
- Weak correlations were found between cortisol levels and self-rated stress or anxiety.

## Abstract

Takotsubo syndrome is a condition associated with stress, anxiety and depression. Biological stress in takotsubo syndrome is scarcely described in the literature. The aim of this study was to investigate if biological and self-rated stress, anxiety and depression in women with takotsubo syndrome reflect a long-term state of psychological burden, with the hypothesis that saliva cortisol is increased six months after the acute event.

Forty-seven women were diagnosed with takotsubo syndrome in a diagnostic cross-sectional study, of those 29 had saliva cortisol measured at awakening and in the evening. Additionally, 34 women completed the perceived stress scale (PSS-14), 35 completed the hospital anxiety and depression scale-anxiety (HADS-A) scale and 33 completed hospital anxiety and depression scale-depression (HADS-D) scale, six months after the acute event. Results were compared with a population-based age-matched group of 227 women from the Swedish cardiopulmonary bioimage study (SCAPIS).

Awakening saliva cortisol levels were significantly increased in takotsubo syndrome patients compared with the SCAPIS group (p = 0.039). No significant differences were seen in evening saliva cortisol levels (p = 0.267). There was a trend, towards higher self-rated stress (p = 0.087), but no significant difference, in anxiety (p = 0.133) or depression (p = 0.385) between takotsubo syndrome patients and the population-based age-matched group. There were significant correlations between awakening saliva cortisol and anxiety (negative, p = 0.036), and between evening cortisol and self-rated stress (positive, p = 0.050) but no correlation with depression was observed.

Women with takotsubo syndrome have higher levels of cortisol in saliva measured in the morning, but similar levels measured in the evening six months after the acute event when compared with population-based controls. We found weak associations between biological (cortisol) and psychological (PPS-14, HADS-A and HADS-D) assessments. The effect size of the difference in awakening cortisol was small and the clinical relevance is uncertain, but the results indicates that takotsubo syndrome patients have signs of biological stress. Our findings, together with previous research on stress, anxiety and depression in patients with takotsubo syndrome, indicate a need for further assessment of psychological stress, possibly by interviews, and for secondary prevention to reduce stress.