Possible association between lithium intoxication and Takotsubo syndrome

More than 25 years after being diagnosed with bipolar disorder and receiving continuous treatment with lithium, a woman develops Takotsubo syndrome.

A rare case of Takotsubo cardiomyopathy

BACKGROUND

The recent advent of the cyclin-dependent kinase (CDK) 4/6 inhibitors has considerably evolved hormone receptor (HR)-positive/human epidermal growth factor receptor 2 (HER2)-negative metastatic breast cancer treatment. Palbociclib, an orally administered pyridopyrimidine derivative, was the first CDK4/6 inhibitor to be introduced into daily clinical practice in combination with classic endocrine backbone, based on progression-free survival (PFS) benefit assessed in the pivotal PALOMA series of randomized clinical trials. Regarding its safety profile, neutropenia and leukopenia are the most common and well-defined adverse effects, while cardiac complications are rather scarce.

CASE REPORT

We present the rare case of a middle-aged female patient with HR+/HER2- metastatic breast cancer, without prior exposure to cardiotoxic antineoplastic agents, who developed Takotsubo cardiomyopathy (TTC) in the context of systemic therapy with palbociclib plus letrozole combination.

CONCLUSIONS

Pharmacovigilance and experimental studies are warranted to confirm any causative relationship and to explore the underlying pathophysiology, respectively.

Ketamine's love story with the heart: A Takotsubo twist

INTRODUCTION

Ketamine is a dissociative anesthetic with N-methyl-d-aspartate and glutamate receptor antagonist properties. It has been the most popular agent to facilitate emergency department procedures for three decades. Considered a safe and effective option for procedural sedation, ketamine has rapid onset, short effective sedation time, and a low risk profile. Ketamine's sympathomimetic effects could theoretically induce stress-related cardiac dysfunction, including cardiomyopathy. A review of the literature demonstrates one prior report of stress (Takotsubo) cardiomyopathy after ketamine sedation.

CASE REPORT

In this case report, we present a case of Takotsubo cardiomyopathy after ketamine sedation for distal radius fracture reduction. The patient presented hemodynamically normal with an unremarkable cardiac ultrasound and progressed to hypoxia from bilateral pulmonary edema, eventually requiring intubation. Inpatient evaluation revealed elevated high sensitivity troponin, non-obstructive coronary arteries on catheterization, and echocardiogram findings of Takotsubo cardiomyopathy. She received operative fixation of her radius fracture by orthopedics and was discharged home on hospital day 9. She had an unremarkable follow up with cardiology but had no echocardiogram to determine full resolution.

CONCLUSION

Although ketamine has robust evidence of safety and efficacy, physicians should be aware of the potential complications of its sympathomimetic effects, from hypertension and tachycardia to overt Takotsubo cardiomyopathy.

Pharmacological Triggers of Takotsubo Cardiomyopathy: An Updated Review of Evidence and Recommendations

BACKGROUND

Previous publications in 2011, 2016, and 2022 have presented lists of drugs associated with takotsubo cardiomyopathy (TCM). This review aims to provide updated drug lists that have been reported as potential causes of TCM.

METHODS

Following the same methodology employed in previous reviews, a detailed investigation was carried out in the PubMed/Medline database from June 2022 to July 2023 to identify drug-induced TCM (DITC) case reports. Various search terms related to the drug-induced transient left ventricular ballooning syndrome, ampulla cardiomyopathy, apical ballooning syndrome, drug-induced broken heart syndrome, drug triggered takotsubo cardiomyopathy, takotsubo cardiomyopathy, and iatrogenic takotsubo cardiomyopathy were utilized. Filters for fulltext availability, case reports, human studies, and English language were applied. Articles reporting drugs associated with TCM development were included in the analysis.

RESULTS

Foremost 192 case reports were initially identified, with 75 drugs meeting the inclusion criteria after a thorough review. The latest revision identified seven drugs that might lead to TCM, with four drugs (57.14%) already reported in previous reviews and three drugs (42.86%) newly identified. Consequently, the updated drug list potentially triggering TCM in 2023 comprises a sum of 75 drugs.

CONCLUSION

The recent 75 drugs provided additional evidence linking to TCM development. The updated list predominantly includes drugs that induce sympathetic overstimulation, although some drugs on the list have unclear associations with sympathetic nervous system activation.

Takotsubo Cardiomyopathy Related to Duloxetine-Atomoxetine Combination in an Adolescent with ADHD and Comorbid GAD

Authors report on an interesting case of a teenager with attention-deficit/hyperactivity disorder and comorbid generalized anxiety disorder, who developed takotsubo cardiomyopathy subsequent to pharmacokinetic and pharmacodynamic interactions between atomoxetine, a selective norepinephrine reuptake inhibitor, and the antidepressant duloxetine. Clinicians should be mindful of the potential for cardiovascular adverse effects when prescribing agents that target noradrenergic receptors.

Drugs as Possible Triggers of Takotsubo Cardiomyopathy- Update 2022: Systematic Review

BACKGROUND

A list of drugs that can induce takotsubo cardiomyopathy (TCM) was published in 2011 and 2016. The aim of the present review was to update this list.

METHODS

Similar to the 2011 and 2016 reviews, from April 2015 to May 2022 case reports of druginduced TCM were identified by a comprehensive search in Medline/PubMed database. The search terms were: takotsubo cardiomyopathy, tako-tsubo cardiomyopathy, stress cardiomyopathy, transientleft- ventricular ballooning syndrome, apical ballooning syndrome, ampulla cardiomyopathy OR broken heart syndrome; together with "iatrogenic", "induced by" OR "drug-induced". Registers published in English or Spanish, in humans, and with full texts were retrieved. Articles that recognized any drug associated with the development of TCM were selected.

RESULTS

Overall, 184 manuscripts were identified by the search. A total of 39 articles were included after an exhaustive revision. Eighteen drugs as possible triggers of TCM were identified in the current update. Of them, 3 (16.7%) have been previously identified, and 15 (83.3%) are different from the previous reports. Thus, the list of drugs as possible triggers of TCM updated in 2022 includes 72 drugs.

CONCLUSION

There are new case reports that link drugs with the development of TCM. The current list is principally made up of drugs that generate sympathetic overstimulation. However, some of the listed drugs do not have a clear link with sympathetic activation.

Takotsubo Syndrome in a Rheumatoid Arthritis Patient Under Tofacitinib: A Case Report

We describe a case of a 57-year-old white woman treated for rheumatoid arthritis (RA) with tofacitinib 10mg daily (started one year ago) and prednisolone 5mg daily. She presented to the emergency department with a tight squeezing chest pain and shortness of breath for 7h and the clinical evaluation revealed regional systolic dysfunction of the left ventricle, mimicking a myocardial infarction, in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. All changes were transient and resolved completely within 4 days. The diagnosis of Takotsubo cardiomyopathy (TKM) was established. This is, as far as we know, the first report of a case of TKM in a RA patient taking tofacitinib. Although the association has not been previously described and the precise cause cannot be identified in this patient, the association with tofacitinib should be considered given the etiopathogenic rationale and the absence of any other identifiable cause.

Takotsubo cardiomyopathy associated with dydrogesterone use

Takotsubo cardiomyopathy is characterised by left ventricular apical ballooning, in the absence of coronary artery disease, and classically occurs at times of intense stress. Due to the striking preponderance of Takotsubo cardiomyopathy occurring in postmenopausal women, it has been postulated that female sex hormones may also be implicated in its pathogenesis. This case report describes the first case of Takotsubo cardiomyopathy associated with the initiation of dydrogesterone (a synthetic retroprogesterone) in a premenopausal woman.

Takotsubo cardiomyopathy caused by infusion reaction to paclitaxel

Takotsubo cardiomyopathy (TCM) secondary to an infusion reaction is extremely rare in the literature. Here, we present an unusual case of TCM in a patient with cervical squamous cell carcinoma who presented with acute hypoxic respiratory failure following the initiation of the first-cycle paclitaxel infusion therapy.

[Venlafaxine was suspected to have triggered life-threatening takotsubo syndrome]

We present a case of a patient who ingested excessive amounts of the antidepressant Venlafaxine, a Selective Serotonin-Norepinephrine Reuptake Inhibitor (SNRI). She developed cardiogenic shock with clinical and echocardiographic signs of takotsubo syndrome, TTS; a life-threatening condition characterized by a transient regional cardiac dysfunction not solely caused by coronary artery occlusion. The pathogenesis remains unclear but catecholamines play a key role. Venlafaxine increases plasma catecholamine levels and with high probability it was judged to be the trigger for our patient's serious state. Our case study included clinical and laboratory data, as well as a literature review on published cases of SNRI associated TTS. Most cases of TTS fortunately show spontaneous recovery of cardiac function with conservative management and supportive treatment. No evidence-based treatment recommendations exist, but traditional inotropic and vasoactive drugs are considered potentially harmful, which can be a dilemma for the treating clinician, when facing an acutely decompensated TTS patient.

Immune checkpoint inhibitor-induced takotsubo syndrome and diabetic ketoacidosis: rare reactions

Immune checkpoint inhibitors (ICIs) are increasingly used to treat certain malignancies due to their higher efficacy compared with conventional chemotherapy. As familiarity with these agents increases, it is becoming apparent that a significant number of patients treated with ICIs experience adverse events. With time, more immune-related adverse events (IRAEs) are being recognised. It is important to be vigilant for IRAEs and recognise that a patient may have multiple IRAEs affecting multiple organ systems. Common cardiovascular adverse events associated with ICIs include myocarditis, arrhythmias and pericarditis. This case report identifies a patient presenting with takotsubo syndrome followed by ketoacidosis (associated with sodium-glucose transport protein 2 (SGLT2) inhibitor) in the setting of combination ipilimumab and nivolumab therapy for metastatic melanoma.

Management of cardiogenic shock by circulatory support during reverse Tako-Tsubo following amphetamine exposure: A report of two cases

Stress-induced cardiomyopathy, also known by various names such as Tako-Tsubo cardiomyopathy (TTC), is a cardiomyopathy that presents different types of transient left ventricular dysfunction. We present two cases of reverse TTC occurring in two young men after amphetamine use and complicated by cardiogenic shock necessitating venoarterial extra-corporeal membrane oxygenation (VA-ECMO). Levosimendan was used in one case to prevent subsequent aggravation of left ventricular function provoked by the use of catecholamine in this context. In both cases, myocardial function recovered rapidly. Amphetamine use can lead to reverse TTC requiring transient mechanical assistance and inotropic support.

Angioedema and Epinephrine Causing a Stress-Induced Cardiomyopathy

Presentations of angioedema range from mild edema to immediate life-threatening airway involvement. Management is typically straightforward and dependent on the degree of presentation. In our case, a 61-year-old female presented with angioedema requiring immediate intubation. Before admission to the intensive care unit, a screening ECG was obtained that revealed ST segment elevations which redirected our patient to the cardiac catherization lab. Our patient was ultimately diagnosed with a stress-induced cardiomyopathy after initially presenting with ACE-inhibitor induced angioedema.

Lamotrigine-induced hemophagocytic lymphohistiocytosis with Takotsubo cardiomyopathy: a case report

BACKGROUND

Hemophagocytic lymphohistiocytosis is a rare hematological syndrome characterized by excessive and uncontrolled activation of the immune system. The often nonspecific nature of early symptoms and the potential for progression to multiorgan failure and death if appropriate therapy is not started promptly, highlight the importance of heightened recognition for this uncommon disease. Although there are well-described associations of hemophagocytic lymphohistiocytosis with infectious, malignant, and autoimmune diseases and an established treatment protocol for these cases, the link between medications and hemophagocytic lymphohistiocytosis is less clearly established and the optimal treatment of these cases less well defined.

CASE PRESENTATION

Here we describe the case of a 45-year-old caucasian woman presenting with signs and symptoms consistent with hemophagocytic lymphohistiocytosis, induced by recent exposure to lamotrigine. She had a rapidly progressive clinical course, complicated by multiorgan failure including stress-induced Takotsubo cardiomyopathy and cardiac arrest. With dexamethasone and etoposide therapy, she made a full and sustained recovery.

CONCLUSIONS

This case highlights that medication-induced hemophagocytic lymphohistiocytosis appears to respond similarly to the same dexamethasone and etoposide treatment regimen developed for other non-drug-induced forms of hemophagocytic lymphohistiocytosis. With the continued cessation of the offending agent there has not been need for maintenance therapy and no relapse to date. In addition, given the risk for cardiomyopathy, a clinical complication not classically associated with hemophagocytic lymphohistiocytosis, echocardiogram and telemetry monitoring should be considered in the initial workup of suspected hemophagocytic lymphohistiocytosis.

Takotsubo Cardiomyopathy Induced by Epinephrine Infiltration for Liposuction: Broken Heart Syndrome

Broken heart syndrome, more commonly known as Takotsubo cardiomyopathy (TCM), is an acute cardiac condition. It is characterized by regional cardiac wall motion abnormalities triggered by physical or emotional stress or administration of catecholamines such as epinephrine. The initial clinical presentation is similar to an acute coronary syndrome and must be ruled out. Visualization of the characteristic wall motion will trigger the diagnosis of TCM. In this case report, we present a 50-year-old woman with additional liposuction and fat grafting after autologous breast reconstruction. Shortly after infiltration with a solution containing epinephrine to achieve vasoconstriction, hypotension and bradycardia was noticed. This escalated into full asystole for which cardiac resuscitation was required. ST-elevations and a decrease in systolic function were clear indicators for urgent coronarography and ventriculography. These confirmed the diagnosis of TCM. Infiltration with epinephrine-containing products to achieve local vasoconstriction is used routinely. Medical professionals should be aware that this can trigger a TCM with an estimated mortality rate of 5%. No evidence of a specific preventive measure currently exists. We know that women with a neurologic or psychiatric comorbidity and high levels of stress are more at risk. Reducing stress and anxiolytic medication prior to surgery could be useful. We also know that the cardiac wall motion abnormality is mainly related to β-adrenoreceptors. The use of a selective α-adrenoreceptor agonist could be considered. Further research in the pathophysiology and incidence of TCM could improve identification of patients at risk and lead to more effective prevention and treatment.

LEVEL OF EVIDENCE: 5

Takotsubo cardiomyopathy associated with serotonin syndrome in a patient with stroke: A case report

RATIONALE

Takotsubo cardiomyopathy (TC) is characterized by transient left ventricular dysfunction. We describe a patient with stroke who presented with TC caused by serotonin syndrome (SS) following the administration of serotonergic and dopaminergic agents.

PATIENT CONCERNS

A 55-year-old man with stroke was administered venlafaxine, tianeptine, ropinirole, carbidopa/levodopa, bromocriptine, and methylphenidate during rehabilitation. The patient presented with clinical features of SS (mental confusion, agitation, hyperhidrosis, chills, rigidity, and tachycardia), which persisted over 24 hours. The day after his SS symptoms disappeared, the patient's blood pressure decreased, and he developed tachycardia.

DIAGNOSES

Echocardiography revealed an extensively akinetic apical segment and a severely hypokinetic midventricular segment of the left ventricle with basal hyperkinesia. The ejection fraction was reduced to 38%, and he was diagnosed with TC by the cardiologist.

INTERVENTIONS

He was administered oxygen at 8 to 10 L/minutes via a Venturi mask, and norepinephrine bitartrate was administered intravenously. Hydration was maintained with normal saline infusion.

OUTCOMES

Following appropriate management of TC, the patient was hemodynamically stable with significant recovery of his left ventricular wall motion.

LESSONS

Prognosis of TC is usually favorable; however, it could be fatal in some cases. Clinicians should be aware of the potential development of TC in patients with stroke presenting with SS following the administration of serotonergic and dopaminergic agents.

[Takotsubo cardiomyopathy developing during anagrelide therapy in a patient with essential thrombocythemia]

A 76-year-old woman taking anagrelide (ANA) for essential thrombocythemia (ET) was rushed to the hospital by ambulance because of severe chest pain. Echocardiography revealed apical akinesis with basal and mid-hyperkinesis, and a coronary angiography revealed no significant stenosis in the dominant coronary artery. The patient was diagnosed with takotsubo cardiomyopathy (Tako). Tako is typically believed to be caused by stress; however, no stress was detected except that related to ANA therapy. ANA is useful in treating ET and is known to have severe cardiovascular effects. We must pay careful attention to Tako during ANA therapy.

Takotsubo cardiomyopathy after intravenous epinephrine administration following cardiac arrest provoked by pneumoperitoneum - a case report

In stress-induced takotsubo cardiomyopathy (TC) high levels of catecholamines, including epinephrine, may be detected in blood. On the other hand, administration of exogenous epinephrine may occasionally result in TC.

A CASE REPORT

The authors describe a case of a 58-year-old, otherwise healthy female, with TC which occurred after intravenous injection of 1 mg of epinephrine against cardiac arrest provoked by pneumoperitoneum performed before planned laparoscopic cholecystectomy. She was admitted 3 days earlier due to biliary colic following a dietary mistake. Bradycardia followed by asystole took place immediately after carbon dioxide insufflation into the peritoneal cavity. Normal heart rhythm, with transient tachycardia, recurred after a short cardiac massage, intravenous atropine and epinephrine administration as well as pneumoperitoneum decompression. ECG after the episode showed nonspecific ST segment changes. Left ventricular dysfunction assessed in echocardiography as contractile abnormalities and decreased global longitudinal strain (GLS) represented an unusual type of TC - intermediate between mid-basal and focal one. These abnormalities, involving mainly the posterior wall, resolved rapidly within 24 hours without any specific treatment. The absence of coronary artery disease was confirmed by 128-row multidetector computed tomography. TC should be considered as a potential complication of epinephrine action; however, different factors related to laparoscopic procedure including general anesthesia, intubation, underlying disease and mental stress might have been also involved in TC triggering in the case presented.

Intrathecal Clonidine Pump Failure Causing Acute Withdrawal Syndrome With 'Stress-Induced' Cardiomyopathy

Clonidine is a central alpha(2)-agonist antihypertensive used widely for opioid/alcohol withdrawal, attention deficit hyperactivity disorder and chronic pain management. We describe a case of clonidine withdrawal causing life-threatening hypertensive crisis and stress-induced cardiomyopathy. A 47-year-old man with chronic back pain, treated with clonidine for many years via intrathecal pump (550 mcg/24 h), presented following a collapse and complaining of sudden worsening of back pain, severe headache, diaphoresis, nausea and vomiting. A few hours prior to presentation, his subcutaneous pump malfunctioned. On presentation, vital signs included pulse 100 bpm, BP 176/103 mmHg, temperature 37.8 °C and O2 saturation 100 % (room air). Acute clonidine withdrawal with hypertensive crisis was suspected. Intravenous clonidine loading dose and a 50 mcg/h infusion were commenced. Five hours later, severe chest pain, dyspnoea, tachycardia, hypoxia, with BP 180/120 mmHg and pulmonary edema ensued. ECG showed sinus tachycardia with no ST elevation. Repeated intravenous clonidine doses were given (25 mcg every 5-10 min), with ongoing clonidine infusion to control blood pressure. Glyceryl trinitrate infusion, positive pressure ventilation and intravenous benzodiazepines were added. Bedside echocardiogram showed stress-induced cardiomyopathy pattern. Serum troponin-I was markedly elevated. His coronary angiography showed minor irregularities in the major vessels. Over the next 3 days in the ICU, drug infusions were weaned. Discharge was 12 days later on oral clonidine, metoprolol, perindopril, aspirin and oxycodone-SR. Two months later, his echocardiogram was normal. The intrathecal pump was removed. We report a case of stress-induced cardiomyopathy resulting from the sudden cessation of long-term intrathecal clonidine. This was managed by re-institution of clonidine and targeted organ-specific therapies.

Clinical features and outcome of epinephrine-induced takotsubo syndrome: Analysis of 33 published cases

BACKGROUND

Takotsubo syndrome (TS) may be triggered by innumerable physical stress factors including epinephrine administration. The aim of this study is to report on the clinical features and outcome of epinephrine-induced TS (Epi-TS) in a large cohort of published cases.

METHODS

A computer assisted search of the electronic data base Pubmed was performed from 1990 to 2014. All cases deemed to have Epi-TS were retrieved and compared to the large recent report by Templin et al. (All-TS).

RESULTS

Thirty-three cases of Epi-TS were retrieved from the literature and compared to 1750 cases of All-TS. Chest pain as a presenting symptom occurred in 45% of cases. The Epi-TS patients were on average 20.6years younger than All-TS patients (p<0.0001). The women were still predominating in Epi-TS but in a significantly lower percentage compared to ALL-TS (73% in Epi-TS vs 89.8% in All-TS, p=0.0054). One third of the Epi-TS cases had basal pattern of TS compared to 2.2% of cases reported in All-TS. Epi-TS cases were characterized by high complication rates, which occurred in 57.6%. The most important risk factor for the development of TS complication was the accidental administration (P<0.001) and the dose of >1mg epinephrine (p=0.02). In spite of high complication rates, the recovery was rapid with no in-hospital mortality.

CONCLUSION

Epi-TS is characterized by a dramatic rapid onset of symptoms after epinephrine administration. Almost half of the cases had apical sparing and one third basal pattern of TS. In spite of high complication rates, the prognosis was good with no in-hospital mortality.

Transient global ventricular dysfunction in an adolescent affected by pancreatic adenocarcinoma

BACKGROUND

Takotsubo cardiomyopathy (TC) is characterized by a transient decrease in ejection fraction and a reversible left ventricular dysfunction. The pathophysiology of TC is not completely understood. Heterogeneous and multifactorial mechanisms are involved: drugs, emotional and physical stress, genetic and hormonal factors.

CASE PRESENTATION

A 17 year-old male with metastatic pancreatic adenocarcinoma, under chemotherapy containing 5-fluorouracil, presented severe left ventricular dysfunction requiring mechanical ventilation and inotropes administration. He completely recovered in 2 weeks.

CONCLUSION

To our knowledge this is the first report of transient form of ventricular dysfunction, mimicking TC, in an adolescent. We believe that children and adolescents receiving 5-fluorouracil should be closely monitored and referred for investigation if they develop cardiac symptoms.

[Two cases of takotsubo cardiomyopathy in patients treated with high doses of inhaled beta-2-agonists]

Takotsubo cardiomyopathy (TCM) is characterised by reversible left ventricular dysfunction in patients presenting with acute coronary syndrome (ACS). TCM is considered multifactorial, and the repetitive exposure to inhaled beta-2-agonists has been suspected to induce TCM in predisposed individuals. We report two cases of TCM in female patients presenting with ACS both exposed to inhaled beta-2-agonists. Eccocardiography revealed apical ballooning and reduced left ventricular function. Coronary angiography was with no significant stenosis. Both patients recovered by anticongestive treatment.

Fatal Takotsubo cardiomyopathy due to epinephrine in shoulder arthroscopy

The authors report a case of a shoulder arthroscopy in which epinephrine saline irrigation was held responsible for acute hypertension followed by fatal Takotsubo cardiomyopathy.

Fatal Case of Recurrent Takotsubo Cardiomyopathy Presenting with Cardiac Arrest and Variable Ventricular Involvement What Role Beta Agonist and Beta Blockers?

In conclusion, we believe that the demise of the patient is due to the combination of severe emotional distress, respiratory distress with fear of impending doom, and the overuse of B2 agonists likely created an opportune environment for Takotsubo cardiomyopathy. We also propose a mechanism whereby recurrences with different wall motion variants may occur during beta blocker therapy.

Takotsubo cardiomyopathy with involvement of delayed-onset rhabdomyolysis and acute kidney injury after rosuvastatin treatment

Takotsubo cardiomyopathy is a disorder characterized by left ventricular apical ballooning with preceding emotional and/or physical stressors. This condition is also an important differential diagnosis of acute coronary syndrome. We herein describe a case of Takotsubo cardiomyopathy, a significant clinical phenomenon, triggered by delayed-onset rhabdomyolysis following the administration of long-term statin treatment, without any preceding stressors or changes in the patient's medical condition, in association with complaints of non-specific muscle-related symptoms. Although an electrocardiogram showed remarkable ST-segment elevation, a careful reading of the electrocardiogram findings revealed the features of Takotsubo cardiomyopathy. Withdrawing the statin therapy improved the patient's cardiac function.

Life-threatening QT prolongation in a boy with attention-deficit/hyperactivity disorder on atomoxetine

As a noncentral nerve-stimulating agent blocking reuptake of noradrenalin, atomoxetine is used for treatment of attention-deficit/hyperactivity disorder (ADHD). Because it has less potential for addiction and abuse and improves core symptoms of ADHD, it is commonly prescribed in many children and adolescents internationally. Its common side effects include headache, abdominal pain, decreased appetite, and weight loss. In addition, cardiac effects such as tachycardia and hypertension have also been reported. In this case report, an 11-year-old Japanese boy with a past medical history of ADHD on atomoxetine for more than 2 years presented with a loss of consciousness. Initial electrocardiogram (ECG) showed significant QT prolongation, and 9 h later, it worsened, along with bradycardia, inversed T waves, and multiple premature ventricle contractions (PVCs). Transthoracic echocardiography showed akinesis with dilation and systolic ballooning of the left ventricle's (LV) apical segment (Takotsubo cardiomyopathy). At that point, bisoprolol and transcutaneous pacing were started. After 5 days, transcutaneous pacing was discontinued due to improvement in his cardiac rhythm. He continued to remain asymptomatic for the next year, while his QT interval returned to normal. Conclusion: This case report suggests a serious side effect of atomoxetine, and to avoid life-threatening cardiovascular events for children and adolescents with ADHD on atomoxetine, prior screening for cardiovascular conditions by ECG with close monitoring is necessary.

Delayed multifocal recurrent stress-induced cardiomyopathy after antidepressants withdrawal

Stress-induced cardiomyopathy is an acute disease characterized by a large left ventricular apical dyskinesia ("apical ballooning"), triggered by intense emotional or physical stress, acute illnesses or, rarely, by alcohol or opiates withdrawal. Connection to stress and apical asynergy suggest a catecholamine-mediated pathogenesis. We recently observed a typical apical stress-induced cardiomyopathy, arising two weeks after a long-lasting antidepressant treatment withdrawal and recurring, a week later, with evidence of inferior wall akinesia. The reported case has several unusual features: 1) both episodes were not preceded by relevant triggering event (except antidepressant discontinuation); 2) early heterozonal relapse was observed; 3) the latency between antidepressant discontinuation and stress-induced cardiomyopathy onset is unusually long. The lack of relevant triggering stress and the evidence of multifocal asynergies could support the hypothesis of a non-catecholaminergic pathogenesis. Moreover, the long latency after antidepressant withdrawal may suggest that prolonged antidepressant treatments may have delayed pathological consequences, possibly related to their known neuroplastic effects.

Mid-ventricular variant takotsubo cardiomyopathy associated with Cannabinoid Hyperemesis Syndrome: a case report

A case of the mid-ventricular variant of takotsubo cardiomyopathy is reported, occurring in a patient with Cannabinoid Hyperemesis Syndrome (CHS), and presented with a review of the relevant literature. The patient is a 32-year-old woman who presented with epigastric pain, nausea and vomiting. Her EKG showed dynamic T-wave changes associated with a modest cardiac biomarker elevation. Ventricular wall motion abnormalities suggestive of the mid-ventricular variant of takotsubo cardiomyopathy were demonstrated by echocardiography, ventriculography and cardiac angiography, the latter showing normal coronary arteries. The patient was a previous marijuana user who had recently ingested marijuana after a period of abstinence. Severe epigastric pain, nausea and cyclic vomiting followed this. She had previously experienced similar gastrointestinal symptoms, relieved by compulsive hot water bathing, and resolving after marijuana cessation. Recent resumption of marijuana use was followed by a recurrence of these symptoms, a pattern characteristic of CHS. The association of cardiomyopathy with CHS has been described only once in the literature, and if this is a true relationship, its mechanism is not clearly defined. Animal models have suggested that endocannabinoid receptors are expressed in the myocardium, which could be a pathway for developing cardiac manifestations with cannabinoid use.

Synephrine-containing dietary supplement precipitating apical ballooning syndrome in a young female

Apical ballooning syndrome (ABS) is a unique reversible cardiomyopathy that is frequently precipitated by emotional or physical stress. In addition, the few drugs reported to precipitate ABS were either illegal or strictly controlled for medical use. This paper reports a case of ABS precipitated by a dietary supplement. Our case accentuates the potential risk of dietary supplements containing synephrine, which is uncontrolled and available to the general public. Therefore, the Korea Food and Drug Administration should regulate these dietary supplements, and warn healthcare workers and the general public of the potential hazards of the indiscriminate abuse of dietary supplements.

Drug-induced takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC), also known as stress cardiomyopathy, is an increasingly recognized clinical syndrome of acute reversible left ventricular dysfunction precipitated by intense emotional or physical stress. Excessive sympathetic stimulation is believed to be central to the pathogenesis of this condition; thus, drugs with sympathetic effect could precipitate TTC. This review outlines previous reports regarding drugs that may induce TTC. Some reports link the use of the drug-primarily associated with sympathetic overstimulation-with the development of TTC Consequently, drug-induced TTC should be considered in patients diagnosed with TTC.

Broken heart syndrome: a risk of teenage rhinoplasty

"Broken heart" syndrome is a rare phenomenon characterized by transient ballooning of the left ventricle and chronic heart failure, usually presenting in postmenopausal women. It is formally known as acute stress-induced cardiomyopathy and, although described in the cardiology literature, it has not been previously described in plastic surgery patients. It is thought to occur secondary to increased catecholamine levels. This case report outlines two instances of the syndrome occurring in teenage girls undergoing cosmetic rhinoplasty.

Takotsubo cardiomyopathy after midodrine therapy

WEB SITE FEATURE

Tako-Tsubo like syndrome triggered by meperidine

We present a case of "inverted Tako-Tsubo" syndrome in a woman sedated with meperidine before undergoing a colonscopy. We discuss possible etiology of this ventricular dysfunction.

[Heart failure and anaphylactic shock. A report of two cases]

Anaphylactic shock can sometimes take the appearance of heart failure, in relation to an acute coronary syndrome, even with normal coronary arteries, that we illustrate by two observations. We firstly report the case of an anaphylactic shock caused by succinylcholine, after anesthesia induction for inguinal hernia surgery in a 50-year-old man with cardiovascular risks, who presented with ventricular fibrillation followed by a cardiac arrest. An acute and severe anterior coronary syndrome was suspected and treated with thrombolysis. Then the electrocardiogram normalized, as well as the left ventricular function. No significant coronary stenosis was retrospectively revealed by coronarography, and a severe coronary vasospasm induced by the anaphylactic reaction was confirmed. We also describe the case of an anaphylactoid shock caused by cisatracurium infusion, that occurred at the beginning of an adnexectomy in a 55-year-old woman without any particular history. She presented with a cardiogenic shock after intravenous administration of epinephrine. The echocardiograpghic evaluation pointed out an aspect of stress-induced cardiomyopathy, and the coronarography showed normal coronary arteries. The left ventricular dysfunction completely normalized, strongly suggesting the diagnosis of Takotsubo-like syndrome after the anaphylactic shock and its treatment. Both of these cases point out the major interest of cardiologic and allergic evaluation in case of heart failure during general anesthesia. Coronary vasospasm and stress-induced cardiomyopathy are two pathologies that may be observed during anaphylactic shock, and their diagnosis should be considered after elimination of coronary thrombosis.