Electroconvulsive therapy in a 72-year-old woman with a history of Takotsubo cardiomyopathy: a case report and review of the literature

The Safety and Strategies for Reinitiating Electroconvulsive Therapy After ECT-Induced Takotsubo Cardiomyopathy: A Case Report and Systematic Review

OBJECTIVES

Takotsubo cardiomyopathy (TCM) is a life-threatening complication of electroconvulsive therapy (ECT). We report the case of a 66-year-old woman who was rechallenged with ECT after ECT-induced TCM. Moreover, we have made a systematic review to assess the safety of and strategies for reinitiating ECT after TCM.

METHODS

We searched for published reports on ECT-induced TCM since 1990 in MEDLINE (PubMed), Scopus, Cochrane Library, ICHUSHI, and CiNii Research.

RESULTS

A total of 24 ECT-induced TCM cases were identified. Patients who developed ECT-induced TCM were predominantly middle-aged and older women. There was no specific trend in anesthetic agents used. Seventeen (70.8%) cases developed TCM by the third session in the acute ECT course. Eight (33.3%) cases developed ECT-induced TCM despite the use of β-blockers. Ten (41.7%) cases developed cardiogenic shock or abnormal vital signs related to cardiogenic shock. All cases recovered from TCM. Eight (33.3%) cases tried to receive ECT retrial. The duration until ECT retrial was between 3 weeks and 9 months. The most common preventive measures during ECT retrial were related to β-blockers; however, the type, dose, and route of administration of β-blockers varied. In all cases, ECT could be reperformed without TCM recurrence.

CONCLUSIONS

Electroconvulsive therapy-induced TCM is more likely to cause cardiogenic shock than nonperioperative cases; nevertheless, it has good prognosis. Cautious reinitiation of ECT after TCM recovery is possible. Further studies are required to determine preventive measures for ECT-induced TCM.

Takotsubo Syndrome: Translational Implications and Pathomechanisms

Takotsubo syndrome (TTS) is identified as an acute severe ventricular systolic dysfunction, which is usually characterized by reversible and transient akinesia of walls of the ventricle in the absence of a significant obstructive coronary artery disease (CAD). Patients present with chest pain, ST-segment elevation or ischemia signs on ECG and increased troponin, similar to myocardial infarction. Currently, the known mechanisms associated with the development of TTS include elevated levels of circulating plasma catecholamines and their metabolites, coronary microvascular dysfunction, sympathetic hyperexcitability, inflammation, estrogen deficiency, spasm of the epicardial coronary vessels, genetic predisposition and thyroidal dysfunction. However, the real etiologic link remains unclear and seems to be multifactorial. Currently, the elusive pathogenesis of TTS and the lack of optimal treatment leads to the necessity of the application of experimental models or platforms for studying TTS. Excessive catecholamines can cause weakened ventricular wall motion at the apex and increased basal motion due to the apicobasal adrenoceptor gradient. The use of beta-blockers does not seem to impact the outcome of TTS patients, suggesting that signaling other than the beta-adrenoceptor-associated pathway is also involved and that the pathogenesis may be more complex than it was expected. Herein, we review the pathophysiological mechanisms related to TTS; preclinical TTS models and platforms such as animal models, human-induced pluripotent stem cell-derived cardiomyocyte (hiPSC-CM) models and their usefulness for TTS studies, including exploring and improving the understanding of the pathomechanism of the disease. This might be helpful to provide novel insights on the exact pathophysiological mechanisms and may offer more information for experimental and clinical research on TTS.

Takotsubo cardiomyopathy following electroconvulsive therapy: an increasingly recognised phenomenon

Treatment of patients with severe depressive illnesses requiring electroconvulsive therapy (ECT) is challenging. This is compounded by the presence of physical comorbidities and potential complications. We report the case of a patient, on long-term bisoprolol, who developed acute epigastric pain and dyspnoea shortly after receiving ECT for treatment-refractory depression. An ECG showed new-onset ischaemic changes and a troponin-I level was elevated at 12 h. A diagnosis of Takotsubo cardiomyopathy was reached following angiography, which demonstrated left ventricular hypokinesia in the absence of coronary artery disease. With supportive treatment the patient made a good recovery. This report highlights the risk of developing Takotsubo cardiomyopathy following ECT despite β-adrenergic receptor blockade, and adds to a growing number of cases reporting this complication. Clinicians involved in the care of patients undergoing ECT must be aware of this complication and should consider Takotsubo cardiomyopathy in patients who develop atypical chest pain after ECT.

CNS disease triggering Takotsubo stress cardiomyopathy

There are a number of hereditary and non-hereditary central nervous system (CNS) disorders, which directly or indirectly affect the heart (brain-heart disorders). The most well-known of these CNS disorders are epilepsy, stroke, infectious or immunological encephalitis/meningitis, migraine, and traumatic brain injury. In addition, a number of hereditary and non-hereditary neurodegenerative disorders may impair cardiac functions. Affection of the heart may manifest not only as arrhythmias, myocardial infarction, autonomic impairment, systolic dysfunction/heart failure, arterial hypertension, or pulmonary hypertension, but also as stress cardiomyopathy (Takotsubo syndrome, TTS). CNS disease triggering TTS includes subarachnoid bleeding, epilepsy, ischemic stroke, intracerebral bleeding, migraine, encephalitis, traumatic brain injury, PRES syndrome, or ALS. Usually, TTS is acutely precipitated by stress triggered by various different events. TTS is one of the cardiac abnormalities most frequently induced by CNS disorders. Appropriate management of TTS from CNS disorders is essential to improve the outcome of affected patients.

Takotsubo cardiomyopathy and anaesthesia: case report and review of the literature

Takotsubo cardiomyopathy is an acute syndrome characterized by cardiac failure from disturbances in the contractility of the left ventricle. It is presumably caused by sympathetic over stimulation. We describe a case of postoperatively developed Takotsubo cardiomyopathy in a 69-year-old female. The syndrome developed in connection with awareness during complete residual paralysis. The literature on this syndrome is reviewed and implications for anaesthesia described.

Current electroconvulsive therapy practice and research in the geriatric population

Electroconvulsive therapy (ECT) is utilized worldwide for various severe and treatment-resistant psychiatric disorders. Research studies have shown that ECT is the most effective and rapid treatment available for elderly patients with depression, bipolar disorder and psychosis. For patients who suffer from intractable catatonia and neuroleptic malignant syndrome, ECT can be life saving. For elderly patients who cannot tolerate or respond poorly to medications and who are at a high risk for drug-induced toxicity or toxic drug interactions, ECT is the safest treatment option. Organic causes are frequently associated with late-life onset of neuropsychiatric conditions, such as parkinsonism, dementia and stroke. ECT has proven to be efficacious even when these conditions are present. During the next decade, research studies should focus on the use of ECT as a synergistic therapy, to enhance other biological and psychological treatments, and prevent symptom relapse and recurrence.

Urine catecholamine levels are not influenced by electroconvulsive therapy in depression or schizophrenia over the long term

AIM

Change in catecholamine seems to be associated with not only effects of electroconvulsive therapy (ECT), but also adverse events associated with ECT. Our aim in this study was to investigate whether or not ECT influences the concentration of catecholamine over the long term. Patients with a major depressive episode or schizophrenia, diagnosed according to DSM-IV criteria, who were newly admitted to Juntendo University Hospital to receive ECT, were recruited.

METHODS

Urine was collected during the 24 h before the first ECT treatment, during the 24 h after the first ECT treatment, during the 24 h after the final ECT treatment and during the 24 h 1 week after the final ECT treatment. Heart rate, the Hamilton Rating Scale for Depression and the Positive and Negative Syndrome Scale were assessed before and after ECT.

RESULTS

Twenty-four patients were included in the final sample, which consisted of 14 patients with major depressive episodes and 10 patients with schizophrenia. Abnormal electrocardiograms were indicated in four patients with depression during the ECT operation but all recovered naturally. There were no significant differences in the levels of dopamine, adrenaline or noradrenaline the day before the first ECT, a day after the first ECT, a day after the final ECT and a week after the final ECT.

CONCLUSION

These results suggest that ECT does not alter urine catecholamine levels after ECT over the long term. Further studies will be required to confirm these findings in a larger sample of patients.

Takotsubo cardiomyopathy as a complication of electroconvulsive therapy

OBJECTIVE

To examine the evidence regarding takotsubo cardiomyopathy as a complication of electroconvulsive therapy (ECT).

DATA SOURCES

Searches in MEDLINE, EMBASE, and International Pharmaceutical Abstracts (1966-August 2011) were conducted.

STUDY SELECTION AND DATA EXTRACTION

Published studies and case reports that mentioned takotsubo cardiomyopathy following ECT were reviewed.

DATA SYNTHESIS

Twelve case reports were available for review. There were 7 documented cases of takotsubo cardiomyopathy, 4 cases of myocardial stunning, and 1 case of cardiogenic shock following ECT. Although takotsubo cardiomyopathy was not mentioned in 5 of the cases, some clinical characteristics were consistent with this diagnosis. Left ventricular ejection fraction and the electrocardiogram returned to normal within a few days in the majority of the cases. All cases were in women, the majority of whom were postmenopausal (average age 64 years). Takotsubo cardiomyopathy developed after a single course of ECT in 6 of the cases, while the syndrome developed after more than 1 course in the other 6 cases. ECT was successfully readministered without syndrome recurrence in 4 of the cases, but only after 3 of the 4 patients received a β-adrenergic receptor blocking agent prior to each subsequent therapy session. The β-adrenergic blocking agents used were esmolol in 1 case and labetolol in the other 2.

CONCLUSIONS

Takotsubo cardiomyopathy is a serious but transient potential complication of electroconvulsive therapy. Limited evidence indicates that β-adrenergic receptor blocking agents may help prevent its reoccurrence in patients needing further electroconvulsive treatment. Health care providers in psychiatry should be aware of this potential complication of electroconvulsive therapy, especially in postmenopausal women. However, many questions remain regarding this issue.

Takotsubo cardiomyopathy after electroconvulsive therapy: a case report and review

Takotsubo cardiomyopathy (TCM) is a syndrome of reversible stress-induced cardiomyopathy associated with profound emotional stress and a variety of medical illnesses and procedures, including electroconvulsive therapy (ECT). We describe 1 case of ECT-induced TCM followed by a successful retrial of ECT. We further discuss the management of ECT-induced TCM and the decision to perform a second trial of ECT in patients with this complication. Given the current understanding of the pathogenesis of TCM, it is appropriate to discontinue ECT during the acute setting of TCM. After the resolution of the acute episode of TCM, a second trial of ECT may be warranted depending on the severity of psychiatric illness (ie, suicidal ideation, catatonia, psychotic symptoms). If a retrial of ECT is performed, oral and intravenous β-blockers should be used for cardioprotection, and patients should be monitored for signs and symptoms of an evolving cardiomyopathy. It is preferable to perform retrials of ECT-at least initially-in a general hospital setting, where immediate invasive monitoring and intensive treatments are available in the event of acute cardiac failure.