Medication-induced Takotsubo Cardiomyopathy presenting with cardiogenic shock—utility of extracorporeal membrane oxygenation (ECMO): case report and review of the literature

Takotsubo Cardiomyopathy Syndrome in Critical Care Transport: A Case and Critical Review

Takotsubo cardiomyopathy syndrome, or simply takotsubo syndrome (TTS), is a form of stress cardiomyopathy thought to be caused by excess catecholamines in association with physical or emotional stress. Providers should maintain a high index of suspicion for TTS in patients with symptoms of acute coronary syndrome, acute decompensated heart failure, substernal chest pain, or dyspnea. However, TTS is a diagnosis of exclusion, and patients should initially be evaluated and treated for other causes, such as acute myocardial infarction. Critical care transport crews may encounter patients with TTS during their primary presentation, before diagnosis, or after the formal diagnosis is made in the catheterization laboratory. Therefore, crews should be familiar with unique aspects of the pathophysiology, diagnosis, and management of TTS. This article presents a case and provides a critical review of TTS for critical care transport clinicians.

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.

Ibuprofen plasma concentration profile in deliberate ibuprofen overdose with circulatory depression treated with therapeutic plasma exchange: a case report

BACKGROUND

Inquiries relating to ibuprofen overdose have more than tripled in the last ten years in our poison control center. Although the vast majority of cases have a benign clinical course, there are few severe or even fatal cases present with refractory circulatory failure.

CASE PRESENTATION

We describe a case of a 48 year-old male with suicidal mono-ingestion of approximately 72 g ibuprofen. Despite an initial rapid spontaneous drop in the total ibuprofen plasma concentration (IPC) from 550 to 275 mcg/mL within the first 5 h after admission, the patient developed a circulatory failure, refractory to aggressive fluid resuscitation and high doses of vasopressors. Due to ibuprofen's favorable pharmacokinetics (>95% bound to albumin, low volume of distribution) and in the absence of specific therapeutic alternatives thereby avoiding escalating vasopressor doses, therapeutic plasma exchange (TPE) for extracorporeal elimination of ibuprofen was considered as a therapeutic rescue option. An improvement of hemodynamics with a significant reduction of vasopressors was observed with TPE-initiation. However, neither the observed IPC-profile nor a pharmacokinetic (PK) simulation provided evidence for a quantitative effective elimination of ibuprofen by TPE. Based on PK-modeling we calculated an overall ibuprofen half-life of 17.2 h for the entire observation period over 5 days.

CONCLUSIONS

To our knowledge this is the first report of a severe ibuprofen-mono intoxication treated with TPE and providing serial IPCs over a period of five days, indicating an estimated fivefold overall-elimination half-life of 17.2 h. Despite TPE clinically improved persistent hemodynamic instability, this procedure was neither consistent with the observed IPC-profile nor correlated with a meaningful quantitative elimination of ibuprofen.

Mechanical circulatory support for refractory cardiogenic shock in Takotsubo syndrome: a case report and review of the literature

Takotsubo syndrome (TTS) complicated by refractory cardiogenic shock is a challenging clinical problem, as treatment with inotropic agents and/or vasopressors is contraindicated. We illustrate this by a patient presenting with chest pain and shortness of breath caused by TTS complicated by cardiogenic shock requiring mechanical circulatory support (MCS). The patient received central extracorporeal life support with a cannula in the left atrium (pre-load reduction of left ventricle) and the return cannula in the ascending aorta (neutral on afterload). Treatment with MCS was complicated by a cardiac tamponade. Left ventricular function recovered after 24 h, and the patient was doing well at the outpatient clinic 7 weeks after discharge. In addition, we reviewed the literature (PubMed search) reporting on MCS in patients with TTS. Including our patient, 17 cases of TTS induced cardiogenic shock receiving MCS have been reported. Age of the patients ranged from 16 years to 74 years, and 71% of the patients were female. Extracorporeal life support was the most used type of MCS (82% of the cases). Two patients died, and complications of MCS were rare (one case of leg ischaemia). Theoretically, MCS devices that reduce pre-load and are neutral on afterload are preferable. However, no specific type of MCS can be recommended as randomized trials are lacking. In conclusion, our case and the available literature suggests that MCS in TTS induced refractory cardiogenic shock is an immediate and feasible lifesaving treatment.

Takotsubo Cardiomyopathy Complicating Percutaneous Pulmonary Valve Implantation in a Child

Takotsubo cardiomyopathy describes a sudden onset cardiomyopathy with acute impairment of left ventricular function and spontaneous resolution over time. Only a few cases of Takotsubo cardiomyopathy in childhood have been described. We report the case of a 12-year-old girl with repaired tetralogy of Fallot who experienced acute onset of left ventricular dysfunction without coronary arterial involvement, suggesting Takotsubo cardiomyopathy, during an interventional catheterization procedure. Cardiogenic shock necessitated mechanical circulatory support with extracorporeal membrane oxygenator for ten days and mechanical ventilation for 12 days. The girl recovered without sequelae. Percutaneous pulmonary valve implantation was performed four months later without complications. Unusual aspects of this case include the use of mechanical circulatory support during the recovery phase of Takotsubo cardiomyopathy in a patient with congenital heart disease.

Drug-Induced Takotsubo Cardiomyopathy

BACKGROUND

The most plausible hypothesis for takotsubo cardiomyopathy (TCM) is a catecholamine surge. Direct administration of catecholamines or medications causing catecholamine surge is frequently used in clinical practice.

METHODS

A Medline/PubMed database search was conducted for case reports or series of drug-induced TCM. All reported cases of drug-induced TCM were systemically identified and analyzed.

RESULTS

We identified 157 cases of drug-induced TCM. Fifty-seven (36.3%) cases were related to the administration of exogenous catecholamines. In 50 (31.9%) other cases, there was potential adrenergic effect. This included drugs with adrenergic vasoconstriction properties (3.2%), hyperadrenergic state due to alcohol or opioid withdrawal (7.7%), inhibitors of catecholamine reuptake (14.7%), anaphylactic reaction that is accompanied by catecholamine release (3.2%), and psychological or somatic stress coinciding with the administration of a drug that was thought to be the culprit (3.2%). Overall, 68.2% of these drug-induced TCM cases were catecholamine related. In 14 (8.9%) cases, the likely etiology of cardiomyopathy was chemotherapy-induced coronary vasospasm.

CONCLUSION

Our systematic review showed that over two-thirds of drug-induced TCM cases were due to direct or indirect catecholamine stimulation. The lowest effective dose and shortest duration of catecholamines should be utilized, and alternative therapies should be considered if feasible.

Incidence, determinants and prognostic relevance of cardiogenic shock in patients with Takotsubo cardiomyopathy

BACKGROUND

Takotsubo cardiomyopathy (TTC) can be accompanied by various life-threatening complications, including cardiogenic shock. The exact incidence and prognostic relevance of cardiogenic shock in TTC patients has not been studied in detail.

METHODS

The frequency and determinants of cardiogenic shock were evaluated in 178 patients with TTC. The clinical course and treatment strategies of TTC patients with cardiogenic shock were systematically analysed. Furthermore, short and long-term mortality rates were assessed with a structured telephone follow-up.

RESULTS

The incidence of cardiogenic shock in this large TTC population was 12.4%. Multivariable logistic regression analysis identified left ventricular ejection fraction as the only significant predictor of cardiogenic shock (odds ratio 0.80; 95% confidence interval (CI) 0.73-0.88; P<0.01). The majority of the TTC patients with cardiogenic shock were treated with catecholamine therapy (86%) and 59% received early initiated mechanical circulatory support. TTC patients with cardiogenic shock showed significantly increased 28-day mortality rates compared to patients without cardiogenic shock (28.6% vs. 4.1%; relative risk 7.05, 95% CI 2.50-19.84; P<0.01). Furthermore, cardiogenic shock patients were at ongoing increased risk of death beyond the first 28 days resulting in considerably elevated 1-year (61.9% vs. 7.4%; P<0.01) and long-term mortality rates at 3.6 years of follow-up (66.7% vs. 19%; P<0.01).

CONCLUSION

Cardiogenic shock is a frequent complication in TTC patients and is associated with increased short and long-term mortality rates. Patients at risk of developing cardiogenic shock may be identified by means of a severely impaired left ventricular function.