Case report: Cocaine-induced takotsubo cardiomyopathy

Cardiac Arrest (CA) as the Initial Presentation of Cocaine-Induced Takotsubo Cardiomyopathy (TCM): A Case Report and Review of Literature

Cocaine is used as an illicit substance responsible for the most common cause of drug-related death. It is a stimulant that acts on the sympathetic nervous system and cardiovascular system leading to exaggerated, prolonged sympathetic activity due to the accumulation of neurotransmitters. Cardiovascular side effects of cocaine are coronary artery spasms, myocarditis, arrhythmias, and congestive heart failure. Takotsubo cardiomyopathy (TCM) is characterized by transient hypokinesis, akinesis, or dyskinesis of the left ventricle (LV) wall with or without apical involvement in the absence of obstructive coronary artery disease. Cocaine-induced TCM is an extremely rare condition emphasizing the need of its prompt diagnosis by the physicians. We present a case report of a 54-year-old male, brought to the emergency department (ED) after an out-of-hospital cardiac arrest (CA), found to have TCM in the setting of cocaine use. Clinicians need to understand the association between cocaine use and the development of TCM as cardiomyopathy of this type can result in complete remission after discontinuing the offending agent.

Tako-tsubo cardiomyopathy in clinical toxinology: A systematic review

Tako-tsubo cardiomyopathy (TTC) is a transient left ventricular dysfunction, normally triggered by emotional or physical stress, although it is also associated with to use of drugs, drug abuse, or some intoxications. In addition, TTC has been reported in some case reports derived from the exposure of patients to animal venoms, toxins or poisons, or bacterial infections. However, to date, a systematic assessment of TTC in clinical toxinology is lacking. Therefore the aim of this study was to collect and integrate the available information about TTC in clinical toxinology. After our search strategy, 19 articles were retrieved, resulting in 20 case reports. Most cases occurred in women (75.0%). The venomous species that trigger TTC are bee/wasp, including probable Africanized honey bee and Vespa orientalis (15.0%), scorpions (Tytius serrulatus and Androctonus australis, 15.0%), a spider (Latrodectus tredecimguttatus, 5.0%), snakes (Gloydius blomhofii and Naja nivea, 10.0%), Clostridium sp (C. tetani, C. botulinum and C. difficile, 45.0%) and jellyfish (Pelagia noctiluca and Carukia barnesi, 10.0%). Among the affected people there were two deaths. In all case reports authors diagnosed TTC by using the combination of some of the following strategies: clinical findings, echocardiography, magnetic cardiac resonance, electrocardiogram changes and/or the increased plasma levels of cardiac damage biomarkers. In most cases images were available. We hypothesized the possible mode of action of venoms, toxins or poisons to induce TTC, however other mechanisms may exist, but they have not been described yet. Therefore, further studies are needed. In some cases, venoms, toxins, or poisons might cause catecholamine discharge either directly or indirectly, therefore, this was suggested as the trigger of TTC. Finally, the appearance of TTC should be considered in clinical toxinology.

Cocaine: An Updated Overview on Chemistry, Detection, Biokinetics, and Pharmacotoxicological Aspects including Abuse Pattern

Cocaine is one of the most consumed stimulants throughout the world, as official sources report. It is a naturally occurring sympathomimetic tropane alkaloid derived from the leaves of Erythroxylon coca, which has been used by South American locals for millennia. Cocaine can usually be found in two forms, cocaine hydrochloride, a white powder, or ‘crack’ cocaine, the free base. While the first is commonly administered by insufflation (‘snorting’) or intravenously, the second is adapted for inhalation (smoking). Cocaine can exert local anaesthetic action by inhibiting voltage-gated sodium channels, thus halting electrical impulse propagation; cocaine also impacts neurotransmission by hindering monoamine reuptake, particularly dopamine, from the synaptic cleft. The excess of available dopamine for postsynaptic activation mediates the pleasurable effects reported by users and contributes to the addictive potential and toxic effects of the drug. Cocaine is metabolised (mostly hepatically) into two main metabolites, ecgonine methyl ester and benzoylecgonine. Other metabolites include, for example, norcocaine and cocaethylene, both displaying pharmacological action, and the last one constituting a biomarker for co-consumption of cocaine with alcohol. This review provides a brief overview of cocaine’s prevalence and patterns of use, its physical-chemical properties and methods for analysis, pharmacokinetics, pharmacodynamics, and multi-level toxicity.

Clinical features and outcomes between African American and Caucasian patients with Takotsubo Syndrome

BACKGROUND

Takotsubo syndrome (TS) is an acute, reversible form of heart failure, often mimicking an acute coronary syndrome (ACS). Data regarding racial differences in TS are inconsistent. The aim is to assess clinical features associated with unfavorable in-hospital outcomes between African American (AA) and Caucasian (CAU) patients.

METHODS

A retrospective electronic health record query identified 44 AA patients and 110 CAU patients with a diagnosis of TS. Our primary outcome was a composite of death, stroke, and cardiogenic shock during hospitalization. Variables associated with an increased risk of the primary composite outcomes were included in a logistic regression model.

RESULTS

Compared to CAU patients, AA patients were a more comorbid population, and presented a higher prevalence of history of illicit drug use (27.3% vs. 13.6% P=0.044). There were no significant differences regarding in-hospital complication rates between AA and CAU patients. In the logistic regression model, infection was associated with greater risk of developing the primary outcome in AA patients (OR=7.26 [95% CI 1.22-43.17], P=0.029), whereas angina was a protective factor (OR=0.11 [95% CI 0.02-0.65], P=0.015). In CAU patients, severely depressed ejection fraction and worse peak creatinine during hospitalization increased risk of developing the primary outcome (OR=5.88 95% CI [2.01-17.17], P<0.001 and OR=1.64 [95% CI 1.15-2.58], P=0.031, respectively). Meanwhile, emotional stressors were protective (OR=0.16 [95% CI 0.03-0.88], P=0.004).

CONCLUSIONS

Despite experiencing the same rate of in-hospital complications, the clinical profiles of AA patients are distinct from CAU patients admitted for TS, and clinical variables correlated with worse in-hospital outcomes also differ by race.

Oxidative Stress in Takotsubo Syndrome-Is It Essential for an Acute Attack? Indirect Evidences Support Multisite Impact Including the Calcium Overload-Energy Failure Hypothesis

Indirect evidences in reviews and case reports on Takotsubo syndrome (TTS) support the fact that the existence of oxidative stress (OS) might be its common feature in the pre-acute stage. The sources of OS are exogenous (environmental factors including pharmacological and toxic influences) and endogenous, the combination of both may be present, and they are being discussed in detail. OS is associated with several pathological conditions representing TTS comorbidities and triggers. The dominant source of OS electrones are mitochondria. Our analysis of drug therapy related to acute TTS shows many interactions, e.g., cytostatics and glucocorticoids with mitochondrial cytochrome P450 and other enzymes important for OS. One of the most frequently discussed mechanisms in TTS is the effect of catecholamines on myocardium. Yet, their metabolic influence is neglected. OS is associated with the oxidation of catecholamines leading to the synthesis of their oxidized forms - aminochromes. Under pathological conditions, this pathway may dominate. There are evidences of interference between OS, catecholamine/aminochrome effects, their metabolism and antioxidant protection. The OS offensive may cause fast depletion of antioxidant protection including the homocystein-methionine system, whose activity decreases with age. The alteration of effector subcellular structures (mitochondria, sarco/endoplasmic reticulum) and subsequent changes in cellular energetics and calcium turnover may also occur and lead to the disruption of cellular function, including neurons and cardiomyocytes. On the organ level (nervous system and heart), neurocardiogenic stunning may occur. The effects of OS correspond to the effect of high doses of catecholamines in the experiment. Intensive OS might represent "conditio sine qua non" for this acute clinical condition. TTS might be significantly more complex pathology than currently perceived so far.

Transient Left Ventricular Acute Failure after Cocaine Use

BACKGROUND

Cocaine is one of the most widely used illicit drugs, and it is the most common cause of drug-related death. The association of cocaine use with acute heart failure is a rare occurrence.

CASE REPORT

We report the case of a 31 years-old woman who presented Takotsubo cardiomyopathy with severe cardiogenic shock after cocaine abuse. That required the use of high doses of positive inotropic amines and mechanical ventilation. The evolution was quickly favorable after the cessation of cocaine.

DISCUSSION

Takotsubo cardiomyopathy is often related to a stressful trigger, and several cases have been described with the use of several psychostimulants. As such, it is not surprising that cocaine use can be associated with the development of Takotsubo cardiomyopathy when it results in excess release of catecholamines and excitation of adrenergic receptors.

CONCLUSION

In critical care unit, Takotsubo cardiomyopathy is a rare complication of cocaine abuse. This etiological diagnosis can be difficult especially in the absence of the concept of toxic intake as it was initially the case for our patient, but the treatment does not differ from other causes of cardiomyopathy and Cessation of cocaine use has been associated with improvement in cardiac function.

Stress Cardiomyopathy Diagnosis and Treatment: JACC State-of-the-Art Review

Stress cardiomyopathy is an acute reversible heart failure syndrome initially believed to represent a benign condition due to its self-limiting clinical course, but now recognized to be associated with a non-negligible rate of serious complications such as ventricular arrhythmias, systemic thromboembolism, and cardiogenic shock. Due to an increased awareness and recognition, the incidence of stress cardiomyopathy has been rising (15-30 cases per 100,000 per year), although the true incidence is unknown as the condition is likely underdiagnosed. Stress cardiomyopathy represents a form of neurocardiogenic myocardial stunning, and while the link between the brain and the heart is established, the exact pathophysiological mechanisms remain unclear. We herein review the proposed risk factors and triggers for the syndrome and discuss a practical approach to diagnosis and treatment of the patients with stress cardiomyopathy, highlighting potential challenges and unresolved questions.