Occurrence of Takotsubo cardiomyopathy and use of antidepressants

Risk of stress cardiomyopathy associated with selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors: a real-world pharmacovigilance analysis

Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) are reported to cause stress cardiomyopathy (SC). This study evaluated the association between SSRI/SNRI use and the occurrence of cardiomyopathy in the publicly available U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) database. Disproportionate analysis and likelihood ratio tests were used to identify risk associated with SSRIs or SNRIs and the incidence of SC, using data from between from 2012 to 2022 acquired from the FAERS database. The study identified 132 individual case safety reports (ICSRs) of SC associated with SSRIs or SNRIs. Venlafaxine (48%) and fluoxetine (27%) were the most common antidepressants of the ICSRs. Approximately 80% of SC cases were reported in females, with individuals aged 45-65 years identified as a high-risk population. Both venlafaxine (ratio-scale information component [RSIC] 2.54, 95% CI 2.06-3.04) and fluoxetine (RSIC 3.20, 95% CI 2.31-4.47) were associated with SC, with likelihood ratio estimates of 3.55 (p = 0.02) for venlafaxine and 4.82 (p = 0.008) for fluoxetine. The median time to cardiomyopathy onset was 20 days, with hospitalization reported in 48.33% of patients. Venlafaxine and fluoxetine were associated with SC risk, particularly in middle-aged women. Caution should be exercised when using SSRIs or SNRIs combined with other serotonergic medications.

Heart and brain interactions : Pathophysiology and management of cardio-psycho-neurological disorders

Cardiovascular diseases (CVD) and mental health disorders (MHD; e.g. depression, anxiety and cognitive dysfunction) are highly prevalent and are associated with significant morbidity and mortality and impaired quality of life. Currently, possible interactions between pathophysiological mechanisms in MHD and CVD are rarely considered during the diagnostic work-up, prognostic assessment and treatment planning in patients with CVD, and research addressing bidirectional disease mechanisms in a systematic fashion is scarce. Besides some overarching pathogenetic principles shared by CVD and MHD, there are specific syndromes in which pre-existing neurological or psychiatric illness predisposes and contributes to CVD development (as in Takotsubo syndrome), or in which the distorted interplay between innate immune and central nervous systems and/or pre-existing CVD leads to secondary MHD and brain damage (as in peripartum cardiomyopathy or atrial fibrillation). Clinical manifestations and phenotypes of cardio-psycho-neurological diseases depend on the individual somatic, psychosocial, and genetic risk profile as well as on personal resilience, and differ in many respects between men and women. In this article, we provide arguments on why, in such conditions, multidisciplinary collaborations should be established to allow for more comprehensive understanding of the pathophysiology as well as appropriate and targeted diagnosis and treatment. In addition, we summarize current knowledge on the complex interactions between the cardiovascular and central nervous systems in Takotsubo syndrome and peripartum cardiomyopathy, and on the neurological and psychiatric complications of atrial fibrillation.

The N-AcetylCysteine and RAMipril in Takotsubo Syndrome Trial (NACRAM): Rationale and design of a randomised controlled trial of sequential N-Acetylcysteine and ramipril for the management of Takotsubo Syndrome

BACKGROUND

Takotsubo Syndrome(TTS), contrary to historical reports, is now increasingly recognised to be associated with substantial mortality and morbidity, both in the short- and long-term. Although TTS is often precipitated by a catecholamine "pulse", in-hospital hypotension is a common occurrence, increasing the risk of mortality. Furthermore, despite the transient catecholamine stimulus, there is increasing evidence that there are significant long term sequelae, including persistently impaired left ventricular(LV) systolic dysfunction, myocardial oedema with fibrosis, as well as persistent impairment of quality of life. A definitive therapeutic option to limit the extent of initial myocardial injury, and to accelerate recovery in TTS is therefore justified. However to date, there has been a lack of prospective studies in this area.

DESIGN AND RATIONALE

NACRAM is a multi-centre, randomised, placebo-controlled trial, sequentially testing early use of intravenous N-acetylcysteine(NAC), followed by/or oral ramipril for 12 weeks. The rationale for utilising these agents is related to their effects on limiting nitrosative stress and expression of the inflammasome activator thioredoxin interacting protein(TXNIP); both processes fundamental to the pathogenesis of TTS.

END POINTS

NACRAM is assessing resolution of myocardial oedema on cardiac magnetic resonance imaging(CMR), improvements in LV systolic function as measured by global longitudinal strain(GLS) on echocardiography, quality of life, and inflammatory markers.

DISCUSSION

To the best of our knowledge, NACRAM will be the first prospective study to help definitively evaluate a therapeutic option in acute attacks of TTS.

Takotsubo Cardiomyopathy: Medical and Psychiatric Aspects. Role of Psychotropic Medications in the Treatment of Adults with "Broken Heart" Syndrome

Takotsubo cardiomyopathy (TTC) is reversible stress-induced cardiomyopathy featuring symptoms of acute myocardial infarction without significant coronary artery abnormalities. TTC is frequently precipitated by stressful emotional events but it also has been reported as a result of substance withdrawal, non-cardiac events, and dangerous drug-to-drug interaction. The plasma levels of both epinephrine and norepinephrine were significantly elevated in TTC patients, suggesting that elevated catecholamine levels might be the main contributing factor. However, the mechanisms underlying susceptibility to development and recurrence are not completely understood.

It has been suggested that even a therapeutic dose of antidepressant could be a cause of drug-induced tachycardia and TTC. Moreover, some cases have been reported in which the development of TTC was associated with the serotonin syndrome, neuroleptic malignant syndrome, and similar fatal consequences.

The aim of this article is to explore the association between underlying psychiatric disorders and TTC and to determine the role of various psychotropic medications in the progression of stress-induced cardiomyopathy. This article also notes and discusses the current theories underlying the pathophysiology of TTC. This review suggests a serious side effect of antidepressants, and to avoid life-threatening cardiovascular events, such as TTC, for patients with affective and anxiety disorders, prior screening for cardiovascular conditions by ECG with close monitoring might be necessary.

Frequently Recurrent Takotsubo Syndrome in COPD

Cardiovascular disease is common among patients with chronic obstructive pulmonary disease (COPD). Takotsubo syndrome (TTS) is a transient cardiac disorder that, in its typical form, involves left ventricular dysfunction with apical ballooning and mimics acute coronary syndrome (ACS). “Bronchogenic TTS” has been proposed as a specific form of TTS (during severe acute dyspnea in asthma or COPD) with atypical presentation. Recurrent TTS in COPD seems to be exceptionally rare since only a handful of clinical cases have previously been reported in the literature. Here, we present a unique case of a frequently recurrent TTS during COPD exacerbation in a 70-year-old woman, with at least 4 different episodes of TTS within 5 years. This case report exemplifies the difficulties of the diagnosis of TTS at the onset of acute COPD exacerbation. Potential pathophysiological mechanisms and therapeutic strategies are also briefly discussed.

Takotsubo syndrome: State-of-the-art review by an expert panel - Part 1

Takotsubo syndrome (TTS) is an acute cardiac condition independent of epicardial coronary obstruction that mimics acute coronary syndrome and is characterized by acute heart failure with reversible ventricular motion abnormalities. This consensus paper is the result of a multinational effort aiming to summarize the current state of the art on TTS. Experts in the field provide a thorough and detailed review of this syndrome. Several novel and unique sections are emphasized in this document, including the current state of the art on genetics of takotsubo syndrome, microRNAs (miRs), racial differences, role of cardiac spectroscopy and intracoronary imaging, as well as mechanical circulatory support. In part 1 of this two-part manuscript, we discuss how TTS came to be known, several patterns and forms it can take in patients, epidemiology and pathophysiology of the syndrome, and clinical presentation.

Psychiatric Illness in Takotsubo (Stress) Cardiomyopathy: A Review

BACKGROUND

Takotsubo cardiomyopathy (TC), also known as stress-induced cardiomyopathy, has been increasingly described in relation to psychiatric illness.

METHODS

We performed a literature review to identify the key findings related to psychiatric illness in TC that may be relevant to the practice of mental health and other health care providers.

RESULTS

The association of psychiatric illness with TC in addition to the spectrum of psychiatric illness found in TC, the role of exacerbation or treatment of psychiatric illness in triggering TC, different modes of presentation, prognostic implications, and long-term management of psychiatric illness in TC are discussed. Additionally, we review the limitations of the pre-existing literature and suggest areas of future research.

CONCLUSIONS

There is a strong association between pre-existing psychiatric illness, particularly anxiety and mood spectrum disorders, and TC. Acute exacerbation of psychiatric illness, rapid uptitration or overdose of certain psychotropic agents, and electroconvulsive therapy may trigger TC. Further studies are needed to better evaluate the prognostic significance and long-term management of psychiatric illness in TC.

Pre-existing Psychiatric Illness is Associated With Increased Risk of Recurrent Takotsubo Cardiomyopathy

BACKGROUND

The increased prevalence of psychiatric illness among patients with takotsubo cardiomyopathy (TC) has been previously described.

OBJECTIVES

We sought to assess the effect of pre-existing psychiatric illness on clinical outcomes following the diagnosis of TC.

METHODS

Adults diagnosed with TC at Vanderbilt University Medical Center between 1999 and 2015 were included in the study. Medical records were retrospectively reviewed to identify any pre-existing mood, anxiety, or schizophrenia-spectrum illness before TC presentation. Multivariable logistic regression was used to test for independent association of pre-existing psychiatric illness with 30-day mortality and recurrent TC; Cox proportional hazard analysis was used to evaluate for association with long-term mortality.

RESULTS

Among 306 patients diagnosed with TC during the study period, 114 (37%) had a pre-existing psychiatric illness. In all, 43 (14%) and 88 (29%) patients died within 30 days of index diagnosis and as of last medical record review, respectively. Of the 269 who survived their index hospitalization, 19 (7%) had a confirmed recurrent episode of TC. In multivariable analyses, pre-existing psychiatric illness was not associated with increased 30-day (P = 0.320) or long-term (P = 0.621) mortality. Pre-existing psychiatric illness was associated with higher risk of recurrent TC (odds ratio = 7.44, 95% CI: 2.30-24.01, P < 0.001).

CONCLUSIONS

Pre-existing psychiatric illness was associated with an increased risk of recurrent TC. No significant association was noted between pre-existing psychiatric illness and survival.

Commentary on 2 Cases of Takotsubo Cardiomyopathy Involving Psychotropic Medication

Takotsubo cardiomyopathy, also known as Takotsubo syndrome (TTS), is a cardiac syndrome first described in Japan in 1990 that typically follows an acute physical or psychiatric stressor, hence its association with the terms "broken heart syndrome" and stress cardiomyopathy. Although it is relatively rare, occurring in only 0.02% of the general population and roughly 2% of patients with acute coronary syndrome, neurological or psychiatric disorders are present in over 50% of affected individuals. One of the major hypotheses regarding the pathophysiology of TTS involves a catecholamine surge, from stress directly, or in some cases from psychiatric medication used to relieve distress. Given the association of TTS with acute stress and psychiatric illness, psychiatrists may be involved in the care of patients with TTS either at the initial presentation of the condition or following recovery. The case reports presented in this issue exemplify these 2 scenarios: one case involves the development of TTS during treatment with atomoxetine, and the other case involves treatment of depression in a patient after recovery from TTS, as well as a TTS recurrence during treatment with fluoxetine.