Breaking addiction can lead to a broken heart: reverse takotsubo cardiomyopathy in a case of heroin withdrawal.
Hunter Launer MD, Alarica Dietzen BS, Daniel Nelson MD
Tulane University School of Medicine
Introduction:
Takotsubo cardiomyopathy (TC) is characterized by acute and often reversible left ventricular dysfunction triggered by emotional or physical stress. Reverse Takotsubo cardiomyopathy (RTC) is a variant described as basal akinesis and apical hyperkinesis. RTC presents clinically like acute coronary syndrome (ACS) but without obstructive coronary arteries. Factors associated with the development of RTC include younger age, neurologic disease, and higher ejection fraction.
Case Presentation:
A 39-year-old female with a history of heavy heroin use presented with intractable nausea, vomiting, and diarrhea. She tested positive for opiates and endorsed using heroin two days prior. Troponin in the emergency department was elevated at 0.973 (normal limit 0.045) peaking 6 hours later to 2.440. EKG showed sinus rhythm without signs of ischemia. She was started on suboxone. Cardiology was consulted and felt her troponin elevation was due to demand ischemia in the setting of hypertension. On day 2 the patient developed chest heaviness. Repeat EKG showed new T wave inversion in the inferior and anterior leads and new troponin peak of 3.200. The patient was taken emergently for cardiac catheterization. The coronary arteries were normal, but the left ventriculogram showed apical hyperkinesis with hypokinesis of mid-anterior wall [image1]. Echocardiogram showed ejection fraction of 60% with hypokinesis of the basal-mid inferoseptal and basal-mid inferior walls. The patient was started on carvedilol and lisinopril and discharged with cardiac follow up.
Discussion:
This case highlights that RTC can present similarly to ACS. While methamphetamine use, iatrogenic epinephrine overdose, and neurologic conditions have all been described as triggers of RTC, to our knowledge this is the first report of heroin withdrawal causing RTC. Likely both the physical and emotional stressors of heroin withdrawal led to an elevated catecholamine state in our patient and may have contributed to the development of RTC.
Conclusion:
RTC, a variant of TC, represents a minority of cases and like TC is trigged by emotional or physical stressors. After ruling out ACS, treatment is largely supportive. In cases of opioid withdrawal, earlier initiation of suboxone may help alleviate the stressors that lead to TC.
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