08 June 2020 : Case report
Recurrent Takotsubo Cardiomyopathy: Getting to the Root of the Problem
Challenging differential diagnosis, Unusual or unexpected effect of treatment, Rare disease, Educational Purpose (only if useful for a systematic review or synthesis)Matthew A. Tunzi1ABCDEFG*, Laith Dinkha2ACDEF, Alec J. Sharp2ABCDEF, Rosco S. Gore2ABCDEF
Am J Case Rep 2020; 21:e923067
BACKGROUND: While takotsubo cardiomyopathy (TC) is a rare cardiomyopathy, recurrent takotsubo cardiomyopathy (rTC) is even more so, occurring in only 4% of patients with TC. Treatment is based on expert opinion and includes standard heart failure treatment using beta blockers (BB) and angiotensin-converting enzyme inhibitors (ACEI). We present a case of rTC demonstrating how using a selective serotonin reuptake inhibitor (SSRI) with cognitive behavioral therapy (CBT) can successfully prevent recurrence.
CASE REPORT: A 64-year-old woman presented with ST-elevation myocardial infarction, and coronary angiography demonstrated non-obstructive coronary artery disease. Left heart catheterization showed apical hypokinesis with preserved function of the basal segments, consistent with TC. She reported having experienced multiple emotional stressors. The patient was started on BB and ACEI, and 5 months later repeat imaging showed resolution of her TC. One month after resolution, she was re-admitted for chest pressure, and imaging demonstrated rTC. This time, in addition to continued conventional therapy, she was started on an SSRI and CBT. Nearly 6 months later, her rTC had resolved.
CONCLUSIONS: Anxiety and depression are more common in patients with TC than in patients with STEMI, but there is little in the literature about the roles of SSRI and CBT in TC treatment. In fact, SSRIs are controversial since they can increase catecholamine concentration, which some experts believe contributes to TC. The positive response of our patient to combination SSRI-CBT therapy suggests that additional research is needed on the use of this approach for prevention and treatment of rTC.
Keywords: Adrenergic beta-Antagonists, Catecholamines, Cognitive Therapy, Heart Failure, Serotonin Uptake Inhibitors, takotsubo cardiomyopathy, Combined Modality Therapy, Coronary Angiography, Echocardiography, Middle Aged, Recurrence, Stress, Psychological
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