Acute Coronary Syndrome (Takotsubo Cardiomyopathy) Following Electroconvulsive Therapy in the Absence of Significant Coronary Artery Disease

Abstract

We report a case of myocardial infarction occurring in a 45-year-old woman in the absence of coronary artery disease during a course of electroconvulsive therapy (ECT) for major depression. After the third ECT session, the patient reported substernal chest pain, and although the electrocardiogram was normal, cardiac enzymes were found to be elevated. Cardiac workup to determine etiology during hospital stay showed no evidence of coronary artery disease on catheterization. Cardiac echocardiograph and computed tomography findings were consistent with a diagnosis of Takotsubo cardiomyopathy. This cardiac syndrome is a stress-induced syndrome occurring in the absence of coronary artery stenosis and associated with surging of catecholamines. It is diagnosed on the basis of the shape of the apical ballooning observed on cardiac imaging, which resembles a "takotsubo" or octopus fishing pot in Japan, where this syndrome was first recognized. Coincidentally, after termination of her ECT course, this patient was also diagnosed with Loeys-Dietz syndrome, an inherited connective tissue disorder that can predispose sufferers to aortic dissection. This case illustrates the importance of careful workup of chest pain in the setting of ECT, even if electrocardiogram findings seem unremarkable initially.

Cardiac Complications of ECT: Myocardial Stunning Syndrome and Takotsubo Cardiomyopathy After ECT

“…These cases are of interest to us because we recently reported a case of reversible cardiomyopathy in a 45-year-old woman who underwent ECT for treatment-resistant major depression. 2 Similar to the patients in the cases of Go et al, our patient was an overweight woman who presented with acute chest pain and dyspnea after ECT. Cardiac enzymes were found to be elevated, suggesting myocardial ischemia, but there was no evidence of coronary artery disease on cardiac catheterization.…”

“…This constellation of signs and symptoms are compatible with stress-induced cardiomyopathy also known as takotsubo cardiomyopathy (TCM). 2 Subsequently, a group at another center reported a similar case of ECTemergent TCM. 3 As in most of the other cases described, this patient was also a postmenopausal woman who developed chest pain and dyspnea after ECT, with associated elevation of cardiac enzymes and regional wall-motion abnormalities on echocardiogram that resolved without incident after several days.…”

Takotsubo cardiomyopathy following electroconvulsive therapy: an increasingly recognised phenomenon

“…Takotsubo cardiomyopathy as a complication of ECT is an increasingly recognised and reported phenomenon 3–5 9 12–14. A literature review published in 2011 highlighted seven previously documented cases of Takotsubo cardiomyopathy following ECT, in addition to four cases of myocardial stunning and one case of cardiogenic shock post-ECT 4.…”

CNS disease triggering Takotsubo stress cardiomyopathy

“…TTS has been reported as an early complication of this treatment, which may occur with or without concomitant neuroleptic therapy [33]. So far, 15 patients have been reported who developed TTS after ECT [33,[146][147][148][149]. Fourteen of the patients were female and one was male.…”