Stress-Induced (Takotsubo) Cardiomyopathy Following Thoracic Epidural Steroid Injection for Postherpetic Neuralgia

Abstract

We present what may be the first documented case of takotsubo cardiomyopathy following a thoracic epidural steroid injection. The 77-year-old patient had many risk factors predisposing her to takotsubo cardiomyopathy, including gender, postmenopausal status, and numerous recent stressful events in her life. Although she presented to the emergency department with symptoms of an acute myocardial infarction, her findings on electrocardiography, echocardiography, coronary angiography, and cardiac enzymes supported the diagnosis of takotsubo cardiomyopathy. While takotsubo cardiomyopathy is rare, it is important for the clinician to distinguish it from an acute myocardial infarction, as the two conditions present similarly but may have distinctly different clinical outcomes.T akotsubo cardiomyopathy (TC), also known as stress-induced cardiomyopathy, is a transient systolic dysfunction of the left ventricle typically triggered by an acute illness or intense emotional or physical stress (1). Postherpetic neuralgia (PHN) is pain persisting in a herpes zoster-aff ected area >6 months after healing of the zoster eruptions (2). We present a patient with signifi cant psychosocial stressors who underwent a thoracic epidural steroid injection for treatment of PHN and then developed TC. CASE REPORTA 77-year-old woman with PHN returned to our anesthesia pain clinic for a repeat thoracic epidural steroid injection. Prior treatment with epidural steroid injections, propoxyphene, and gabapentin had adequately managed her pain. Previously, she had herpes zoster, multiple myeloma, stage III chronic kidney disease, anemia, hypertension, hypothyroidism, a deep venous thrombosis, and degenerative disk disease. A brother had recently died, and her husband had recently been admitted to a nursing home for his declining health.After reexamination, a T4-5 epidural steroid injection under fl uoroscopic guidance was planned. No sedation was administered. Th e patient was positioned prone on the fl uoroscopy table, and the overlying tissue was anesthetized with 1% lidocaine. A 17-gauge Tuohy needle was inserted via a left paramedian approach under fl uoroscopic guidance, and the loss of resistance technique was used to identify the epidural space on the fi rst pass. After negative aspiration of blood or cerebrospinal fl uid, a solution containing 80 mg of triamcinolone and 4 mL of 0.125% bupivacaine was injected. Th e patient remained stable throughout the procedure. At discharge, she had no new neurological defi cits or complaints. She attended an unrelated appointment and then returned home to take a nap. Soon after, she developed a headache and progressively worsening chest pain. She was taken to the emergency department (ED), where she reported substernal chest pain radiating into her left neck, dyspnea, nausea, and an episode of vomiting.While in the ED, she received nitroglycerin, fentanyl, heparin, and aspirin. An electrocardiogram showed mild ST-segment elevation with Q waves in the precordial leads and widening of the QRS complex. Her...

Perioperative Takotsubo Cardiomyopathy: A Systematic Review of Published Cases

“…During the second screening, articles that were not case reports (20), that were not perioperative (25) or did not fulfill the a priori revised Mayo Clinic Criteria (23) were excluded, leaving 93 articles describing 102 patients for the analysis. 13…”

“…Although there was wide variation, onset was more commonly seen either in the first half of the surgery or in the early postoperative period (Table 2). In addition to the stress typically associated with the perioperative period, 5 patients reported emotional stressors including an exaggerated fear of surgery, 38,39 a family tragedy, 65 and psychiatric disorders. 15,69 pTCM did not seem to have any predilection for any particular type of surgery.…”