Tako-tsubo syndrome following nortriptyline overdose

Abstract

Background. Tako-tsubo syndrome (TTS) refers to the apical ballooning of the left ventricle observed when angiographic ventriculography is performed in patients presenting with electrocardiographic changes suggestive of acute coronary syndrome (new transient ST-segment deviation (>0.05 mV) or T-wave inversion (>0.2 mV)), mild elevation of cardiac markers, but normal coronary arteries at the angiogram. Case report. A 54-year-old woman developed the characteristic features of TTS 44 hours following nortriptyline overdose. The admission ECG showed increased QRS duration rapidly reversible after sodium bicarbonate infusion. There was a minimal increase in troponin I level. The ECG performed at the time of chest pain revealed deeply negative T waves in leads I, II, III, aVF, V1 to V6 and remained abnormal at 5 weeks follow-up. In contrast, a complete recovery of left ventricular function was observed within one week. Discussion. The pathophysiology of TTS, a variant of myocardial stunning, is still incompletely understood but could be related to sympathetic overstimulation. The possibility of TTS following toxic exposure is discussed.

Stress (Takotsubo) Cardiomyopathy in Poisoned Patients

“…To our knowledge, no systematic study has evaluated the frequency and mechanisms in this setting. We report TTC described in the literature after poisoning with non direct sympathomimetic substances in table 2 [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24].…”

Tako‐Tsubo Cardiomyopathy Following Modafinil Use

“…All three cases were associated with elevated norepinephrine levels of 20.64 nmol/L (normal, <4.43 nmol/L), 1,692 pg/mL (normal, <450 pg/mL), and 1,864 pg/mL (normal level, <399 pg/mL), respectively. TC has also been reported following overdoses of venlaxafine (300 mg), nortriptyline (1,000 mg), and dextroamphetamine/amphetamine (adderall, dose unspecified) …”

“…TC has also been reported following overdoses of venlaxafine (300 mg), nortriptyline (1,000 mg), and dextroamphetamine/amphetamine (adderall, dose unspecified). [11][12][13] It is theorized that excess stimulation of the sympathetic nervous system (SNS) leads to catecholamine mediated myocardial stunning. The elevated concentra-tions of norepinephrine (nortriptyline) or norepinephrine and serotonin (duloxetine and venlaxafine) that results from re-uptake inhibition in the neuronal synapse by these drugs may result in enough of a sympathetic drive to cause TC.…”

Stress cardiomyopathy syndrome: A contemporary review

“…Reported triggers of SC include death of a family member, altercation, fear of death, divorce, fi nancial loss, surgery, acute medical illness, near drowning, electroconvulsive therapy, and natural disasters such as earthquakes [2][3][4][5][6][7][8][9][10][11][12]. Some of the cardiovascular morbidity and, possibly, mortality associated with electronic weapons, such as stun guns, may be related to SC [35].…”

“…The original syndrome name derives from the appearance of the left ventricular (LV) systolic phase angiogram; in these patients, it resembles the traditional Japanese octopus trap, which is called a takotsubo. Those with the syndrome commonly present proximate to an identifi able stressful trigger (emotional or physiologic) [2][3][4][5][6][7][8][9][10][11][12]. As awareness of the syndrome has increased, more case reports have been published, leading to its incorporation into the American Heart Association classifi cation of reversible cardiomyopathies [13].…”