Case Presentation: 78-year-old female with a past medical history of diabetes, hypertension, and vascular dementia was brought to the hospital by her family for worsening dementia, behavioral disturbances including agitation, insomnia, hallucinations and delusions. Her lab workup showed hemoglobin of 11.5 g/dl, troponin of 0.09 ng/ml, CK of 88 u/l, CK-MB of 2.25 ng/ml. Electrocardiogram showed new T-wave inversions in the anterior leads, new Q waves in the inferior leads and prolonged QTc interval (482ms). Echocardiogram showed left ventricular ejection fraction of 20-25%, apical ballooning of left ventricular apex and hyperkinesia of the basal walls. Notably, patient denied chest pain and didn’t have a past history of coronary artery disease. Chest X ray did show pulmonary edema, for which she was started on furosemide. A diagnosis of psychosis, secondary to worsening dementia was made and Haloperidol, olanzapine and ziprasidone were initiated. Given her normal CK and CK-MB, absence of ST segment changes and medical history, a decision was made to not pursue urgent cardiac catheterization. Troponin levels were monitored and they were trending downwards. Patient did not develop any new EKG changes and continued to have no chest pain. Her mental status returned to baseline within a week. Follow up echocardiogram showed significant improvement in previously noted wall motion abnormalities and left ventricular ejection fraction improved to 50%.
Discussion: Takotsubo cardiomyopathy, also referred to as stress cardiomyopathy is a unique form of LV systolic dysfunction. Typically, patients present with symptoms of acute myocardial infarction including chest pain, S-T changes, and positive cardiac enzymes. Characteristic echocardiogram findings include regional wall motion abnormalities, which extend beyond a single epicardial coronary artery distribution. The precise mechanism that causes this type of LV dysfunction in unknown. Postulated pathogenic mechanisms include catecholamine excess, microvascular dysfunction and multivessel coronary artery spasm. This condition is usually seen in association with intense emotional or physical stressors and is rarely reported with acute psychotic states. The influence of psychiatric illness in the pathogenesis of Takotsubo cardiomyopathy is an under-recognized association. Such patients have higher circulating catecholamine levels which may increase their risk of developing Takotsubo cardiomyopathy. This potential association opens room for further research, including the elective decision to avoid catheterization in such cases. Our patient responded effectively to mood stabilizers and made complete recovery without undergoing cardiac catheterization.
Conclusions: Takotsubo cardiomyopathy is characterized by transient regional systolic dysfunction of the left ventricle, mimicking myocardial infarction, in the absence of obstructive coronary artery disease or acute plaque rupture. It is mostly seen in post-menopausal women, in association with emotional or physical stresses. We present a case of Takotsubo cardiomyopathy, in a patient with acute psychosis, which was reversed successfully after mood stabilization and supportive therapy. We aim to sensitize physicians to identify acute psychosis as a potential precipitant in patients presenting with Takotsubo cardiomyopathy and diagnosis and management of this condition.