Eur J Case Rep Intern Med. 2018 Jul 26;5(7):000894. doi: 10.12890/2018_000894. eCollection 2018.

Iatrogenic Takotsubo Cardiomyopathy Secondary to Norepinephrine by Continuous Infusion for Shock.

European journal of case reports in internal medicine

Alfredo Vieira, Bárbara Batista, Tiago Tribolet de Abreu

PMID: 30756050 PMCID: PMC6346780 DOI: 10.12890/2018_000894

Abstract

Takotsubo cardiomyopathy is a condition characterized by transient left ventricular systolic and diastolic dysfunction, with a possible direct causal role of catecholamine in its pathophysiology. We present a case of a woman with shock and adrenal insufficiency in whom Takotsubo cardiomyopathy developed after treatment with norepinephrine. This case confirms the direct causal role of catecholamine in the pathophysiology of Takotsubo cardiomyopathy. An 82-year-old woman presented with asthenia, anorexia, nausea and abdominal pain. The patient had been on chronic corticosteroid therapy until 3 months before, when she underwent abdominal surgery and corticosteroids were stopped. She now presented with acute kidney injury, hyponatremia and hyperkalemia and shock. A norepinephrine continuous infusion was administered to maintain a mean arterial pressure over 65 mmHg. An echocardiogram showed severe hypokinesis in the apical segments and hyperdynamic basal segments, with an ejection fraction of 25%. Plasma cortisol level was 4.5 μg/dL (reference range 5-25). Corticosteroid therapy was begun and norepinephrine was tapered and stopped. A new echocardiogram showed normalization of cardiac wall motion and an ejection fraction of 70%. This case highlights the importance of the correction of the cause of shock, as well as the risks associated with the use of norepinephrine if hypotension is severe or if it persists despite fluid administration, as usually recommended. It also confirms the direct causal role of catecholamine in the pathophysiology of Takotsubo cardiomyopathy. To the best of our knowledge, this is the first report of stress-induced cardiomyopathy secondary to norepinephrine by continuous infusion for shock.

LEARNING POINTS: Takotsubo cardiomyopathy is a condition characterized by transient left ventricular dysfunction of the apex and midventricle in the absence of attributable coronary artery disease.In patients with shock and adrenal insufficiency, who can be erroneously interpreted as septic shock, Takotsubo cardiomyopathy can develop after treatment with norepinephrine.In the management of shock, there are risks associated with recommending the use of norepinephrine if hypotension is severe or if it persists despite fluid administration, when the cause of shock is other than septic shock and is not corrected.There is a direct causal role of catecholamine in the pathophysiology of Takotsubo cardiomyopathy.

Keywords: Shock; Takotsubo cardiomyopathy; adrenal insufficiency; norepinephrine; vasoactive agents; vasoconstrictor agents

Conflict of interest statement

References

1. Arthritis Rheum. 2012 Aug;64(8):2677-86 - PubMed
2. N Engl J Med. 2013 Oct 31;369(18):1726-34 - PubMed
3. Proc (Bayl Univ Med Cent). 2016 Apr;29(2):166-7 - PubMed
4. N Engl J Med. 2017 Oct 19;377(16):e24 - PubMed
5. Int J Cardiol. 1994 Jun 1;45(1):23-33 - PubMed

Publication Types

• Journal Article