“Broken Heart Syndrome” After Separation (From OxyContin)
2006; Elsevier BV; Volume: 81; Issue: 6 Linguagem: Inglês
10.4065/81.6.825
ISSN1942-5546
AutoresJ. Rivera, Adam J. Locketz, K. Fritz, Terese T. Horlocker, David G. Lewallen, Abhiram Prasad, John F. Bresnahan, Michelle A. O. Kinney,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoWe describe a 61-year-old woman with “broken heart syndrome” (Takotsubo-like cardiomyopathy) after abrupt postsurgical withdrawal of OxyContin. Her medical history was remarkable for long-term opioid dependence associated with the treatment of multijoint degenerative osteoarthritis. The patient presented to the emergency department 1 day after discharge from the hospital following total knee arthroplasty revision with acute-onset dyspnea and mild chest pain. She had precordial ST-segment elevation characteristic of acute myocardial infarction and elevated cardiac biomarkers. Emergency coronary angiography revealed no major coronary atherosclerosis. However, the left ventricular ejection fraction was severely decreased (26%), and new regional wall motion abnormalities typical of broken heart syndrome were noted. In addition to resuming her opioid therapy, she was treated supportively with bilevel positive airway pressure, diuretic therapy, morphine, aspirin, metoprolol, enalaprilat, intravenous heparin, nitroglycerin infusion, and dopamine infusion. Ventricular systolic function recovered completely by the fourth hospital day. To our knowledge, broken heart syndrome after opioid withdrawal has not been reported previously in an adult. Our case illustrates the importance of continuing adequate opiate therapy perioperatively in the increasing number of opioid-dependent patients to prevent potentially life-threatening complications such as broken heart syndrome. We describe a 61-year-old woman with “broken heart syndrome” (Takotsubo-like cardiomyopathy) after abrupt postsurgical withdrawal of OxyContin. Her medical history was remarkable for long-term opioid dependence associated with the treatment of multijoint degenerative osteoarthritis. The patient presented to the emergency department 1 day after discharge from the hospital following total knee arthroplasty revision with acute-onset dyspnea and mild chest pain. She had precordial ST-segment elevation characteristic of acute myocardial infarction and elevated cardiac biomarkers. Emergency coronary angiography revealed no major coronary atherosclerosis. However, the left ventricular ejection fraction was severely decreased (26%), and new regional wall motion abnormalities typical of broken heart syndrome were noted. In addition to resuming her opioid therapy, she was treated supportively with bilevel positive airway pressure, diuretic therapy, morphine, aspirin, metoprolol, enalaprilat, intravenous heparin, nitroglycerin infusion, and dopamine infusion. Ventricular systolic function recovered completely by the fourth hospital day. To our knowledge, broken heart syndrome after opioid withdrawal has not been reported previously in an adult. Our case illustrates the importance of continuing adequate opiate therapy perioperatively in the increasing number of opioid-dependent patients to prevent potentially life-threatening complications such as broken heart syndrome. Opioids are becoming increasingly common for the treatment of pain that is not due to incurable malignancies. In fact, Gilson et al1Gilson AM Ryan KM Joranson DE Dahl JL A reassessment of trends in the medical use and abuse of opioid analgesics and implications for diversion control: 1997-2002.J Pain Symptom Manage. 2004; 28: 176-188Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar reported a greater than 400% increase in oxycodone use between 1997 and 2002. We report a case of “broken heart syndrome” (Takotsubo-like cardiomyopathy) after perioperative opioid withdrawal in an opioid-dependent adult patient. Given the increase in prolonged use of opioids for treatment of a wide array of medical and surgical conditions, clinicians should be aware of this potential complication of opioid withdrawal. A 61-year-old woman presented to the emergency department with acute-onset dyspnea and mild chest pain. She had been discharged from the hospital the previous afternoon after undergoing right total knee arthroplasty revision surgery 8 days previously. Her medical history included hypertension, hypothyroidism, and long-term opioid dependence associated with treatment of multijoint degenerative osteoarthritis. The patient had a 45-pack-year history of smoking but had quit more than 15 years before the current admission. She had no history of diabetes mellitus or hyperlipidemia. She reported back pain and nausea but denied abdominal pain, vomiting, leg pain, or increased leg swelling. Physical examination on admission revealed a heart rate of 146 beats/min, a blood pressure of 170/106 mm Hg, and an oxygen saturation of 94% while the patient wore a non-rebreathing mask that delivered 15 L of oxygen per minute. Pupillary size was not documented at the time of admission, but the patient was pale, anxious, diaphoretic, and in acute respiratory distress. A soft systolic murmur was audible, and diffuse crackles were heard in the lower two thirds of both lung fields. Electrocardiography showed tachycardia with ST-segment elevation in the precordial leads (Figure 1). The troponin T and creatine kinase-MB isoenzyme levels were 0.45 ng/mL (reference range, <0.03 ng/mL) and 5.8 ng/mL (reference range, <6.2 ng/mL), respectively. Free plasma and total 24-hour urinary levels of metanephrine and normetanephrine were normal. Chest x-ray films showed bilateral pulmonary infiltrates. The B-type natriuretic peptide level was more than 2300 pg/mL (reference range, <96 pg/mL). Because the patient refused tracheal intubation, the respiratory failure due to pulmonary edema was managed with use of bilevel positive airway pressure and diuretic therapy. In addition, she was treated with morphine, aspirin, metoprolol, enalaprilat, intravenous heparin, and a nitroglycerin infusion. Spiral computed tomography of the chest showed no pulmonary emboli. Emergency coronary angiography (Figure 2) detected no major coronary artery blockages, but left ventriculography (Figure 3) identified a severely reduced ejection fraction of 26% with severe hypokinesis of the posterolateral, anterolateral, diaphragmatic, and basal septal segments. New-onset moderate to severe mitral regurgitation was also present. Cardiac imaging before the orthopedic surgery had shown normal left ventricular function and trivial mitral regurgitation.FIGURE 2Coronary angiograms of the right (left) and left (right) coronary arteries showing no serious obstructive coronary artery disease.View Large Image Figure ViewerDownload (PPT)FIGURE 3Left ventriculograms during diastole (left) and systole (right) showing mild hypokinesis of the apical segment (arrows) with severe hypokinesis of posterolateral, anterolateral, diaphragmatic, and basal septal segments.View Large Image Figure ViewerDownload (PPT) Before the most recent knee surgery, the patient had been treated for several months with OxyContin (Purdue [Pharma LP], Stamford, Conn) (40 mg twice daily) and hydromorphone (4 mg every 3 hours as needed for break-throughpain). Her perioperative analgesia was multimodal, including regional nerve blocks, acetaminophen (1 g every 8 hours), and opioids. The regional anesthesia included bupivacaine via a sciatic nerve injection and a femoral nerve catheter infusion. Postoperatively, her oral opioid regimen was increased to 60 mg of oral OxyContin twice daily, with 10 to 15 mg of immediate-release oxycodone provided every 2 to 5 hours for breakthrough pain. Seven days after her knee surgery, the patient was transferred to an acute care nursing facility. The last recorded vital signs before hospital dismissal were a blood pressure of 124/80 mm Hg, heart rate of 80 beats/min, and respiratory rate of 18/min. The OxyContin was inadvertently discontinued during transfer to the nursing facility, and the dose of her immediate-release oxycodone was also decreased to 5 mg every 4 hours as needed. This error in discharge medication orders was not discovered until shortly before the patient's readmission. The postoperative opioid regimen was reinitiated shortly after readmission. The day after admission the patient developed arterial hypotension that was treated with intravenous infusion of dopamine, which was discontinued without complications after 3 days. She was also treated for pneumonia. Transthoracic echocardiography on the fourth hospital day showed complete recovery of left ventricular systolic function (ejection fraction, 65%-70%) and resolution of the mitral regurgitation. After 5 days in the intensive care unit and 2 days on the cardiac ward, the patient was again discharged to an acute care nursing facility. In 1991, Sato et al, from Japan, first described ballooning of the left ventricle as “tako-tsubo-like left ventricular dysfunction.”2Kurisu S Sato H Kawagoe T et al.Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction.Am Heart J. 2002; 143: 448-455Abstract Full Text Full Text PDF PubMed Scopus (731) Google Scholar Tako is the Japanese word for octopus, and tsubo means pot or trap. (A photograph of a tako tsubo can be found in the Medical Images section of this issue ofMayo Clinic Proceedings.3Reyburn AM Vaglio Jr, JC Transient left ventricular apical ballooning syndrome.Mayo Clin Proc. 2006; 81: 824Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar) The authors chose this name because they believed that the abnormal contraction of the left ventricle caused it to look similar to a tako tsubo, with a round bottom and a narrow neck. Since their description, this syndrome has also been referred to as broken heart syndrome, reversible cardiomyopathy, stress-induced cardiomyopathy, regional systolic dysfunction, ampulla cardiomyopathy, and transient left ventricular apical ballooning syndrome.2Kurisu S Sato H Kawagoe T et al.Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction.Am Heart J. 2002; 143: 448-455Abstract Full Text Full Text PDF PubMed Scopus (731) Google Scholar, 4Abe Y Kondo M Matsuoka R Araki M Dohyama K Tanio H Assessment of clinical features in transient left ventricular apical ballooning.J Am Coll Cardiol. 2003; 41: 737-742Abstract Full Text Full Text PDF PubMed Scopus (541) Google Scholar, 5Desmet WJ Adriaenssens BF Dens JA Apical ballooning of the left ventricle: first series in white patients.Heart. 2003; 89: 1027-1031Crossref PubMed Scopus (457) Google Scholar, 6Sharkey SW Lesser JR Zenovich AG et al.Acute and reversible cardiomyopathy provoked by stress in women from the United States.Circulation. 2005; 111: 472-479Crossref PubMed Scopus (839) Google Scholar, 7Bybee KA Kara T Prasad A et al.Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.Ann Intern Med. 2004; 141: 858-865Crossref PubMed Scopus (1224) Google Scholar, 8Tsuchihashi K Ueshima K Uchida T Angina pectoris-Myocardial Infarction Investigations in Japan et al.Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction.J Am Coll Cardiol. 2001; 38: 11-18Abstract Full Text Full Text PDF PubMed Scopus (1346) Google Scholar, 9Akashi YJ Tejima T Sakurada H et al.Left ventricular rupture associated with Takotsubo cardiomyopathy.Mayo Clin Proc. 2004; 79: 821-824PubMed Google Scholar, 10Akashi YJ Nakazawa K Sakakibara M Miyake F Koike H Sasaka K The clinical features of takotsubo cardiomyopathy.QJM. 2003; 96: 563-573Crossref PubMed Scopus (272) Google Scholar, 11Bybee KA Prasad A Barsness GW et al.Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome.Am J Cardiol. 2004; 94: 343-346Abstract Full Text Full Text PDF PubMed Scopus (487) Google Scholar, 12Kawai S Suzuki H Yamaguchi H et al.Ampulla cardiomyopathy (‘Takotsubo’ cardiomyopathy)—reversible left ventricular dysfunction: with ST segment elevation.Jpn Circ J. 2000; 64: 156-159Crossref PubMed Scopus (283) Google Scholar, 13Park JH Kang SJ Song JK et al.Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU.Chest. 2005; 128: 296-302Crossref PubMed Scopus (243) Google Scholar Apical ballooning occurs in about 1% to 2% of patients hospitalized for acute coronary syndrome.6Sharkey SW Lesser JR Zenovich AG et al.Acute and reversible cardiomyopathy provoked by stress in women from the United States.Circulation. 2005; 111: 472-479Crossref PubMed Scopus (839) Google Scholar, 10Akashi YJ Nakazawa K Sakakibara M Miyake F Koike H Sasaka K The clinical features of takotsubo cardiomyopathy.QJM. 2003; 96: 563-573Crossref PubMed Scopus (272) Google Scholar, 11Bybee KA Prasad A Barsness GW et al.Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome.Am J Cardiol. 2004; 94: 343-346Abstract Full Text Full Text PDF PubMed Scopus (487) Google Scholar Although cases of men with broken heart syndrome have been reported, most patients with this cardiomyopathy are postmenopausal women with preceding emotional or physiologic stress.2Kurisu S Sato H Kawagoe T et al.Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction.Am Heart J. 2002; 143: 448-455Abstract Full Text Full Text PDF PubMed Scopus (731) Google Scholar, 4Abe Y Kondo M Matsuoka R Araki M Dohyama K Tanio H Assessment of clinical features in transient left ventricular apical ballooning.J Am Coll Cardiol. 2003; 41: 737-742Abstract Full Text Full Text PDF PubMed Scopus (541) Google Scholar, 5Desmet WJ Adriaenssens BF Dens JA Apical ballooning of the left ventricle: first series in white patients.Heart. 2003; 89: 1027-1031Crossref PubMed Scopus (457) Google Scholar, 6Sharkey SW Lesser JR Zenovich AG et al.Acute and reversible cardiomyopathy provoked by stress in women from the United States.Circulation. 2005; 111: 472-479Crossref PubMed Scopus (839) Google Scholar, 7Bybee KA Kara T Prasad A et al.Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.Ann Intern Med. 2004; 141: 858-865Crossref PubMed Scopus (1224) Google Scholar, 8Tsuchihashi K Ueshima K Uchida T Angina pectoris-Myocardial Infarction Investigations in Japan et al.Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction.J Am Coll Cardiol. 2001; 38: 11-18Abstract Full Text Full Text PDF PubMed Scopus (1346) Google Scholar, 9Akashi YJ Tejima T Sakurada H et al.Left ventricular rupture associated with Takotsubo cardiomyopathy.Mayo Clin Proc. 2004; 79: 821-824PubMed Google Scholar, 10Akashi YJ Nakazawa K Sakakibara M Miyake F Koike H Sasaka K The clinical features of takotsubo cardiomyopathy.QJM. 2003; 96: 563-573Crossref PubMed Scopus (272) Google Scholar, 11Bybee KA Prasad A Barsness GW et al.Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome.Am J Cardiol. 2004; 94: 343-346Abstract Full Text Full Text PDF PubMed Scopus (487) Google Scholar, 12Kawai S Suzuki H Yamaguchi H et al.Ampulla cardiomyopathy (‘Takotsubo’ cardiomyopathy)—reversible left ventricular dysfunction: with ST segment elevation.Jpn Circ J. 2000; 64: 156-159Crossref PubMed Scopus (283) Google Scholar, 14Wittstein IS Thiemann DR Lima JA et al.Neurohumoral features of myocardial stunning due to sudden emotional stress.N Engl J Med. 2005; 352: 539-548Crossref PubMed Scopus (2373) Google Scholar, 15Sharkey SW Shear W Hodges M Herzog CA Reversible myocardial contraction abnormalities in patients with an acute noncardiac illness.Chest. 1998; 114: 98-105Crossref PubMed Scopus (117) Google Scholar Unexpected deaths of relatives, major financial losses, or other life crises are examples of emotional stresses associated with broken heart syndrome. Apical ballooning has also been seen after physiologic stresses such as pneumothorax, pneumonia, stroke, grand mal seizure, and hip fracture. Park et al13Park JH Kang SJ Song JK et al.Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU.Chest. 2005; 128: 296-302Crossref PubMed Scopus (243) Google Scholar reported that 22% of patients admitted to an intensive care unit for noncardiac and non-postsurgical reasons developed transient left ventricular apical ballooning. Patients typically present with symptoms and complications similar to those of an acute coronary syndrome.2Kurisu S Sato H Kawagoe T et al.Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction.Am Heart J. 2002; 143: 448-455Abstract Full Text Full Text PDF PubMed Scopus (731) Google Scholar, 4Abe Y Kondo M Matsuoka R Araki M Dohyama K Tanio H Assessment of clinical features in transient left ventricular apical ballooning.J Am Coll Cardiol. 2003; 41: 737-742Abstract Full Text Full Text PDF PubMed Scopus (541) Google Scholar, 5Desmet WJ Adriaenssens BF Dens JA Apical ballooning of the left ventricle: first series in white patients.Heart. 2003; 89: 1027-1031Crossref PubMed Scopus (457) Google Scholar, 6Sharkey SW Lesser JR Zenovich AG et al.Acute and reversible cardiomyopathy provoked by stress in women from the United States.Circulation. 2005; 111: 472-479Crossref PubMed Scopus (839) Google Scholar, 7Bybee KA Kara T Prasad A et al.Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.Ann Intern Med. 2004; 141: 858-865Crossref PubMed Scopus (1224) Google Scholar, 8Tsuchihashi K Ueshima K Uchida T Angina pectoris-Myocardial Infarction Investigations in Japan et al.Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction.J Am Coll Cardiol. 2001; 38: 11-18Abstract Full Text Full Text PDF PubMed Scopus (1346) Google Scholar, 9Akashi YJ Tejima T Sakurada H et al.Left ventricular rupture associated with Takotsubo cardiomyopathy.Mayo Clin Proc. 2004; 79: 821-824PubMed Google Scholar, 10Akashi YJ Nakazawa K Sakakibara M Miyake F Koike H Sasaka K The clinical features of takotsubo cardiomyopathy.QJM. 2003; 96: 563-573Crossref PubMed Scopus (272) Google Scholar, 11Bybee KA Prasad A Barsness GW et al.Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome.Am J Cardiol. 2004; 94: 343-346Abstract Full Text Full Text PDF PubMed Scopus (487) Google Scholar, 12Kawai S Suzuki H Yamaguchi H et al.Ampulla cardiomyopathy (‘Takotsubo’ cardiomyopathy)—reversible left ventricular dysfunction: with ST segment elevation.Jpn Circ J. 2000; 64: 156-159Crossref PubMed Scopus (283) Google Scholar, 14Wittstein IS Thiemann DR Lima JA et al.Neurohumoral features of myocardial stunning due to sudden emotional stress.N Engl J Med. 2005; 352: 539-548Crossref PubMed Scopus (2373) Google Scholar, 15Sharkey SW Shear W Hodges M Herzog CA Reversible myocardial contraction abnormalities in patients with an acute noncardiac illness.Chest. 1998; 114: 98-105Crossref PubMed Scopus (117) Google Scholar, 16Villareal RP Achari A Wilansky S Wilson JM Anteroapical stunning and left ventricular outflow tract obstruction.Mayo Clin Proc. 2001; 76: 79-83Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar The systematic review by Bybee et al7Bybee KA Kara T Prasad A et al.Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.Ann Intern Med. 2004; 141: 858-865Crossref PubMed Scopus (1224) Google Scholar found that chest pain was the presenting symptom in 33% to 71% of cases of broken heart syndrome, with shortness of breath being another common presenting problem. Slightly elevated cardiac enzymes, hemodynamic instability, and cardiogenic shock are common sequelae.2Kurisu S Sato H Kawagoe T et al.Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction.Am Heart J. 2002; 143: 448-455Abstract Full Text Full Text PDF PubMed Scopus (731) Google Scholar, 5Desmet WJ Adriaenssens BF Dens JA Apical ballooning of the left ventricle: first series in white patients.Heart. 2003; 89: 1027-1031Crossref PubMed Scopus (457) Google Scholar, 6Sharkey SW Lesser JR Zenovich AG et al.Acute and reversible cardiomyopathy provoked by stress in women from the United States.Circulation. 2005; 111: 472-479Crossref PubMed Scopus (839) Google Scholar, 7Bybee KA Kara T Prasad A et al.Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.Ann Intern Med. 2004; 141: 858-865Crossref PubMed Scopus (1224) Google Scholar, 8Tsuchihashi K Ueshima K Uchida T Angina pectoris-Myocardial Infarction Investigations in Japan et al.Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction.J Am Coll Cardiol. 2001; 38: 11-18Abstract Full Text Full Text PDF PubMed Scopus (1346) Google Scholar, 9Akashi YJ Tejima T Sakurada H et al.Left ventricular rupture associated with Takotsubo cardiomyopathy.Mayo Clin Proc. 2004; 79: 821-824PubMed Google Scholar, 10Akashi YJ Nakazawa K Sakakibara M Miyake F Koike H Sasaka K The clinical features of takotsubo cardiomyopathy.QJM. 2003; 96: 563-573Crossref PubMed Scopus (272) Google Scholar, 11Bybee KA Prasad A Barsness GW et al.Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome.Am J Cardiol. 2004; 94: 343-346Abstract Full Text Full Text PDF PubMed Scopus (487) Google Scholar, 12Kawai S Suzuki H Yamaguchi H et al.Ampulla cardiomyopathy (‘Takotsubo’ cardiomyopathy)—reversible left ventricular dysfunction: with ST segment elevation.Jpn Circ J. 2000; 64: 156-159Crossref PubMed Scopus (283) Google Scholar, 14Wittstein IS Thiemann DR Lima JA et al.Neurohumoral features of myocardial stunning due to sudden emotional stress.N Engl J Med. 2005; 352: 539-548Crossref PubMed Scopus (2373) Google Scholar, 15Sharkey SW Shear W Hodges M Herzog CA Reversible myocardial contraction abnormalities in patients with an acute noncardiac illness.Chest. 1998; 114: 98-105Crossref PubMed Scopus (117) Google Scholar, 16Villareal RP Achari A Wilansky S Wilson JM Anteroapical stunning and left ventricular outflow tract obstruction.Mayo Clin Proc. 2001; 76: 79-83Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar Similar to acute coronary syndrome, pulmonary edema, arrhythmias, left ventricular wall rupture, mitral regurgitation, left ventricular mural thrombus, and death have been reported in patients with broken heart syndrome.2Kurisu S Sato H Kawagoe T et al.Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction.Am Heart J. 2002; 143: 448-455Abstract Full Text Full Text PDF PubMed Scopus (731) Google Scholar, 5Desmet WJ Adriaenssens BF Dens JA Apical ballooning of the left ventricle: first series in white patients.Heart. 2003; 89: 1027-1031Crossref PubMed Scopus (457) Google Scholar, 6Sharkey SW Lesser JR Zenovich AG et al.Acute and reversible cardiomyopathy provoked by stress in women from the United States.Circulation. 2005; 111: 472-479Crossref PubMed Scopus (839) Google Scholar, 7Bybee KA Kara T Prasad A et al.Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.Ann Intern Med. 2004; 141: 858-865Crossref PubMed Scopus (1224) Google Scholar, 8Tsuchihashi K Ueshima K Uchida T Angina pectoris-Myocardial Infarction Investigations in Japan et al.Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction.J Am Coll Cardiol. 2001; 38: 11-18Abstract Full Text Full Text PDF PubMed Scopus (1346) Google Scholar, 9Akashi YJ Tejima T Sakurada H et al.Left ventricular rupture associated with Takotsubo cardiomyopathy.Mayo Clin Proc. 2004; 79: 821-824PubMed Google Scholar, 10Akashi YJ Nakazawa K Sakakibara M Miyake F Koike H Sasaka K The clinical features of takotsubo cardiomyopathy.QJM. 2003; 96: 563-573Crossref PubMed Scopus (272) Google Scholar, 11Bybee KA Prasad A Barsness GW et al.Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome.Am J Cardiol. 2004; 94: 343-346Abstract Full Text Full Text PDF PubMed Scopus (487) Google Scholar, 15Sharkey SW Shear W Hodges M Herzog CA Reversible myocardial contraction abnormalities in patients with an acute noncardiac illness.Chest. 1998; 114: 98-105Crossref PubMed Scopus (117) Google Scholar, 16Villareal RP Achari A Wilansky S Wilson JM Anteroapical stunning and left ventricular outflow tract obstruction.Mayo Clin Proc. 2001; 76: 79-83Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar Therefore, vigilance for potential complications is important. Treatment is usually supportive. Depending on the clinical picture, aspirin, β-blockers, diuretics, angiotensin-converting enzyme inhibitors, calcium channel blockers, vasopressors, anticoagulants, or intra-aortic balloon pump may be necessary. The transient nature of this cardiomyopathy makes it distinct from acute coronary syndrome, and left ventricular function usually normalizes within days to weeks.2Kurisu S Sato H Kawagoe T et al.Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction.Am Heart J. 2002; 143: 448-455Abstract Full Text Full Text PDF PubMed Scopus (731) Google Scholar, 4Abe Y Kondo M Matsuoka R Araki M Dohyama K Tanio H Assessment of clinical features in transient left ventricular apical ballooning.J Am Coll Cardiol. 2003; 41: 737-742Abstract Full Text Full Text PDF PubMed Scopus (541) Google Scholar, 5Desmet WJ Adriaenssens BF Dens JA Apical ballooning of the left ventricle: first series in white patients.Heart. 2003; 89: 1027-1031Crossref PubMed Scopus (457) Google Scholar, 6Sharkey SW Lesser JR Zenovich AG et al.Acute and reversible cardiomyopathy provoked by stress in women from the United States.Circulation. 2005; 111: 472-479Crossref PubMed Scopus (839) Google Scholar, 7Bybee KA Kara T Prasad A et al.Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.Ann Intern Med. 2004; 141: 858-865Crossref PubMed Scopus (1224) Google Scholar, 8Tsuchihashi K Ueshima K Uchida T Angina pectoris-Myocardial Infarction Investigations in Japan et al.Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction.J Am Coll Cardiol. 2001; 38: 11-18Abstract Full Text Full Text PDF PubMed Scopus (1346) Google Scholar, 9Akashi YJ Tejima T Sakurada H et al.Left ventricular rupture associated with Takotsubo cardiomyopathy.Mayo Clin Proc. 2004; 79: 821-824PubMed Google Scholar, 10Akashi YJ Nakazawa K Sakakibara M Miyake F Koike H Sasaka K The clinical features of takotsubo cardiomyopathy.QJM. 2003; 96: 563-573Crossref PubMed Scopus (272) Google Scholar, 11Bybee KA Prasad A Barsness GW et al.Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome.Am J Cardiol. 2004; 94: 343-346Abstract Full Text Full Text PDF PubMed Scopus (487) Google Scholar, 12Kawai S Suzuki H Yamaguchi H et al.Ampulla cardiomyopathy (‘Takotsubo’ cardiomyopathy)—reversible left ventricular dysfunction: with ST segment elevation.Jpn Circ J. 2000; 64: 156-159Crossref PubMed Scopus (283) Google Scholar, 14Wittstein IS Thiemann DR Lima JA et al.Neurohumoral features of myocardial stunning due to sudden emotional stress.N Engl J Med. 2005; 352: 539-548Crossref PubMed Scopus (2373) Google Scholar, 15Sharkey SW Shear W Hodges M Herzog CA Reversible myocardial contraction abnormalities in patients with an acute noncardiac illness.Chest. 1998; 114: 98-105Crossref PubMed Scopus (117) Google Scholar, 16Villareal RP Achari A Wilansky S Wilson JM Anteroapical stunning and left ventricular outflow tract obstruction.Mayo Clin Proc. 2001; 76: 79-83Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar In the review by Bybee et al,7Bybee KA Kara T Prasad A et al.Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.Ann Intern Med. 2004; 141: 858-865Crossref PubMed Scopus (1224) Google Scholar in-hospital mortality ranged from 0% to 8%. In the largest series included in their review (88 patients), the mortality rate was about 1%.8Tsuchihashi K Ueshima K Uchida T Angina pectoris-Myocardial Infarction Investigations in Japan et al.Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction.J Am Coll Cardiol. 2001; 38: 11-18Abstract Full Text Full Text PDF PubMed Scopus (1346) Google Scholar The rates of recurrence reported in the systematic review ranged from 0% to 8%.7Bybee KA Kara T Prasad A et al.Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.Ann Intern Med. 2004; 141: 858-865Crossref PubMed Scopus (1224) Google Scholar Although diagnostic criteria for transient left ventricular apical ballooning had been suggested previously on the basis of small case series, in 2004, Mayo Clinic investigators proposed criteria based on a systematic review of the literature.7Bybee KA Kara T Prasad A et al.Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.Ann Intern Med. 2004; 141: 858-865Crossref PubMed Scopus (1224) Google Scholar These criteria include transient akinesis or dyskinesis of apical and midventricular segments in association with regional wall motion abnormalities beyond the distribution of a single vessel with no obstructive coronary artery disease or acute plaque rupture. New ST-segment elevation or T-wave inversion on electrocardiography in the absence of other explanations for these changes are additional criteria. Other factors such as severe head trauma, intracranial bleeding, pheochromocytoma, myocarditis, and hypertrophic cardiomyopathy that are associated with increased catecholamine levels and similar electrocardiographic and regional wall motion abnormalities should be excluded before broken heart syndrome is diagnosed.7Bybee KA Kara T Prasad A et al.Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.Ann Intern Med. 2004; 141: 858-865Crossref PubMed Scopus (1224) Google Scholar The exact mechanism for the disorder has not yet been identified, but given the strong association with stress, the pathophysiology of this syndrome likely involves catecholamine-induced myocardial dysfunction. It has been speculated that myocytes may be directly injured by catecholamines,2Kurisu S Sato H Kawagoe T et al.Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction.Am Heart J. 2002; 143: 448-455Abstract Full Text Full Text PDF PubMed Scopus (731) Google Scholar, 6Sharkey SW Lesser JR Zenovich AG et al.Acute and reversible cardiomyopathy provoked by stress in women from the United States.Circulation. 2005; 111: 472-479Crossref PubMed Scopus (839) Google Scholar, 13Park JH Kang SJ Song JK et al.Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU.Chest. 2005; 128: 296-302Crossref PubMed Scopus (243) Google Scholar, 14Wittstein IS Thiemann DR Lima JA et al.Neurohumoral features of myocardial stunning due to sudden emotional stress.N Engl J Med. 2005; 352: 539-548Crossref PubMed Scopus (2373) Google Scholar, 15Sharkey SW Shear W Hodges M Herzog CA Reversible myocardial contraction abnormalities in patients with an acute noncardiac illness.Chest. 1998; 114: 98-105Crossref PubMed Scopus (117) Google Scholar, 16Villareal RP Achari A Wilansky S Wilson JM Anteroapical stunning and left ventricular outflow tract obstruction.Mayo Clin Proc. 2001; 76: 79-83Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar but circulating catecholamine measurements in patients with broken heart syndrome have yielded inconsistent results.2Kurisu S Sato H Kawagoe T et al.Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction.Am Heart J. 2002; 143: 448-455Abstract Full Text Full Text PDF PubMed Scopus (731) Google Scholar, 9Akashi YJ Tejima T Sakurada H et al.Left ventricular rupture associated with Takotsubo cardiomyopathy.Mayo Clin Proc. 2004; 79: 821-824PubMed Google Scholar, 10Akashi YJ Nakazawa K Sakakibara M Miyake F Koike H Sasaka K The clinical features of takotsubo cardiomyopathy.QJM. 2003; 96: 563-573Crossref PubMed Scopus (272) Google Scholar, 13Park JH Kang SJ Song JK et al.Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU.Chest. 2005; 128: 296-302Crossref PubMed Scopus (243) Google Scholar, 14Wittstein IS Thiemann DR Lima JA et al.Neurohumoral features of myocardial stunning due to sudden emotional stress.N Engl J Med. 2005; 352: 539-548Crossref PubMed Scopus (2373) Google Scholar Nevertheless, Ueyama et al17Ueyama T Kasamatsu K Hano T Yamamoto K Tsuruo Y Nishio I Emotional stress induces transient left ventricular hypocontraction in the rat via activation of cardiac adrenoceptors: a possible animal model of ‘tako-tsubo’ cardiomyopathy.Circ J. 2002; 66: 712-713Crossref PubMed Scopus (279) Google Scholar found that in rats, emotional stress-induced transient apical ballooning could be prevented with adrenergic receptor antagonists. Some investigators hypothesize that regional differences in sympathetic innervation or catecholamine receptor density may account for the specific regions of ventricular dysfunction.7Bybee KA Kara T Prasad A et al.Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.Ann Intern Med. 2004; 141: 858-865Crossref PubMed Scopus (1224) Google Scholar, 13Park JH Kang SJ Song JK et al.Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU.Chest. 2005; 128: 296-302Crossref PubMed Scopus (243) Google Scholar, 14Wittstein IS Thiemann DR Lima JA et al.Neurohumoral features of myocardial stunning due to sudden emotional stress.N Engl J Med. 2005; 352: 539-548Crossref PubMed Scopus (2373) Google Scholar, 15Sharkey SW Shear W Hodges M Herzog CA Reversible myocardial contraction abnormalities in patients with an acute noncardiac illness.Chest. 1998; 114: 98-105Crossref PubMed Scopus (117) Google Scholar, 16Villareal RP Achari A Wilansky S Wilson JM Anteroapical stunning and left ventricular outflow tract obstruction.Mayo Clin Proc. 2001; 76: 79-83Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar In addition, females may be predisposed to stress-associated dynamic left ventricular outflow tract obstruction.16Villareal RP Achari A Wilansky S Wilson JM Anteroapical stunning and left ventricular outflow tract obstruction.Mayo Clin Proc. 2001; 76: 79-83Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar Endomyocardial biopsies have not shown compelling evidence of acute myocarditis in patients with broken heart syndrome.2Kurisu S Sato H Kawagoe T et al.Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction.Am Heart J. 2002; 143: 448-455Abstract Full Text Full Text PDF PubMed Scopus (731) Google Scholar, 4Abe Y Kondo M Matsuoka R Araki M Dohyama K Tanio H Assessment of clinical features in transient left ventricular apical ballooning.J Am Coll Cardiol. 2003; 41: 737-742Abstract Full Text Full Text PDF PubMed Scopus (541) Google Scholar, 5Desmet WJ Adriaenssens BF Dens JA Apical ballooning of the left ventricle: first series in white patients.Heart. 2003; 89: 1027-1031Crossref PubMed Scopus (457) Google Scholar, 7Bybee KA Kara T Prasad A et al.Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.Ann Intern Med. 2004; 141: 858-865Crossref PubMed Scopus (1224) Google Scholar, 10Akashi YJ Nakazawa K Sakakibara M Miyake F Koike H Sasaka K The clinical features of takotsubo cardiomyopathy.QJM. 2003; 96: 563-573Crossref PubMed Scopus (272) Google Scholar, 12Kawai S Suzuki H Yamaguchi H et al.Ampulla cardiomyopathy (‘Takotsubo’ cardiomyopathy)—reversible left ventricular dysfunction: with ST segment elevation.Jpn Circ J. 2000; 64: 156-159Crossref PubMed Scopus (283) Google Scholar, 14Wittstein IS Thiemann DR Lima JA et al.Neurohumoral features of myocardial stunning due to sudden emotional stress.N Engl J Med. 2005; 352: 539-548Crossref PubMed Scopus (2373) Google Scholar However, vasospasm,2Kurisu S Sato H Kawagoe T et al.Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction.Am Heart J. 2002; 143: 448-455Abstract Full Text Full Text PDF PubMed Scopus (731) Google Scholar, 6Sharkey SW Lesser JR Zenovich AG et al.Acute and reversible cardiomyopathy provoked by stress in women from the United States.Circulation. 2005; 111: 472-479Crossref PubMed Scopus (839) Google Scholar, 7Bybee KA Kara T Prasad A et al.Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.Ann Intern Med. 2004; 141: 858-865Crossref PubMed Scopus (1224) Google Scholar, 8Tsuchihashi K Ueshima K Uchida T Angina pectoris-Myocardial Infarction Investigations in Japan et al.Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction.J Am Coll Cardiol. 2001; 38: 11-18Abstract Full Text Full Text PDF PubMed Scopus (1346) Google Scholar, 16Villareal RP Achari A Wilansky S Wilson JM Anteroapical stunning and left ventricular outflow tract obstruction.Mayo Clin Proc. 2001; 76: 79-83Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar impaired fatty acid metabolism,6Sharkey SW Lesser JR Zenovich AG et al.Acute and reversible cardiomyopathy provoked by stress in women from the United States.Circulation. 2005; 111: 472-479Crossref PubMed Scopus (839) Google Scholar, 7Bybee KA Kara T Prasad A et al.Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.Ann Intern Med. 2004; 141: 858-865Crossref PubMed Scopus (1224) Google Scholar and abnormal myocardial perfusion with evidence of microvascular dysfunction2Kurisu S Sato H Kawagoe T et al.Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction.Am Heart J. 2002; 143: 448-455Abstract Full Text Full Text PDF PubMed Scopus (731) Google Scholar, 7Bybee KA Kara T Prasad A et al.Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.Ann Intern Med. 2004; 141: 858-865Crossref PubMed Scopus (1224) Google Scholar, 8Tsuchihashi K Ueshima K Uchida T Angina pectoris-Myocardial Infarction Investigations in Japan et al.Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction.J Am Coll Cardiol. 2001; 38: 11-18Abstract Full Text Full Text PDF PubMed Scopus (1346) Google Scholar, 11Bybee KA Prasad A Barsness GW et al.Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome.Am J Cardiol. 2004; 94: 343-346Abstract Full Text Full Text PDF PubMed Scopus (487) Google Scholar, 12Kawai S Suzuki H Yamaguchi H et al.Ampulla cardiomyopathy (‘Takotsubo’ cardiomyopathy)—reversible left ventricular dysfunction: with ST segment elevation.Jpn Circ J. 2000; 64: 156-159Crossref PubMed Scopus (283) Google Scholar, 14Wittstein IS Thiemann DR Lima JA et al.Neurohumoral features of myocardial stunning due to sudden emotional stress.N Engl J Med. 2005; 352: 539-548Crossref PubMed Scopus (2373) Google Scholar have been postulated as potential mechanisms. To our knowledge, this is the first documented case of broken heart syndrome secondary to opioid withdrawal in an adult. The literature does include a report of an opioid- and benzodiazepine-dependent infant who had temporary apical dyskinesis on echocardiography and increased cardiac enzymes after blockage of the central venous catheter through which her pain medications were administered.18Biswas AK Feldman BL Davis DH Zintz EA Myocardial ischemia as a result of severe benzodiazepine and opioid withdrawal.Clin Toxicol (Phila). 2005; 43: 207-209Google Scholar We believe that opioid withdrawal was the main cause of our patient's back pain, anxiety, diaphoresis, nausea, tachycardia, and elevated blood pressure.19Kosten TR O'Connor PG Management of drug and alcohol withdrawal.N Engl J Med. 2003; 348: 1786-1795Crossref PubMed Scopus (434) Google Scholar Her antihypertensive medications were the same before, during, and after hospitalization for knee surgery. The only medications discontinued at discharge from the hospital were pantoprazole, loratadine, and the previously mentioned opioids. Furthermore, the patient arrived at the emergency department about 25 hours after her last dose of OxyContin, which corresponds to slightly more than 5 elimination half-lives for OxyContin (normal half-life, 4.5 hours).20Physicians' Desk Reference. 60th ed. Thompson PDR, Montvale, NJ2006: 2700Google Scholar Although her discharge medication orders included a small amount of immediate-release oxycodone, her total opioid dose after discharge was decreased by more than 80% compared to what she had received in the hospital. Because opioid withdrawal has been linked to increased sympathetic activity,21Hoffman WE McDonald T Berkowitz R Simultaneous increases in respiration and sympathetic function during opiate detoxification.J Neurosurg Anesthesiol. 1998; 10: 205-210Google Scholar we believe that increased sympathetic activity secondary to opioid withdrawal probably contributed to the development of broken heart syndrome in this patient. One could argue that independent of any other factors, the stress of our patient's surgery and postoperative recovery may have induced her severe myocardial dysfunction. However, she had recently undergone other surgical procedures, including a left total hip arthroplasty revision, during the previous year without complications. Therefore, we believe it is unlikely that the most recent surgical stress alone would have led to her left ventricular dysfunction. In addition, when the patient was initially discharged to the acute care nursing facility, her clinical status was stable, and the last recorded vital signs do not suggest that serious left ventricular dysfunction was present at the time of dismissal. Treating patients who are receiving long-term opioid therapy requires recognition of the importance of avoiding withdrawal to prevent serious complications and unnecessary hospitalizations. This case also underscores the importance of medication reconciliation, the process by which all medications are consciously continued, discontinued, or modified. Ideally, it would ensure that patients receive intended medications and no unintended medications throughout the continuum of care.
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