1171

Abstract

Introduction: Apical ballooning syndrome (a.k.a. takotsubo cardiomyopathy) is a reversible condition mimicking acute coronary syndrome. Reverse apical ballooning syndrome is an infrequent variant of the former where the apical segments remain preserved in the setting of mid and basal ventricular dysfunction. We describe an unique case encountered in our institution recently. Case description: A 59 year Caucasian female with no prior history of coronary artery disease or hypertension presented with non-radiating chest pain associated with shortness of breath. She carried a diagnosis of COPD, hypothyroidism, pulmonary embolism and chronic low back pain. For the chronic back pain, she has ben on intrathecal pump with mixture of Fentanyl, Hydromorphone, Bupivacaine and Clonidine since 2001. One day prior to her admission, her clonidine was discontinued. On arrival to hospital her BP was 190/100 of mm of Hg. The initial electrocardiogram revealed ST depression and T wave inversion in inferior and lateral leads. The level of troponin I and BNP was significantly elevated. Cardiac CT scan demonstrated absence of pulmonary embolism, normal aortic anatomy, mild coronary artery disease and biventricular dysfunction with basal and midventricular segmental akinesis and apical hyperkinesis. A transthoracic echocardiogram similarly demonstrated dilation and akinesis of the mid-basal ventricle with a hyper-contractile apex and ejection fraction [EF] 25%. Management included re-institution of oral clonidine and beta-blocker. She was discharged on beta-blocker and ACEI for repeat echocardiogram in 4 weeks. Given the absence of other precipitating factor, we presumed that the most likely cause of her ventricular dysfunction is clonidine withdrawal. This is the first case in literature describing an association of clonidine withdrawal and reverse apical ballooning syndrome. The exact pathogenesis of the ballooning syndromes is not well understood, though most have been described in the settings of stress with presumed role of catecholamine surge. Reverse apical syndrome has been reported in association with serotonin syndrome, status epilepticus, delirium tremens, subarachnoid hemorrhage and septic shock. All these clinical entities are very common in ICU practices and often carries dismissal prognosis.