Abstract 13369: Takotsubo Cardiomyopathy Following Electroconvulsive Therapy

Abstract

Case Presentation: A 71-year-old woman presented to our institution for treatment-refractory depression requiring electroconvulsive therapy (ECT). She underwent a transthoracic echocardiogram (TTE) during a pre-ECT evaluation, which demonstrated no regional wall motion abnormalities and a left ventricular ejection fraction (LVEF) of 60 - 65%. The patient subsequently underwent ECT. During the procedure, sinus tachycardia with associated ST-segment changes were noted on telemetry. Esmolol was administered with subsequent improvement in her tachycardia, however ST-segment changes persisted. A twelve-lead electrocardiogram was obtained and was notable for new T-wave inversions in leads V1-V4 and Q-waves in leads III and aVF. However, STEMI criteria was not met. A TTE obtained shortly after her ECT demonstrated ballooning of the LV apex and an LVEF of 35%, consistent with takotsubo cardiomyopathy. Laboratory evaluation was notable for a high sensitivity troponin peak of 130 ng/L and a brain natriuretic peptide level of 746 pg/mL. Cardiac catheterization was not performed as the patient had a negative stress test prior to admission. The patient’s symptoms improved over the next two days, and she was discharged with close outpatient follow-up. Discussion: Takotsubo cardiomyopathy occurs following physical or psychological stress. Greater than half of patients with takotsubo cardiomyopathy have neurologic or psychiatric disorders. Takotsubo cardiomyopathy is an increasingly recognized serious complication of ECT and can be seen in post-menopausal women with depression. The introduction of beta blocker therapy has been used to prevent recurrent episodes of post-ECT takotsubo cardiomyopathy. Despite this, there are reports of post-ECT takotsubo cardiomyopathy in patients on chronic beta blocker therapy. Thus, the risks and benefits of proceeding with additional ECT treatments must be weighed after an initial episode of takotsubo cardiomyopathy.