Abstract 17123: Opioid Withdrawal Causing a Broken Heart!

Abstract

Introduction: Takotsubo syndrome is a condition characterized by transient acute left ventricular systolic dysfunction. Although it was previously thought of as a benign self-limiting condition, it is now known to be associated with significant morbidity and mortality. Case: A 26-year-old male patient with past medical history of Fentanyl abuse now on methadone, presented with features of opioid withdrawal. ECG on arrival was normal sinus rhythm with QTc 488 ms. with a troponin of 2.63. Due to excessive agitation and vomiting, he was given IV haloperidol and ondansetron. The patient then became unresponsive and sustained a cardiac arrest. He was found to be in polymorphic ventricular tachycardia and was able to be resuscitated. ECG after resuscitation demonstrated new yamaguchi T waves with a QTc 597 ms and troponin of 6.60. Transthoracic echocardiography subsequently revealed a reduced ejection fraction of 35% with apical hypokinesis, and he was referred for an ischemic evaluation with CTA coronary that showed normal coronary arteries. He was diagnosed with takotsubo cardiomyopathy and was initiated on dapagliflozin, metoprolol succinate and losartan. For opioid dependence, he was prescribed buprenorphine/naloxone being mindful of his QTc and was provided a wearable cardioverter defibrillator on discharge. Final ECG demonstrated QTc of 465 ms. Discussion: Opioid withdrawal is known to cause a high adrenergic state and this catecholamine excess can result in cardiac stunning, creating transient left ventricular dysfunction along with wall motion abnormalities. Patients with takotsubo cardiomyopathy typically have normal coronary arteries. Approximately 4.5% of these patients can die during their hospitalization and 4% can die within 30 days of discharge. So, clinicians must keep a high index of suspicion for this syndrome in patients with history of substance use disorder, especially in the setting of troponin elevation.