Takotsubo syndrome (TS)
is an acute and reversible wall motion abnormality of the left or right
ventricular myocardium. The condition was named after the Japanese octopus pots
(“takostubo”) that resembles the characteristic left ventricular end-systolic apical
ballooning shape that can be seen on the transthoracic echocardiogram or on the
ventriculography of these patients [1]. Typically occurs in post-menopausal
women and is usually elicited by an identifiable emotional or physical stress
in about two thirds of cases [1,2]. Although its etiology is still not
completely understood, the most widely reported hypothesis is a direct
catecholamine-mediated myocardial stunning, caused by high levels of serum
catecholamines. Other possible mechanisms include multivessel vasospasm,
estrogen induced and cardiovascular stress responses [1]. TS is usually
manifested by symptoms similar to those of an acute coronary syndrome (ACS),
such as acute substernal chest pain, nausea, syncope, dyspnea or palpitations.
On ECG we will find usually ST-segment elevation, T-wave inversion or QTc
prolongation, sometimes with temporal evolution as seen in ACS. The biomarkers
are usually elevated, with troponin values equally elevated compared to ACS
[2,3]. The diagnose in our patient was particularly challenging since she
didn’t report any symptoms. Although the presence of troponin elevation, ECG
and echocardiogram findings poses a suspicion on TS, the final differential
diagnoses was made by coronary angiographic and ventriculography. These shows
absence of either obstructive coronary artery disease or acute plaque rupture
and the observation of the typical left ventricle contraction pattern, on
ventriculography [3]. The recommended treatment is supportive with management
of complications. Prognosis in the acute phase is similar to that of ACS, with
approximately 30% of patients having serious cardiac complications but unlike
them, in TS a full recovery of the left ventricular function occurs in days to
several weeks [2,4].
In recent years, there
has been as increasing number of literature linking pre-existing or active
psychiatric disease and TS. Of note the majority pre-existing are related with
mood or anxiety disorders with few cases related with other psychiatric
illness, including schizophrenia-spectrum and other psychotic disorders [2,4].
Related to an “acute” presentation or exacerbation of psychiatric disorders, in
the International Takotsubo Registry only 10% of patients were diagnosed with
“acute psychiatric disorders”. Despite this, the proportion of TS clearly
triggered by acute psychiatric decompensation remains unknown [4]. The
pathology behind these association is largely speculative with the most
reported mechanism being an interaction between the brain and heart mediated by
autonomic nervous system activation and an increase blood catecholamine levels
[1,5]. Although some psychotropic medications have also been associated as
triggers on TS, most of them in the setting of relatively rapid uptitration or
in overdose [4], in the case that we report, this association is not a possible
mechanism since the patient stopped all the medication 1 month before. TS has
been described in context of acute alcohol withdrawal to, for the case
presented is not a possibility mechanism since she suspended all the consume 1
month before [5].
There are no particular
orientations in the literature towards the treatment of acute psychiatric
illness in the context of TS. This is particularly true in the case of
psychotic disorders, since it is such a rare phenomenon. Accordingly, the
treatment of our specific patient was oriented by general guidelines and
recommendations, taking into account her clinical picture and comorbidities.
Risperidone was initially chosen because of its anti-psychotic efficacy,
anxiolytic properties, long-term metabolic effects and low risk of QTc interval
prolongation, compared to other anti-psychotics [6].
Conclusion
Our case adds important
information to the rare interaction between psychosis and TS. Also, to the best
of our knowledge, this is the first reported case of TS as a manifestation of a
first episode psychosis in the context of schizoaffective disorder.
