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Reverse Takotsubo Cardiomyopathy Precipitated by Chronic Cocaine and Cannabis Use

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Abstract

This case report describes a 31-year-old man with 10 years of cocaine and cannabis dependence who developed reverse Takotsubo cardiomyopathy (rTC), a rare variant of Takotsubo cardiomyopathy. He presented to the Emergency Department (ED) with severe left temporal headache and vomiting which began whilst smoking cannabis and several hours after smoking methamphetamine and using cocaine via insufflation. Computed tomography and angiography of the brain was normal, and the headache resolved with analgesia. Urine drug screen was positive for benzodiazepines, cannabinoids, cocaine, opiates (attributed to morphine administered in ED) and amphetamines. Three hours later he had a seizure and within 10 min developed cardiogenic shock with antero-inferior ST segment depression on electrocardiogram and troponin-T rise to 126 ng/L. Coronary angiography demonstrated normal coronary arteries. Transthoracic echocardiogram demonstrated severely impaired left ventricular (LV) systolic function with ejection fraction 15–20% and hypokinesis sparing the apex. Thyrotoxicosis, nutritional, vasculitic, autoimmune and viral screens were negative. Cardiac magnetic resonance imaging demonstrated severe LV functional impairment with dilated and hypocontractile basal segments, and T2 hyperintensity consistent with myocardial oedema and rTC. He received supportive management. Proposed mechanisms of rTC include catecholamine cardiotoxicity and coronary artery vasospasm. In this case, multiple insults including severe headache, cannabis hyperemesis and cocaine and methamphetamine-induced serotonin toxicity culminated in a drug-induced seizure which led to catecholamine cardiotoxicity resulting in rTC. Clinicians should be cognizant of stress cardiomyopathy as a differential diagnosis in patients with substance use disorders.

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Authors and Affiliations

  1. Drug Health Services, Royal Prince Alfred Hospital, Level 6, King George V Building, 83-117 Missenden Road, Camperdown, NSW, 2050, Australia

    Emily Nash, Darren M. Roberts & Nazila Jamshidi

  2. Sydney Medical School, The University of Sydney, Sydney, NSW, Australia

    Emily Nash & Nazila Jamshidi

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  1. Emily Nash
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Contributions

EN reviewed the literature and drafted the manuscript. DMR critically revised the manuscript. NJ conceived the idea to report the case and critically revised the manuscript. All authors approved the final version and agree to be accountable for the accuracy and integrity of the work.

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Correspondence to Nazila Jamshidi.

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The patient provided written informed consent for publication.

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Nash, E., Roberts, D.M. & Jamshidi, N. Reverse Takotsubo Cardiomyopathy Precipitated by Chronic Cocaine and Cannabis Use. Cardiovasc Toxicol 21, 1012–1018 (2021). https://doi.org/10.1007/s12012-021-09692-9

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