Recurrence of Takotsubo cardiomyopathy post-ECT: Shocking insight from the literature

Abstract

Takotsubo cardiomyopathy (TCM) is a transient akinesis of the left ventricle commonly involving the apex, which is typically induced by severe physical or emotional stressors. TCM is being increasingly recognised as a rare but serious complication of electroconvulsive therapy (ECT).

The precise mechanism of this phenomena remains unclear, although some merit is given to a hypothesis involving coronary artery spasm caused by catecholamine surge. It has been established that individuals with conditions amenable to ECT, such as depression and chronic anxiety, have higher baseline levels of catecholamines and altered neuron catecholamine reuptake secondary to pharmacological interventions. It has been shown in the literature more than half of the documented cases of TCM occur in patients with a history or acute episodes of a neurological or psychiatric condition. Additionally, ECT has specifically been linked with increased catecholamine release, thus further predisposing patients to developing TCM.

Whilst rates of recurrence are low, details pertaining to TCM recurrence post ECT are likely to be inaccurate due to lack of follow up and appreciation of subtle TCM symptomatology. A single study has reported recurrence of 1 in 6 patients, however this lends itself to a small data set and no statistical analysis, which is a common problem in the literature. If further ECT is required, this must not occur until left ventricular function normalises on repeat echocardiogram, with some evidence

for use of angiotensin receptor blockers or angiotensin converting enzyme inhibitors from a preventative perspective. Evidence for the use of beta-adrenergic antagonists is less well established but may reduce the adrenergic response in this context.