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Withdrawal states causing cardiomyopathy

10/4/2017

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  • Introduction
    • Withdrawal states can have a wide range of cardiovascular and neurological signs and symptoms
    • While neurological findings such as agitation, seizures, or lethargy are often the predominant focus in management, cardiovascular changes can have significant implications on a patient’s clinical course
    • Cardiomyopathies, specifically stress-induced cardiomyopathy, can accompany withdrawal states from multiple agents
  • Pathophysiology
    • Stress Induced Cardiomyopathy à Takotsubo Cardiomyopathy (TTC)
    • Transient LV dysfunction due to akinesia of midapical segments without primary coronary vessel pathology
    • Catecholamine toxicity leading to vasospasm of distal coronary arteries
    • Supraphysiologic levels of epi change function of myocyte beta receptors
    • Intracardiac gradient secondary to basal hypercontractility with LVOT obstruction causing           apical ischemia/wall stress
Picture
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  • Offending Agents
    • EtOH Withdrawal
      •   Most common etiology of withdrawal induced cardiomyopathy
      •  Chronic EtOH use alters neurotransmitter and receptor biology
      •  Increasing insensitivity to GABA (tolerance) with a secondary increasing of the number of glutamate receptors to allow normal state of arousal in the setting of increased inhibitory  tone.
      • Sudden withdrawal of EtOH decreases inhibitory tone resulting in unopposed excitatory signaling from glutamate pathways
      • Peripherally presents as tremulousness and autonomic/sympathetic hyperactivity
    • Benzodiazepine withdrawal
      • TTC seen in few case reports following acute benzodiazepine withdrawal
      • Presumed similar mechanism to EtOH
    • Opioid withdrawal
      • Case reports after long acting opioid methadone
      • Sympathetic surge resulting in echocardiographic findings of TTC
    • Methamphetamine and cocaine cardiomyopathy
      • Seen during acute intoxication rather than withdrawal period
      • Adrenergic surge can cause TTC or can exacerbate underlying vascular disease
  • Evaluation & Treatment
    • Patient may present with chest pain, shortness of breath, or other findings suggestive of LV failure
    • EKG can show nonspecific findings or anterior ST elevations with minor enzyme elevations
      • If there is concern for ACS PCI if available
      • If no critical coronary disease, ventriculogram may show characteristic shape
    • Echocardiogram with hyperactive basal segments and akinetic apex
    • Supportive Care
      • Ionotropic support if needed
      • Anticoagulation
      • Fluid balance management
      • Benzodiazepines, alpha-2 agents as tolerated
    • Symptoms often resolve spontaneously in 1-4 weeks 
 
 
References:
Stout BJ, Hoshide R, Vincent DS. Takotsubo Cardiomyopathy in the Setting of Acute Alcohol Withdrawal. Hawai’i Journal of Medicine & Public Health. 2012;71(7):193-194.
 
Peng TJ, Patchett ND, Bernard SA. Takotsubo Cardiomyopathy and Catatonia in the Setting of Benzodiazepine Withdrawal. Case Reports in Cardiology. 2016;2016:8153487. doi:10.1155/2016/8153487.
 
Spadotto V, Zorzi A, ElMaghawry M, Meggiolaro M, Pittoni GM. Heart failure due to “stress cardiomyopathy”: a severe manifestation of the opioid withdrawal syndrome. European Heart Journal Acute Cardiovascular Care. 2013;2(1):84-87. doi:10.1177/2048872612474923.

Authored by: Russell Trigonis, MD


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  • RESIDENCY
    • About CMC
    • Curriculum
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    • Explore Charlotte
    • Official Site
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    • Fellowships at CMC
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  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Incentive Shifts & Moonlighting >
      • AEC Incentive Shifts
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      • MICU X moonlighting
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        • Pineville Cardiac Rehab
        • Union Cardiac Rehab
    • Schedules >
      • Block Schedule
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      • Conference and Resident Lectures
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    • Resources >
      • Fox Reference Library
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      • Airway Lecture
      • Student Resources
      • PGY - 1
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      • PGY - 3
      • Simulation Reading
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      • Resume Builder
    • Individualized Interactive Instruction
    • Off Service Rotators