Heart failure due to 'stress cardiomyopathy': a severe manifestation of the opioid withdrawal syndrome

Abstract

Takotsubo cardiomyopathy (TTC) is a transient left ventricular (LV) dysfunction due to akinesia of the LV mid-apical segments ('apical ballooning') in the absence of critical coronary stenoses which can be complicated in the acute phase by heart failure, mitral regurgitation, life-threatening ventricular arrhythmias, or apical LV thrombosis. The syndrome is typically precipitated by intense emotional or physical stress; however, other causes of sympathetic overstimulation including administration of exogenous sympathomimetics or withdrawal of sympathetic antagonists can trigger TTC. We report the case of a patient who unexpectedly developed an 'apical ballooning' with severe reduction in the LV systolic function and heart failure after the withdrawal of methadone. The case supports the concept that increased sympathetic activity secondary to opioids withdrawal can trigger a stress-induced severe LV dysfunction. Physicians should be aware that the abrupt discontinuation of a long-term therapy with opioids may lead to serious cardiac complications. The administration of clonidine may be considered to prevent early clinical manifestations of addictive withdrawal, including TTC.

Keywords: Apical ballooning; Tako Tsubo; heart failure; methadone; opioids; stress cardiomyopathy.

Figure 1.

Electrocardiogram at admission. Twelve-lead electrocardiogram performed at admission showing mild QT-interval prolongation (QTc=490 ms). Non-significant, ascending ST-segment depression in leads V3–V5 and aVF is also evident.

Figure 2.

Electrocardiographic (A) and echocardiographic (B, C) findings at admission in the intensive care unit. Twelve-lead electrocardiogram showing repolarization abnormalities (T-wave inversion and QTc-interval prolongation) in leads V2–V5, aVL, I, and II. Transthoracic echocardiography (TTE) performed at admission to the intensive care unit, four-chamber apical view, in systole (B) and diastole (C) showing mid-apical left ventricular segments akinesia (arrows) conferring the typical ‘apical ballooning’ pattern.