Vasopressor Management in Setting of Takotsubo Cardiomyopathy With Systolic Anterior Motion of Mitral Valve

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Journal of General Internal Medicine



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LEARNING OBJECTIVE #1: Treat cardiogenic shock in setting of Takotsubo cardiomyopathy with systolic anterior motion of mitral valve LEARNING OBJECTIVE #2: Distinguish the effectiveness of different vasopressors in appropriate settings CASE: Patient is an 86 year old female with history of restless leg syndrome who was brought to the emergency department after being found at home with altered mental status. Initial EKG showed ST elevations in leads II, III, aVF and V3-V5 with elevated troponin. Patient was taken emergently for left heart catheterization, which revealed no significant stenosis in the coronary arteries. Left ventriculogram showed reduced ejection fraction at 30-35%, hypercontractile base, and apical and mid-ventricular segment akinesis. Troponin peaked at 14.572. Follow-up transthoracic echocardiogram showed reduced ejection fraction, apical dyskinesis, and basal septal hypertrophy with systolic anterior motion of mitral valve (SAM). Patient was consequently diagnosed with Takotsubo cardiomyopathy with SAM. After the procedures, patient was hemodynamically stable and was started on minimum dose guideline directed medical therapy with carvedilol and lisinopril. However, patient was unable to tolerate and went into cardiogenic shock requiring vasopressors. Patient was initially started on norepinephrine with the addition of dobutamine and dopamine with minimal improvement in blood pressure. Patient was then started on phenylephrine with fluid support and cessation of dobutamine followed by discontinuation of dopamine and norepinephrine in that order, which saw stabilization of blood pressure. Guideline directed medical therapy was held on discharge due to recent cardiogenic shock, with plans to monitor outpatient and start treatment when appropriate. IMPACT/DISCUSSION: This case illustrates the importance of appropriate management of both fluid status and choice of vasopressor in the setting of Takotsubo cardiomyopathy with SAM. Patients with Takotsubo cardiomyopathy with SAM are volume dependent given the concern for left ventricular outflow obstruction. As such, fluids can be used judiciously to optimize preload which will improve the cardiac output and also reduce further obstruction. Additionally, the choice of vasopressor therapy should be focused on maintaining the afterload to reduce the pressure gradient across the aortic valve, which will increase the diastolic filling time of the left ventricle and maintain cardiac output. Chronotropic properties will reduce the diastolic filling time, and inotropes can exacerbate the outflow obstruction. Therefore, alpha agonists should be prioritized as the vasopressor of choice to maintain the afterload through their vasoconstrictive properties, as opposed to beta agonists or general agonists. CONCLUSION: - Understand properties of various vasopressors and use appropriately in different settings. - Understand the pathophysiology and management of Takotsubo cardiomyopathy and systolic anterior motion of mitral valve.


Cardiovascular System | Internal Medicine



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