*Research article by Johnson a,b Jeremy C.S., Byrne a,b Gerard J.A.

a Older Persons’ Mental Health Service, Royal Brisbane & Women’s Hospital;

b Discipline of Psychiatry, School of Clinical Medicine, Unviersity of Queensland

Introduction

Takotsubo cardiomyopathy (TTC) is an acute and reversible weakening of the cardiac muscle, resulting in ballooning of the ventricles (“takotsubo” is the Japanese term for “octopus trap”, referring to the appearance of the left ventricle). It usually presents with chest pain and dyspnoea [1], is most commonly seen in postmenopausal women following significant stress and has a 30-day mortality rate of about 5%. TTC is also known as “broken heart syndrome” or “stress induced cardiomyopathy” because stressful events, such as the loss of a loved one, often act as precipitants. TTC was historically hypothesised to be caused by elevated serum catecholamines such as norepinephrine (noradrenaline) [2, 3]. More recently, persuasive arguments have been advanced for a pathological mechanism related to sympathetic hyperactivation [4, 5]. This is consistent with findings that chronic anxiety, associated with increased bursts of sympathetic activity due to mental and physical stress [6], and the predisposing factor of early life trauma [7], increase the risk of TTC. Thus, psychiatrists may be involved in the care of these patients and should be aware of the risk of TTC following significant stress, anxiety and relapse of psychiatric illness.

The cardiac symptoms of TTC have been elucidated [1], whereas precipitating events have not yet been systematically evaluated. Nonetheless, a meta-analysis [1] identified that in 74% of cases, TTC was preceded by a significant stressor. Psychological stressors include loss of a family member, marital conflict and work-related stressors, but also events such as the loss of a pet [8]. Cases have been reported in which relapsing psychiatric illnesses were the precipitating stressors (e.g., bipolar and major depressive disorders) [9] as well as catatonia [10, 11]. There have also been reports of TTC associated with dementia [9, 12–16], including one case of vascular dementia [13], although not as the precipitating stressor. Here we report a case of TTC where a major neurocognitive disorder (possible vascular subtype) increased vulnerability to stress following the loss of a main support person, in the context of multiple risk factors.