Acute Coronary Syndrome (Takotsubo Cardiomyopathy) Following Electroconvulsive Therapy in the Absence of Significant Coronary Artery Disease

We report a case of myocardial infarction occurring in a 45-year-old woman in the absence of coronary artery disease during a course of electroconvulsive therapy (ECT) for major depression. After the third ECT session, the patient reported substernal chest pain, and although the electrocardiogram was normal, cardiac enzymes were found to be elevated. Cardiac workup to determine etiology during hospital stay showed no evidence of coronary artery disease on catheterization. Cardiac echocardiograph and computed tomography findings were consistent with a diagnosis of Takotsubo cardiomyopathy. This cardiac syndrome is a stress-induced syndrome occurring in the absence of coronary artery stenosis and associated with surging of catecholamines. It is diagnosed on the basis of the shape of the apical ballooning observed on cardiac imaging, which resembles a "takotsubo" or octopus fishing pot in Japan, where this syndrome was first recognized. Coincidentally, after termination of her ECT course, this patient was also diagnosed with Loeys-Dietz syndrome, an inherited connective tissue disorder that can predispose sufferers to aortic dissection. This case illustrates the importance of careful workup of chest pain in the setting of ECT, even if electrocardiogram findings seem unremarkable initially.