Anaesthetic management of patients with Takotsubo cardiomyopathy

We read with interest the report on Takotsubo syndrome during induction of general anaesthesia by Jabaudon et al. [1]. There is increasing evidence supporting the phenomenon of stress-induced cardiomyopathy [2]. We, too, have encountered cases fitting the diagnostic criteria for Takotsubo syndrome that resulted in transient cardiomyopathy. As described in the report, the syndrome mimicked an acute coronary syndrome with cardiac enzyme elevation, and presented a significant challenge for the anaesthetists managing these patients peri-operatively. Reports of recurrence of the syndrome [2] warrant examination of our management. As the syndrome appears to be stress-related, management should aim to attenuate the stress response peri-operatively. There is insufficient evidence to favour regional or general anaesthetic techniques. An alternative to high dose opioids is the alpha2 adrenergic agonists dexmedetomidine or clonidine. These agents can be started pre-operatively without causing respiratory depression and produce excellent sedative effects [3]. They exert a central sympatholytic action, improving haemodynamic stability in response to tracheal intubation and surgical stress and reduce general anaesthetic and opioid requirements. Furthermore, they may be beneficial in the prophylaxis and treatment of peri-operative myocardial ischaemia [4]. The role of magnesium in attenuating the stress response is also worth considering. Magnesium plays an important role in many physiological processes such as regulation of blood catecholamine concentrations, particularly adrenaline and noradrenaline [5].