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Table of Contents
Year : 2014  |  Volume : 17  |  Issue : 3  |  Page : 251-252
In response to "Postoperative Takotsubo syndrome": The role of atropine, dopamine and noradrenaline in the management of Takotsubo syndrome

Icahn School of Medicine at Mount Sinai; Division of Cardiology, Elmhurst Hospital Center, Elmhurst, New York, NY, USA

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Date of Web Publication3-Jul-2014

How to cite this article:
Madias JE. In response to "Postoperative Takotsubo syndrome": The role of atropine, dopamine and noradrenaline in the management of Takotsubo syndrome. Ann Card Anaesth 2014;17:251-2

How to cite this URL:
Madias JE. In response to "Postoperative Takotsubo syndrome": The role of atropine, dopamine and noradrenaline in the management of Takotsubo syndrome. Ann Card Anaesth [serial online] 2014 [cited 2020 Apr 4];17:251-2. Available from:

The Editor,

The contribution by Bhojraj et al. published in the April-June, 2014 issue of the Journal, [1] about a 56-year-old woman, who suffered a bout of Takotsubo syndrome (TTS) in the postoperative period following vaginal hysterectomy is of interest, particularly in terms of her management. The authors summarized comprehensively what is currently known or believed to be the proper management of TTS in their discussion and "resuscitated (the patient) with atropine sulfate 0.6 mg, intravenous fluids and sodium bicarbonate 25 ml"; also "dopamine hydrochloride and noradrenaline were started at 5 μg/kg/min and 4 μg/min, respectively". One wonders whether use of intravenous fluids, and institution of the intra-aortic balloon counter pulsation, would have been preferable, although a consensus on the above is currently lacking. Perhaps, dopamine and noradrenaline may be further aggravating an illness believed to be due to a catecholamine "storm", [2] and atropine may be contraindicated, since it abolishes the counterbalancing to the sympathetic, parasympathetic autonomic nervous system influences. [3] However there is ambivalence about the latter, since TTS may also be mediated by the parasympathetic component of the autonomic nervous system (and thus atropine may be beneficial), [3] particularly early in the TTS, when some patients experience relative bradycardia, as the reported patient who had a heart rate of 60 beats/min.

The patients' preoperative status was felt to be in an American Society of Anesthesiologists Grade I, and one wonders whether coronary arteriography could have been avoided in the presence of the profound hemodynamic deterioration associated with the described left ventricular (LV) features as per echocardiography (ECHO) with minor changes in the electrocardiogram (ECG) and with "cardiac enzymes mildly elevated". Perhaps the ECHO-derived LV ejection fraction (LVEF) in conjunction with troponin I or T (Tp I or Tp T) and brain natriuretic peptide or N-terminal pro B-type natriuretic peptide (NT-pro-BNP) could have been used to differentiate TTS from an acute coronary syndrome in this patient, either employing the product of peak Tp I value and the LVEF, [4] or the ratio of NT-pro-BNP and Tp T (or Tp I). [5] The report includes only ECG leads aVR, aVL, aVF, and V1-V6, which reveals attenuation in the voltage of the QRS complexes (QRSATT) between the preoperative and first postoperative ECG in keeping with a recently published diagnostic insight for TTS. [6] I will be thankful if the authors could provide information on whether leads I, II, and III also revealed such QRSATT, and whether further QRSATT was noted in subsequently recorded ECGs.

   References Top

1.Bhojraj S, Sheth S, Pahlajani D. Postoperative Takotsubo cardiomyopathy. Ann Card Anaesth 2014;17:157-60.  Back to cited text no. 1
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2.Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539-48.  Back to cited text no. 2
3.Samuels MA. The brain-heart connection. Circulation 2007;116:77-84.  Back to cited text no. 3
4.Nascimento FO, Yang S, Larrauri-Reyes M, Pineda AM, Cornielle V, Santana O, et al. Usefulness of the troponin-ejection fraction product to differentiate stress cardiomyopathy from ST-segment elevation myocardial infarction. Am J Cardiol 2014;113:429-33.  Back to cited text no. 4
5.Fröhlich GM, Schoch B, Schmid F, Keller P, Sudano I, Lüscher TF, et al. Takotsubo cardiomyopathy has a unique cardiac biomarker profile: NT-proBNP/myoglobin and NT-proBNP/troponin T ratios for the differential diagnosis of acute coronary syndromes and stress induced cardiomyopathy. Int J Cardiol 2012 9;154:328-32.  Back to cited text no. 5
6.Madias JE. Transient attenuation of the amplitude of the QRS complexes in the diagnosis of Takotsubo syndrome. Eur Heart J Acute Cardiovasc Care 2014;3:28-36.  Back to cited text no. 6

Correspondence Address:
John E Madias
Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, New York, NY 11373
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9784.135892

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