Download Reverse takotsubo cardiomyopathy with use of

Reverse takotsubo cardiomyopathy with use of male
enhancers
Carlos E. Rodriguez-Castro, MD, Fatima Saifuddin, MD, Mateo Porres-Aguilar, MD, Sarmad Said, MD, David Gough, MD,
Tariq Siddiqui, MD, Debabrata Mukherjee, MD, and Aamer Abbas, MD
Reverse takotsubo cardiomyopathy is a rare heart failure condition characterized by systolic dysfunction of the basal segments of the left ventricle
in the absence of obstructive coronary artery disease. We present a case
of a 54-year-old man with an overdose of Extenze (a male enhancer pill
containing yohimbine) who was hospitalized with heart failure due to
reverse takotsubo cardiomyopathy.
T
he pathogenesis of reverse takotsubo cardiomyopathy is
not well understood, but physical or mental stress is frequently an associated trigger. Less commonly reported,
sympathomimeti c states have been linked to this disease
entity. Reverse takotsubo cardiomyopathy has been reported
in cases of hyperadrenergic states secondary to pheochromocytomas, catecholamine-secreting tumors, administration of
beta-receptor agonists, such as dobutamine, and consumption
of caffeine and energy drinks. In this report, we describe a case
of reverse takotsubo cardiomyopathy relating to an overdose of
Extenze, a male enhancer pill containing yohimbine.
CASE PRESENTATION
A 54-year-old man was admitted to the intensive care unit
after ingesting multiple pills of Tylenol and Extenze, a product
that contains yohimbine. He complained of abdominal discomfort and mild dyspnea. He was anxious and had a heart rate of
110 beats/minute. The electrocardiogram showed sinus tachycardia, right bundle branch block, and ST segment depression in
lead V3 (Figure 1). A radiograph showed pulmonary congestion
(Figure 2). His initial troponin I level was 0.94 ng/L; 7 hours
later, it was 13 ng/L. Three hours after admission, he became
disoriented, hypotensive, and hypoxic and was intubated for
respiratory distress due to heart failure. An echocardiogram
showed left ventricular systolic dysfunction with basal hypokinesis but normal mid/distal anterior, inferior, and apical contraction (Figure 3). Coronary angiography was normal without
any anatomical or functional abnormalities such as coronary
spasm, myocardial bridging, or coronary artery disease (Figure
4). Since the patient had an echocardiogram showing reverse
takotsubo cardiomyopathy with severely depressed LV systolic
function on the same day prior to cardiac catheterization, no
ventriculogram was performed. The patient was treated with
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vasopressors, diuretics, and invasive ventilatory support. After
72 hours, the patient was extubated and transferred to a regular
floor. He recovered fully and was discharged after 1 week of
hospitalization. Unfortunately, the patient did not follow up
in the cardiology clinic; thus, no follow-up echocardiogram
was performed.
DISCUSSION
Takotsubo cardiomyopathy is an increasingly reported syndrome characterized by transient systolic dysfunction of the
apical and or mid segments of the left ventricle without the
presence of coronary artery disease (1, 2). In contrast, reverse
takotsubo cardiomyopathy is a condition with transient systolic
dysfunction of the basal segments of the left ventricle. Although
transient, reverse, or inverted takotsubo cardiomyopathy was
recognized as a different clinical entity >20 years ago, a definite
comprehensive pathophysiologic theory for this condition is
still lacking (3). Seemingly, reverse takotsubo, which is more
common in young female patients with a mean age of 36 years,
is thought to be triggered by physical or emotional stress rather
than catecholaminergic states. The presence of adrenoreceptors,
which are at their apex in older patients, makes the occurrence
of the apical variant of takotsubo cardiomyopathy more common among the older population, in contrast to the younger
population, where the abundance of adrenoreceptors is within
the base of the heart, which may lead to the reverse variant of
takotsubo cardiomyopathy (4). There have been documented
reports of reverse takotsubo in association with pheochromocytomas, intravenous administration of beta-receptor agonists
(dobutamine) or catecholamines, as well as with the use of energy drinks containing caffeine and 1,3-dimethylamylamine (5).
The pathophysiology behind this condition relies on two
primary theories: vascular dysfunction and catecholamineinduced toxicity. Multifocal vasospasm has been demonstrated
From the Department of Internal Medicine (Rodriguez-Castro, Porres-Aguilar,
Said), Division of Cardiovascular Diseases (Gough, Siddiqui, Mukherjee, Abbas),
Texas Tech University Health Sciences Center, El Paso, Texas; and Jinnah
Postgraduate Medical Center, Karachi, Pakistan (Saifuddin).
Corresponding author: Carlos E. Rodríguez-Castro, MD, Department of Internal
Medicine, Texas Tech University Health Science Center, 4800 Alberta Avenue, El
Paso, TX 79905 (e-mail: [email protected]).
Proc (Bayl Univ Med Cent) 2015;28(1):78–80
Figure 1. Supraventricular tachycardia with incomplete right bundle branch block and nonspecific ST wave abnormalities.
in some patients undergoing angiography (6). Molecular studies
have revealed that high doses of epinephrine are directly toxic
to the cells, causing a rise in adenosine 3’,5’-cyclic monophosphate and calcium levels that then trigger the formation of free
oxygen radicals, the initiation of expression of stress response
genes, and induction of apoptosis (7).
The yohimbine contained in the male enhancement formula
Extenze is a competitive antagonist that is selective for alpha-2
receptors located in the central nervous system, where it acts
to increase blood pressure and heart rate. It has been well acknowledged that with relatively low doses it can produce side effects such as tachycardia, chest pain, hypertension, lacrimation,
Figure 2. Chest x-ray showing pulmonary vascular congestion.
January 2015
tremors, and diaphoresis (8, 9). In addition, yohimbine-containing products have been implicated in cases of hypertension
emergencies, severe Raynaud’s phenomenon, angina pectoris,
refractory priapism, and even death (10–14). Currently, the association of reverse takotsubo cardiomyopathy and yohimbine
is not known. Nonetheless, we think that, given the mechanism
of action of yohimbine as a sympathomimetic drug acting on
Figure 3. An apical four-chamber view showing severe hypokinesis of the basal/
mid inferoseptal segment and anterolateral segment of the left ventricle. The
apical segment of the left ventricle has normal contractility.
Reverse takotsubo cardiomyopathy with use of male enhancers
79
a
b
Figure 4. Anteroposterior cranial views of the (a) right coronary artery and (b) left
coronary arteries show no evidence of any significant coronary artery disease.
the alpha-2 adrenergic receptors, overdose potentially influenced
the development of reverse takotsubo cardiomyopathy similar
to cases related to pheochromocytomas and administration of
dobutamine.
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Baylor University Medical Center Proceedings
Volume 28, Number 1