Published: 3 March 2022

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Triptan-associated Takotsubo cardiomyopathy: A heartbreak from a headache

Published 3 March 2022
Prescriber Update 43(1): 4–5
March 2022

Key messages

  • Takotsubo cardiomyopathy is a reversible form of cardiomyopathy characterised by transient systolic dysfunction and apical ballooning of the left ventricle.
  • Emotional and physical stress are the most well-known triggers of Takotsubo cardiomyopathy. However, this condition has also been reported in association with triptan use.
  • If triptan-associated Takotsubo cardiomyopathy is suspected, initiate supportive therapy in hospital.


The Centre for Adverse Reactions Monitoring (CARM) recently received a report of Takotsubo cardiomyopathy associated with rizatriptan use.

Takotsubo cardiomyopathy (TCM)

TCM is an acute reversible form of left ventricular (LV) systolic dysfunction not related to obstructive coronary disease. TCM is also known as stress cardiomyopathy, broken heart syndrome, stress-induced cardiomyopathy, and apical ballooning syndrome. TCM starts abruptly and unpredictably. Signs and symptoms of TCM are similar to an acute myocardial infarction.1

TCM is a rare condition first identified in 1990 in Japan and is typically more common in women and older adults.2 Emotionally or physically stressful events can trigger TCM. Cases have also been reported with substance withdrawal and the use of some medicines.2

Internationally, there are a few case reports associating triptan use and TCM. Most of these reports are in patients taking sumatriptan.1

Mechanism

The precise mechanism of TCM is not yet fully understood. Catecholamine-induced cardiotoxicity and microvascular dysfunction have been proposed to be involved.2

Acute migraines can cause a sudden surge in catecholamine levels and the triptan medicines used to treat migraines cause vasoconstriction. The combination of these effects may rarely induce TCM.1

Clinical presentation, diagnosis, and management

The clinical presentation of patients with TCM are similar to those with acute coronary syndrome. The most common presenting symptom is acute substernal chest pain, but some patients present with dyspnoea or syncope. An electrocardiogram, cardiac troponin levels, coronary angiography, and assessment of LV systolic function are generally required to diagnose TCM.2

Patients with TCM have a good prognosis. Typically, patients that survive the acute episode of TCM recover systolic LV function within one to four weeks.3

Conservative treatment and resolution of the physical or emotional stress usually result in rapid resolution of symptoms. However, some patients can develop acute complications, such as shock and acute heart failure, requiring intensive therapy.4

Given the lack of clinical trial data, there is no clear optimal medication regimen or treatment duration for TCM patients. Once haemodynamically stable, patients are treated with standard medicines for heart failure until systolic function is recovered.4 

New Zealand case report

CARM has only received one case report of TCM (up to 31 December 2021). Following a dose of rizatriptan, the patient developed a sensation of radiating chest heaviness (CARM ID #142597). New Zealand data sheets for rizatriptan and sumatriptan do not list TCM as an adverse event. However, reports of serious coronary events have been associated with triptan medicines.5,6

References

  1. Mohan J, Parekh A, DeYoung M. 2019. Sumatriptan induced takotsubo cardiomyopathy; the headache of the heart: a case report. Frontiers in Cardiovascular Medicine 18(6): 134. DOI: 10.3389/fcvm.2019.00134 (accessed 7 December 2021).
  2. Reeder G and Prasad A. 2021. Clinical manifestations and diagnosis of stress (takotsubo) cardiomyopathy. In: UpToDate 26 March 2021. URL: uptodate.com/contents/clinical-manifestations-and-diagnosis-of-stress-takotsubo-cardiomyopathy (accessed 8 December 2021).
  3. Boyd B and Solh T. 2020. Takotsubo cardiomyopathy review of broken heart syndrome. Journal of the American Academy of Physician Assistants 33(3). URL: journals.lww.com/jaapa/FullText/2020/03000/Takotsubo_cardiomyopathy__Review_of_broken_heart.4.aspx (accessed 7 December 2021).
  4. Reeder G and Prasad A. 2021. Management and prognosis of stress (takotsubo) cardiomyopathy. In: UpToDate 14 October 2021. URL: uptodate.com/contents/management-and-prognosis-of-stress-takotsubo-cardiomyopathy (accessed 8 December 2021).
  5. Mylan New Zealand Limited. 2021. Rizatriptan New Zealand Data Sheet 21 May 2021. URL: medsafe.govt.nz/profs/Datasheet/r/rizamelttab.pdf (accessed 17 December 2021).
  6. Apotex New Zealand Ltd. 2016. Apo-Sumatriptan New Zealand Data Sheet 22 November 2016. URL: medsafe.govt.nz/Profs/datasheet/a/aposumatriptantab.pdf (accessed 17 December 2021).
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