A Case of Takotsubo Cardiomyopathy with Cardiogenic Shock, in Which Administration of Norepinephrine Caused Adverse Effect

We experienced a case of takotsubo cardiomyopathy with cardiogenic shock in which norepinephrine, often an effective vasopressor for shock, caused an adverse effect. A 75-year-old woman with hypertension was referred to our hospital with syncope and bilateral shoulder pain. Her blood pressure was 109/73 mmHg. Electrocardiography revealed ST segment depression on I, II, aVL, V4-6. Troponin I was elevated. Echocardiography showed severe MR and SAM. CAG showed normal coronary artery and LVG showed dyskinesia in mid-septal portion of left ventricle. During procedure, the systolic pressure went down to below 70 mmHg and norepinephrine was administered. It caused abrupt elevation of left ventricular systolic pressure to 220 mmHg and decrease in SpO₂. Pull-back pressure tracking showed LVOT gradient of 60 mmHg. Instead, phenylephrine and landiolol were administered intravenously. Her clinical state improved and both medication could be decreased gradually. Repeated echocardiography revealed improvement in LV function and resolution of the LVOT gradient. Takotsubo disease with mid-ventricle dyskinesia results in LVOT obstruction and cardiogenic shock. Norepinephrine acts on α1 adrenergic receptors and used as first line vasopressor, but it also acts on β1 adrenergic receptors and therefore worsens the degree of LVOT obstruction and results in the exacerbation of heart failure in such cases. The recognition of this pathophysiology is crucial for rapid selection of vasopressors and consequent hemodynamic stabilization.