Atropine aggravates signs and symptoms of Takotsubo cardiomyopathy

We present a novel case of Takotsubo cardiomyopathy, associated with worsening chest pain and T-wave inversions on electrocardiogram after atropine use. Our patient was an 82-year-old woman who complained of substernal chest discomfort of 5 hours duration. Atropine 0.5 mg was administered intravenously by the emergency medical service for symptomatic bradycardia. The patient subsequently complained of worsening chest pain and developed new T-wave inversions on the electrocardiogram. Cardiac catheterization was diagnostic and revealed normal coronary arteries but akinesis of the apical segment. Although the pathogenesis of Takotsubo cardiomyopathy is not completely understood, catecholamine-mediated myocardial stunning due to enhanced sympathetic activity is the most widely accepted underlying mechanism. The withdrawal of parasympathetic drive in such cases should exacerbate sympathetic activity, leading to the genesis or worsening of disease activity. The role of atropine in relation to Takotsubo cardiomyopathy has been questioned before. However, it was always in the setting of general anesthesia induction, at which time atropine had been used for reversal of symptomatic bradycardia; consequently, determining the exact role of atropine in the disease process was difficult. Our patient received only atropine and therefore illustrated its capacity to worsen signs and symptoms of Takotsubo Cardiomyopathy. Because patients with Takotsubo cardiomyopathy may present with recurrent chest pain, we would recommend caution against the use of atropine for symptomatic bradycardia in such patients in the emergency department. Transcutaneous pacemaker should be preferred.