Takotsubo syndrome due to 4-fluoroamphetamine

To the Editor:

The paper of Al-Abri et al.¹ published online ahead of print on October 28, 2014, in the Journal, about the 18-year-old man who suffered from Takotsubo syndrome (TTS), after taking 4-fluoroamphetamine (4-FA) is of interest for clinicians confronted by the epidemic of drug addiction, and emphasizes the need for a high index of suspicion for underlying TTS in such patients², so that this diagnosis can be made expeditiously. I have some remarks for the authors to consider (1) taking into consideration the 4-FA's pharmacodynamics, as described by the authors, it would have been useful to evaluate serially for serotonin, dopamine, norepinephrine, and epinephrine blood levels; (2) one wonders whether salbutamol, dopamine, dobutamine, and epinephrine, which have been administered in the management of this patient, have contributed to the illness since all 4 drugs can trigger TTS,² although the authors did not know at that time that they were dealing with a case of TTS, and thus they were managing a patient with cardiogenic shock; and (3) the diagnostic non-contribution of the electrocardiogram (ECG) in this case of TTS was probably due to electrical cancelation in a case of widespread left ventricular (LV) involvement, rendering an isoelectric ST-segment vector in all ECG leads, particularly in a patient, like this one, who had a spared LV apex, which by its anatomic topography with unopposed muscular elements, would have been expected, if involved, to generate a non-isoelectric ST-segment vector toward it, and generating ST-elevations in leads V3–V5.

Declaration of interest

The author reports no declarations of interest. The author alone is responsible for the content and writing of the paper.