Takotsubo syndrome in a patient with adrenal insufficiency, severe hyponatremia and coexistent coronary artery disease.

Some endocrine disorders, including primary and secondary adrenal insufficiency (AI), predispose to takotsubo syndrome (TTS). Hyponatremia is a frequent feature seen in adrenal crisis; however, TTS cases preceded by low serum sodium associated with other diseases are also reported. A CASE REPORT: The authors describe a case of a 72-year-old female with primary AI (Addison's disease) after adrenalectomy due to adrenal hypertrophy she underwent in childhood. Before admission, she missed a few doses of replacement therapy with prednisone and fludrocortisone. On admission, she presented with hypotension, severe heart failure (HF) and hyponatremia. Negative T-waves in ECG and left ventricular (LV) apical ballooning in echocardiography were suggestive of TTS. Restarted replacement therapy and symptomatic HF treatment resulted in gradual LV function normalization within 6 days. Cardiac magnetic resonance (CMR) performed after 4 weeks was normal and did not reveal any late gadolinium enhancement (LGE). However, elective coronary angiography made a month later showed critical stenosis of the left anterior descending coronary artery which was treated with coronary angioplasty. The authors suggest that each patient with adrenal crisis as well as with severe hyponatremia should be evaluated by echocardiography. The case presented confirms a possible coexistence of TTS and obstructive coronary artery disease.