Dilated Cardiomyopathy, De Novo Heart Failure, and Cardiogenic Shock With End-Organ Failure in a Patient With No Cardiac History Following a Trial of Amitriptyline

A 69-year-old female with no cardiac history presented with dilated cardiomyopathy and de novo congestive heart failure, with an ejection fraction of less than 20%. This patient had struggled over the prior six weeks with exacerbation of chronic obstructive pulmonary disease complicated by pneumonia and as such had taken several trials of antibiotics. Four days prior to her presentation, she was prescribed amitriptyline by her primary care physician to help with sleep. Two days after the presentation, she developed cardiogenic shock secondary to acutely decompensated heart failure. End-organ dysfunction presented as aspartate aminotransferase (AST) and alanine aminotransferase (ALT) of greater than 1000 U/L and a glomerular filtration rate (GFR) as low as 23 mL/min. Cardiac catheterization showed non-obstructive coronary artery disease, and cardiac MRI showed an ejection fraction of 14%. She was discharged 14 days after her initial presentation with a diagnosis of NYHA Class 3 Stage C acute systolic heart failure with dilated cardiomyopathy.