Cannabis-Related Takotsubo Cardiomyopathy Presenting With Ventricular Tachycardia and Cardiogenic Shock Successfully Treated With Milrinone and Intra-Aortic Balloon Pump

A 63-year-old woman presented with intractable nausea, vomiting, dyspnea, and weakness after cannabis use. She had multiple prior admissions for cannabinoid hyperemesis syndrome. Upon arrival to the emergency department, she was hypotensive, tachycardic, and hypoxic. Laboratory results revealed an elevated troponin level (22,900 ng/L), NT-proBNP (21,092 pg/mL), lactic acidosis (lactic acid level of 7.1 mmol/L), and hypokalemia (potassium level of 2.6 mmol/L). The electrocardiogram showed ST-segment elevation in the anterior leads, and telemetry captured a wide complex tachycardia requiring cardioversion. The urine drug screening was positive for tetrahydrocannabinol. She was intubated and taken for urgent cardiac catheterization, which showed no coronary lesions. Right heart catheterization confirmed cardiogenic shock. She was initiated on norepinephrine, which was later transitioned to milrinone along with placement of an intra-aortic balloon pump for circulatory support. Transthoracic echocardiogram demonstrated a left ventricular ejection fraction of 15% to 20%, with mid to apical wall hypokinesis, which improved to baseline after 4 weeks of intensive management with milrinone and the intra-aortic balloon pump.