Takotsubo cardiomyopathy is an acute condition characterised by transient left ventricular systolic dysfunction, often triggered by severe physical and emotional stress, presenting with an acute coronary syndrome-like presentation but with normal coronaries. It has been associated in multiple reports with serotonin-noradrenaline reuptake inhibitors, most commonly venlafaxine, specifically in overdose and postmenopausal women, with fewer cases following routine dose escalation or younger adults. This case illustrates the combined influence of medication exposure, underlying autonomic vulnerabilities, and psychosocial stressors in the development of Takotsubo cardiomyopathy.

A woman in her early-30s with a background of mixed anxiety and depression, functional neurological disorder (FND), and postural orthostatic tachycardia syndrome (POTS) was admitted following an overdose of mirtazapine. Mirtazapine was discontinued following bradycardia and hypotension; venlafaxine modified release 75 mg was commenced during admission and increased to 150 mg during routine Home Treatment Team follow-up. Clinical review identified high consumption of energy drinks. Seven weeks following dose titration, she developed acute severe chest pain and three witnessed non-epileptic seizures requiring urgent medical assessment. Investigations revealed 3865 ng/L troponin without acute ST-T wave changes on ECG; however, echocardiography showed ejection fraction of 40% ± 5% with regional wall motion abnormalities. Cardiology diagnosed Takotsubo cardiomyopathy, as confirmed by cardiac MRI. She was managed with beta-blockers and angiotensin-converting enzyme inhibitors and subsequently discharged home with follow-up in 6 months for repeat cardiac MRI.

The patient was diagnosed with Takotsubo cardiomyopathy and demonstrated clinical improvement following venlafaxine cessation and heart failure management. This presentation is atypical, both in terms of the patient’s age and occurrence following routine dose escalation within therapeutic limits. Existing evidence associates Takotsubo cardiomyopathy primarily with venlafaxine overdose and in postmenopausal women. The convergence of venlafaxine at a dose of 150mg, at which noradrenaline reuptake inhibition becomes clinically relevant, together with high caffeine intake from energy drinks, and preexisting autonomic dysfunction POTS and FND likely contributed to a state of synergistic catecholamine excess, consistent with myocardial stunning. This case supports a multifactorial understanding of Takotsubo cardiomyopathy, highlighting the interaction between physiological vulnerability and external stressors.

This case highlights the importance of considering underlying physical health vulnerabilities, including autonomic dysregulation, during routine psychopharmacological prescribing and dose titration, with heightened vigilance for cardiac symptoms when escalating venlafaxine in at-risk patients, even in the absence of formal contraindications.

Multiple projects across the country are fortunately looking closely at violence and aggression happening to health and social care workers. This is a piece of work around experience of support made available to resident doctors in psychiatry following violence and aggression incidents.

This QI project aims to improve the quality of support and spread awareness about available channels to resident doctors following abuse incidents. A baseline survey was conducted to explore awareness of available channels, rate satisfaction with them, improve them as well as suggest new possible ways of providing support.

As a part of the QI project, we did a baseline survey to explore whether resident doctors had access to support after a violence and aggression incident and how satisfied they were with it. We then did a root cause analysis (RCA) workshop where resident doctors identified reasons for not accessing these channels.

41 resident doctors participated in the survey. 12 residents reported experiencing anincident of violence and aggression (1–2) times and 8 of these residents were in a junior entry level (CT1–CT3). 22 of these incidents were identified as verbal. 85.71% of residents were not aware of available channels of support in the trust. This coincided with 75% of residents not seeking support. Of the participants that did seek support, 2.44% graded the level of satisfaction with the type of support as 1 (very unsatisfied) and the follow-up answer was (due to lack of communication following the report and not knowing what the outcome of the report was). We then carried out an RCA and the resident doctors identified multiple causes to not seeking support including (not knowing how to access support, feeling speaking up is a burden, feeling the process is not followed through, feeling like they don’t belong due to rotating every 6 months) etc.

The residents have overall agreed there is room for improvement on the level of support available. We used the suggested themes in the RCA to come up with an action plan. Measures we have come up with are including all information around support channels in the induction file given to all new starting resident doctors, spreading awareness about available support on the trust intranet, liaising with the incident reporting system representatives in the trust to improve reporting process and include proper follow up. We are also still meeting regularly to discuss and improve our action plan.