Neurohumoral Features of Myocardial Stunning Due to Sudden Emotional Stress
Ilan S. Wittstein, M.D., David R. Thiemann, M.D., Joao A.C. Lima, M.D., Kenneth L. Baughman, M.D., Steven P. Schulman, M.D., Gary Gerstenblith, M.D., Katherine C. Wu, M.D., Jeffrey J. Rade, M.D., Trinity J. Bivalacqua, M.D., Ph.D., and Hunter C. Champion, M.D., Ph.D.
Background Reversible left ventricular dysfunction precipitatedby emotional stress has been reported, but the mechanism remainsunknown.
Methods We evaluated 19 patients who presented with left ventriculardysfunction after sudden emotional stress. All patients underwentcoronary angiography and serial echocardiography; five underwentendomyocardial biopsy. Plasma catecholamine levels in 13 patientswith stress-related myocardial dysfunction were compared withthose in 7 patients with Killip class III myocardial infarction.
Results The median age of patients with stress-induced cardiomyopathywas 63 years, and 95 percent were women. Clinical presentationsincluded chest pain, pulmonary edema, and cardiogenic shock.Diffuse T-wave inversion and a prolonged QT interval occurredin most patients. Seventeen patients had mildly elevated serumtroponin I levels, but only 1 of 19 had angiographic evidenceof clinically significant coronary disease. Severe left ventriculardysfunction was present on admission (median ejection fraction,0.20; interquartile range, 0.15 to 0.30) and rapidly resolvedin all patients (ejection fraction at two to four weeks, 0.60;interquartile range, 0.55 to 0.65; P<0.001). Endomyocardialbiopsy showed mononuclear infiltrates and contraction-band necrosis.Plasma catecholamine levels at presentation were markedly higheramong patients with stress-induced cardiomyopathy than amongthose with Killip class III myocardial infarction (median epinephrinelevel, 1264 pg per milliliter [interquartile range, 916 to 1374]vs. 376 pg per milliliter [interquartile range, 275 to 476];norepinephrine level, 2284 pg per milliliter [interquartilerange, 1709 to 2910] vs. 1100 pg per milliliter [interquartilerange, 914 to 1320]; and dopamine level, 111 pg per milliliter[interquartile range, 106 to 146] vs. 61 pg per milliliter [interquartilerange, 46 to 77]; P<0.005 for all comparisons).
Conclusions Emotional stress can precipitate severe, reversibleleft ventricular dysfunction in patients without coronary disease.Exaggerated sympathetic stimulation is probably central to thecause of this syndrome.
Source Information
From the Division of Cardiology, Department of Medicine (I.S.W., D.R.T., J.A.C.L., S.P.S., G.G., K.C.W., J.J.R., H.C.C.), and the Brady Urological Institute (T.J.B.), Johns Hopkins University School of Medicine, Baltimore; the Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore (D.R.T.); and the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston (K.L.B.).
Address reprint requests to Dr. Wittstein at the Division of Cardiology, Johns Hopkins Hospital, Carnegie 568, 600 N. Wolfe St., Baltimore, MD 21287, or at iwittste{at}jhmi.edu.
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