NEUROHUMORAL
FEATURES OF MYOCARDIAL STUNNING DUE TO SUDDEN EMOTIONAL STRESS
Wittstein, IS, et al. N Engl
J Med. 2005 Feb 10;352(6):539-48.
BACKGROUND: Reversible left ventricular dysfunction precipitated by emotional stress has been reported, but the mechanism remains unknown.
METHODS: We
evaluated 19 patients who presented with left ventricular dysfunction after
sudden emotional stress. All patients underwent coronary angiography and serial
echocardiography; five underwent endomyocardial
biopsy. Plasma catecholamine levels in 13 patients with stress-related
myocardial dysfunction were compared with those in 7 patients with Killip class III myocardial infarction.
RESULTS: The
median age of patients with stress-induced cardiomyopathy
was 63 years, and 95 percent were women. Clinical presentations included chest
pain, pulmonary edema, and cardiogenic shock. Diffuse
T-wave inversion and a prolonged QT interval occurred in most patients.
Seventeen patients had mildly elevated serum troponin
I levels, but only 1 of 19 had angiographic evidence of clinically significant
coronary disease. Severe left ventricular dysfunction was present on admission
(median ejection fraction, 0.20; interquartile range,
0.15 to 0.30) and rapidly resolved in all patients (ejection fraction at two to
four weeks, 0.60; interquartile range, 0.55 to 0.65;
P<0.001). Endomyocardial biopsy showed mononuclear
infiltrates and contraction-band necrosis. Plasma catecholamine levels at
presentation were markedly higher among patients with stress-induced cardiomyopathy than among those with Killip
class III myocardial infarction (median epinephrine level, 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 [interquartile range, 1709 to 2910] vs. 1100 pg per
milliliter [interquartile range, 914 to 1320]; and
dopamine level, 111 pg per milliliter [interquartile
range, 106 to 146] vs. 61 pg per milliliter [interquartile
range, 46 to 77]; P<0.005 for all comparisons).
CONCLUSIONS:
Emotional stress can precipitate severe, reversible left ventricular
dysfunction in patients without coronary disease. Exaggerated sympathetic
stimulation is probably central to the cause of this syndrome.