Reversible left ventricular dysfunction precipitated by emotional stress has been
reported, but the mechanism remains unknown.
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.
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).
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.
Copyright 2005 Massachusetts Medical Society.