Stress cardiomyopathy of the critically ill: Spectrum of secondary, global, probable and subclinical forms

Abstract

Stress cardiomyopathy (SC) typically presents as potential acute coronary syndrome (ACS) in previously healthy people. While there may be physical or mental stressors, the initial symptom is usually chest pain. This form conforms to the published Mayo diagnostic criteria, is well reported and as the presentation is initially cardiac, is considered primary SC. Increasingly we see SC develop several days into the hospitalization secondary to medical or surgical critical illness. This condition is more complex, presents atypically, is not easy to recognize and carries a much worse prognosis. Label of Secondary SC is appropriate as it manifests in sicker hospitalized patients with numerous comorbidities. We review the limited but provocative literature pertinent to SC in the critically ill and describe important clues to identify global, subclinical and probable forms of SC. We illustrate the several unique clinical features, demographic differences and propose a diagnostic algorithm to optimize cardiac care in the critically ill.

Fig. 1

Stress cardiomyopathy likely accounts for the largest portion of critically ill patients with cardiac injury (troponin elevation). Many patients with global stunning likely have a form of SC as well. True ACS is rare in the critically ill. RWMA indicates regional wall motion abnormalities; and VT, ventricular tachycardia.

Fig. 2

Stress cardiomyopathy in the critically ill may manifest with cardiac dysfunction and wall motion abnormalities (secondary SC). However, a larger subset likely have subclinical SC with cardiac stunning, ECG changes, hypotension or isolated troponin elevation. In the community many transient cardiac conditions may represent subclinical SC as well. RWMA indicates regional wall motion abnormalities.

Fig. 3

Diagnostic algorithm in the critically ill with cardiac injury. Except for the rare patient with concern for true ACS, catheterization plays a limited role. Echocardiography is the mainstay for diagnosis of secondary SC.