Stress (Tako-tsubo) cardiomyopathy in critically-ill patients

BACKGROUND: Stress cardiomyopathy (SC) is a transient ventricular dysfunction rarely described in the critical care setting. OBJECTIVE: To evaluate the mechanisms, incidence, treatment and prognosis of SC. METHOD: This is a retrospective observational study of every critically-ill patient admitted to the ICU over a period of two years. RESULTS: Among 1314 patients admitted in the ICU, 20 patients (1.5%) were diagnosed with SC. A total of 249 patients experienced cardiogenic shock, whereas 8% were suffering from SC. SC was suspected because of hemodynamic impairment (80% of cases), ECG modifications (15%) and/or dyspnea (15%). SC was apical (typical Tako-tsubo) in 90% and atypical in 10% of cases. Several mechanisms or conditions may explain the occurrence of SC and are may be combined: catecholamine toxicity (45%), psychological stress, seizures or neurological impairment (35%), non-epicardial coronary ischemia (20%) and left ventricular outflow track (LVOT) obstruction (10%). SC could have indirectly caused death by worsening heart failure in three patients and arrhythmias were seen in 40% of patients. SAPS2, renal impairment, malnutrition, norepinephrine infusion and thrombocytopenia were associated with death in the univariate analysis. Catecholamines were required in 85% and intra-aortic balloon pump in 20% of patients. CONCLUSIONS: SC is a rare reversible cardiac impairment in the critically-ill patient that can induce arrhythmias and cardiogenic shock. The likely mechanisms are combined: catecholamine toxicity, stress or neurological involvement and less frequently ischemia or LVOT obstruction.