Diverse left ventricular morphology and predictors of short-term outcome in patients with stress-induced cardiomyopathy

Abstract

Background

There is paucity of data with regard to the clinical spectrum according to left ventricle (LV) morphological variation in stress-induced cardiomyopathy (SCMP) patients, and still there is controversy in terms of prognosis since some people believe that the published in-hospital mortality data of patients with SCMP are underestimated. Therefore, we sought to investigate the morphological features of LV and in-hospital outcome of patients with SCMP and explored predictors of short-term prognosis.

Methods

This was a multicenter, observational study of 208 SCMP patients. Morphological features of LV were determined by echocardiography and were divided into typical (apical) and atypical ballooning types, which were subcategorized into mid-LV ballooning and basal ‘inverted’ ballooning type. All-cause mortality of patients with SCMP during hospitalization was recorded.

Results

The apical ballooning type was most common (67.3%) in SCMP followed by the mid-LV ballooning type (28.3%), and the basal ‘inverted’ ballooning type (4.3%). There were no differences in stressor types and in-hospital mortality between patients with typical and atypical SCMP. Notably, all the in-hospital mortality of SCMP patients occurred in patients with physical stressors, where age, shock, and LV ejection fraction were the independent risk factors for predicting in-hospital mortality.

Conclusions

SCMP patients showed diverse patterns of LV morphology, but there were no definite differences on clinical spectrum among SCMP patients presenting various LV morphological patterns. In terms of short-term prognosis, underlying physical conditions combined with old age, hemodynamic compromise, and low LV systolic function might be the most important factors in SCMP patients.

Introduction

Stress-induced cardiomyopathy (SCMP) is regarded as an acute reversible cardiomyopathy that mimics acute coronary syndrome. Traditionally, it is characterized by transient regional wall motion abnormalities of the left ventricular mid and apical segment demonstrating apical ballooning feature. Therefore, it is also termed ‘apical ballooning syndrome’ or ‘Takotsubo cardiomyopathy’. While considerable evidence supports emotional stress as a precipitating cause of SCMP and suggests exaggerated sympathetic stimulation as a probable mechanism of SCMP development [1], [2], [3], many other causes have been reported as precipitating factors for development of SCMP, such as physical stress and pharmacological agents. Nowadays, SCMP is increasingly being observed during routine daily practice, including diagnostic or therapeutic procedures [4], [5], [6], [7], surgery [8], [9], and intensive care [10]. Besides various precipitating causes, a diverse morphological spectrum also has been reported for SCMP. Several case reports suggested that SCMP is associated with various morphological features of the left ventricle (LV), which differ from those in previous reports [5], [11]. Moreover, a recent study demonstrated and categorized diverse LV morphological features [12]. Despite the acute severity, complications are rare and the long-term prognosis of patients with SCMP is generally considered favorable [13], [14], [15]. However, recent study suggested that the short-term prognosis (i.e., in-hospital outcome) of patients with SCMP is not as favorable as generally considered [16]. In concordance with this report, some people have the notion that the published in-hospital mortality data are underestimated [17]. Therefore, we sought to investigate LV morphological features and in-hospital outcome in patients with SCMP and to assess predictors of short-term prognosis.