Acute and Reversible Cardiomyopathy Provoked by Stress in Women From the United States

TLDR

A rapidly reversible left‑ventricular systolic dysfunction triggered by psychological stress is an emerging clinical entity, mainly reported in Japan. In a 32‑month prospective cohort of 22 women in Minneapolis, the syndrome manifested as acute chest pain, ST‑segment changes, apical ballooning, no coronary stenosis, and diffuse wall‑motion abnormalities on MRI, all following profound psychological stress. All 22 women (mean age 65) survived, with 37% requiring vasopressors or IABP, and all achieved normalized ejection fraction within about six days, underscoring a favorable outcome.

Abstract

Background— A clinical entity characterized by acute but rapidly reversible left ventricular (LV) systolic dysfunction and triggered by psychological stress is emerging, with reports largely confined to Japan. Methods and Results— Over a 32-month period, 22 consecutive patients with this novel cardiomyopathy were prospectively identified within a community-based practice in the Minneapolis–St. Paul, Minn, area. All patients were women aged 32 to 89 years old (mean 65±13 years); 21 (96%) were ≥50 years of age. The syndrome is characterized by (1) acute substernal chest pain with ST-segment elevation and/or T-wave inversion; (2) absence of significant coronary arterial narrowing by angiography; (3) systolic dysfunction (ejection fraction 29±9%), with abnormal wall motion of the mid and distal LV, ie, “apical ballooning”; and (4) profound psychological stress (eg, death of relatives, domestic abuse, arguments, catastrophic medical diagnoses, devastating financial or gambling losses) immediately preceding and triggering the cardiac events. A significant proportion of patients (37%) had hemodynamic compromise and required vasopressor agents and intra-aortic balloon counterpulsation. Each patient survived with normalized ejection fraction (63±6%; P <0.001) and rapid restoration to previous functional cardiovascular status within 6±3 days. In 95%, MRI identified diffusely distributed segmental wall-motion abnormalities that encompassed LV myocardium in multiple coronary arterial vascular territories. Conclusions— A reversible cardiomyopathy triggered by psychologically stressful events occurs in older women and may mimic evolving acute myocardial infarction or coronary syndrome. This condition is characterized by a distinctive form of systolic dysfunction that predominantly affects the distal LV chamber and a favorable outcome with appropriate medical therapy.