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Perioperative Stress Cardiomyopathy

Case Reports Matter!

London, Martin J. MD

doi: 10.1213/XAA.0000000000000203
Editorials: Editorial

Department of Anesthesiology, University of California, San Francisco, California,

This issue of the A & A Case Reports includes 3 interesting cases of perioperative “stress cardiomyopathy.”1–3 Two of these cases are considered by the authors to constitute “neurogenic stunned myocardium,” a reasonable classification given their immediate temporal relation to catastrophic neurologic events. The first case involves a 23-year-old woman with subarachnoid hemorrhage who developed severe left ventricular (LV) dysfunction with hypokinesia of the basal LV segments with preservation of the apical segments (often termed an “inverted” or “reverse” takotsubo pattern).1 The second case involves a 43-year-old man with intraparenchymal hemorrhage complicated by a history of methamphetamine use without obvious cardiovascular sequelae, who developed severe “global hypokinesia” after induction of anesthesia on hospital day 4 for resection of a cavernoma near the pontomedullary junction.2 Of note, severe hypertension (210/130 mm Hg), a potential marker of “sympathetic storm,” a factor well recognized to precipitate cardiopulmonary dysfunction with severe neurologic injury,4 was noted on admission.

The third case involved a patient who developed LV dysfunction after induction for a liver transplant, for which dexmedetomidine infusion was used to reduce “perioperative stress” in the subsequent attempt at surgery.3 This case more neatly fits into the popular category of “takotsubo cardiomyopathy” based on the occurrence of LV dysfunction in the absence of a significant neurologic event, temporal relation to some form of “stress” (the patient was noted to be anxious about his surgery), “classical” transthoracic echocardiogram findings of LV dysfunction with apical akinesia and preserved basal segment function,5 and normal coronary arteries on coronary angiography.

Although not used in the titles of the reports, stress cardiomyopathy is the most appropriate “umbrella term” based on existing knowledge of common etiologic mechanisms for these slightly different clinical syndromes.6–8 Luckily, all 3 patients eventually either completely or partially resolved their cardiomyopathy, although the patient with a history of methamphetamine abuse showed incomplete resolution suggesting a greater degree of subclinical preexisting cardiac pathology. Despite the common belief that these clinical syndromes are relatively “benign” with regard to short-term morbidity or long-term outcome (particularly the classical “takotsubo” variety), all 3 cases involved major resource expenditure and considerable physical and emotional stress to the patient. The authors of these 3 cases present excellent and unique discussions regarding various aspects of potential etiology and clinical management strategies (including an extensive compilation of clinical characteristics of 66 cases of subarachnoid hemorrhage-associated neurogenic stunned myocardium in the literature),1 the results of which do not bear repeating here.

It has been nearly a decade since Hessel9 expertly summarized the state of the art in Anesthesia & Analgesia regarding perioperative “brain heart” interactions potentially responsible for 2 cases of stress cardiomyopathy and nearly 5 years since I had the pleasure of coauthoring with him a provocative editorial in response to 2 additional cases (felt precipitated by perioperative pain), in which we exhorted “Enough Case Reports. Let’s try to answer some specific questions!”10 Therein, we proposed that simply recycling descriptions of “octopus traps” (the takotsubo of takotsubo cardiomyopathy) was unlikely to be of value in advancing our knowledge of perioperative stress cardiomyopathic syndromes unless it is done in a more systematic manner. We also suggested establishing a perioperative registry of cases (based on existing precedent in the cardiology literature).

Since then, Anesthesia & Analgesia has rejected all such submissions, typically including in the decision letters a copy of our editorial. I was heartened to see that this approach was echoed quite recently (2014) by Mazzeo et al.11 in their comprehensive review in the British Journal of Anaesthesia. So it may seem paradoxical and perhaps even hypocritical for me to write an editorial about yet more stress cardiomyopathy case reports.

However, since my previous editorial, the literature on this topic has been steadily advancing, including a myriad of additional case reports (from multiple clinical environments), sophisticated animal preparations,6 and expert reviews and commentaries about appropriate schemas for classification,12 criteria for diagnosis,13 and etiologic mechanisms,14 and have been presented and debated. To the best of my knowledge, no perioperative registries for these syndromes have been established. As evidenced by these 3 case reports, the level of scholarship has advanced further than “recycling pictures of octopus traps.” We are in a more mature phase where new cases are appropriately considered in the context of a complex and rapidly expanding literature base.

This growing literature offers few simple answers to how best to prevent or appropriately treat these sometimes subtle syndromes. It has been suggested that a substantial proportion of perioperative troponin leakage is possibly related to stress cardiomyopathy.15 In fact, it is also now suggested that stress cardiomyopathy can and does coexist in the setting of documented coronary disease!16 Suggestions that we prevent stress are supported with modest observational data that β-blockade may be of value in patients with subarachnoid hemorrhage17 and perhaps by increasing the use of sympatholytic drugs such as dexmedetomidine, but the evidence is weak.18 These are probably the easiest suggestions to make, but proving causation with observational data or a case report is impossible and randomized trials are nearly impossible to consider given the low incidence of these syndromes. A recently published randomized trial reported in the Journal of the American Medical Association19 suggesting that premedication with lorazepam is of no measurable benefit can be construed as a blow to the reduce stress approach, but that would be an oversimplification of a very complex environment. Unfortunately, this topic is not considered a high priority by most cardiology societies. Neither the recently published American Heart Association20 nor the European Society of Cardiology Guidelines21 for perioperative evaluation and management of patients undergoing noncardiac surgery mention the terms takotsubo, stress cardiomyopathy, or neurogenic stunned myocardium. As a peer reviewer of the American Heart Association Guideline, I had suggested incorporation of some information on these syndromes. However, the group felt that there was insufficient evidence to make recommendations. I have no doubt that in the future it will be accorded the appropriate consideration given to the slow “tsunami” of literature on these topics.

In the meantime, I have reconsidered my previous editorial with Hessel.10 The field has advanced in the past 5 years, and there is a role for case reports to help us better understand the variable presentation of stress cardiomyopathy.

Martin J. London, MD

Department of Anesthesiology

University of California

San Francisco, California

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