Silent left ventricular apical ballooning and Takotsubo cardiomyopathy in an Australian intensive care unit

Abstract

Aims Recent reports have shown a high incidence of silent left ventricular apical ballooning (LVAB) in the intensive care unit (ICU) setting with potential implications for safe use of inotropes and vasopressors. We examined the incidence, predictors, and associated outcomes of LVAB in patients in a contemporary tertiary Australian ICU. Methods and resultsIn a prospective cohort study, patients were screened within 24 h of admission to the ICU and enrolled if they were deemed critically unwell based on mechanical ventilation, administration of >5 mg/min of noradrenaline, or need for renal replacement therapy. Exclusion criteria were a primary diagnosis of Takotsubo cardiomyopathy, admission to ICU after cardiac surgery, or with acute myocardial infarction or heart failure. Echocardiography was performed, and the presence/absence of LVAB was documented. A total of 116 patients were enrolled of whom four had LVAB (3.5%, 95% confidence interval 0.9-8.6%). Female sex was the only baseline demographic or clinical characteristic associated with incident LVAB. Medical history, ICU admission indication, and choice of inotropes were not associated with increased risk. Patients with LVAB had no deaths and had similar lengths of ICU and hospital stay compared with patients with no LVAB. Conclusions The incidence of silent LVAB suggestive of TC was substantially lower in this study than recently reported in other international ICU settings. We did not observe a suggestion of worse outcomes. A larger, multi-centre study, prospectively screening for LVAB may help understand any variation between centres and regions, with important implications for ICU management.

Regional left ventricular systolic dysfunction associated with critical illness: incidence and effect on outcome

“…Moreover, most patients who did undergo coronary angiography had normal coronary arteries, and patients with follow‐up echocardiogram had a rapid recovery of cardiac function, usually within days, which is not seen in myocardial infarction without coronary intervention. 27 In our study, we identified 12 patients (3%) with apical or midventricular hypokinesia, in concordance with typical Takotsubo, which is an incidence in agreement with other ICU‐oriented studies focusing on this subject, 14 , 15 , 28 although some studies have reported higher numbers. 17 …”

Takotsubo syndrome: between evidence, myths, and misunderstandings

“…Since the onset of TS is frequently associated with preceding stress from various sources, it appears reasonable that critically ill patients develop TS as a secondary disease. Indeed, the incidence of TS in critical care units in observational studies is substantial and higher than expected [95][96][97][98]. Therefore, TS should be suspected in patients with unexplained heart failure, hypotension, shock, arrhythmia, or troponin elevation, and dedicated echocardiography should be performed.…”

Clinical characteristics and risk factors for death in patients with stress cardiomyopathy in the ICU

“…The proportion of patients in our study with complications of systolic heart failure and cardiogenic shock, was 77.36% and 39.62%, respectively. A total of 86.79% of patients were given (7,8). The APACHE II score has been validated as an accurate predictor of clinical outcomes and mortality in critically ill patients (12).…”

“…Several mechanisms or aetiologies may explain the occurrence of SC in ICU and are may be combined: catecholamine toxicity, psychological stress, neurological impairment, ischemia and left ventricular outflow track obstruction (6). Previous studies have reported that SC incidence in the ICU ranged from 1.5% to 5.6% (6)(7)(8). One study showed that >20% of patients admitted to the ICU displayed SC-like LV apical ballooning (9).…”