Nineteen patients (mean age, 63 years) who presented with left ventricular dysfunction after sudden emotional stress were studied. Clinical presentations included chest pain, pulmonary edema, and cardiogenic shock. Only one patient had angiographic evidence of clinically significant coronary disease. Severe left ventricular dysfunction was present on admission (median ejection fraction, 20%) and rapidly resolved in all patients (median ejection fraction at 2-4 weeks, 60%). Endomyocardial biopsy showed mononuclear infiltrates and contraction-band necrosis. Plasma catecholamine levels at presentation were markedly higher among patients with stress-induced cardiomyopathy than among those with myocardial infarction (median epinephrine level, 3.36 times higher; norepinephrine level, 2.08 times higher). The authors concluded that emotional stress can precipitate severe, reversible left ventricular dysfunction in patients without coronary artery disease. Exaggerated sympathetic stimulation probably plays a role in the etiology of this syndrome.
Comment: An outpouring of catecholamines causes magnesium to be released from cells into the bloodstream, and then excreted in the urine. This depletion of intracellular magnesium not only increases the vulnerability of myocardial cells to necrosis, but also exacerbates the deleterious effects of catecholamines. Administration of magnesium has been shown to prevent catecholamine-induced myocardial necrosis in animals.
People subjected to severe stress might do well to supplement with magnesium and to relax a few times a week in a warm Epsom salt (magnesium sulfate) bath. Furthermore, parenteral magnesium might be beneficial in the treatment of acute, stress-induced myocardial dysfunction. People who may have intracellular potassium depletion should receive a potassium supplement in conjunction with parenteral magnesium therapy, because magnesium promotes the cellular uptake of potassium, potentially leading to hypokalemia.
Wittstein IS, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539-548.
