Acute Treatment of Patients With Stress Cardiomyopathy and Hemodynamic Compromise
In patients with no hemodynamic instability and pulmonary congestion, treatment is directed to relief congestion with diuretic agent and vasodilators. Arterial vasodilators and β-adrenergic blockers are useful especially if hypertension is present. For patients with hemodynamic instability (hypotension/shock), treatment depends on the presence of LVOTO obstruction. In the absence of LVOTO, inotropic agents, and if not sufficient, mechanical left ventricular assist devices (IABP, Impella) should be considered. In the presence of LVOTO, intravenous fluids and low dose of short-acting β-adrenergic blockers (i.e., esmolol or metoprolol) may be used with caution to reduce the LVOTO or peripherally active vasopressor drugs (i.e., phenylephrine or vasopressin) to maintain adequate perfusion pressure as a temporizing solution to LVOTO resolution or mechanical support. Extracorporeal membrane oxygenation is used as a mechanical cardiac assist device for refractory cases of stress cardiomyopathy with LVOTO or biventricular failure. ACEinh = angiotensin-converting enzyme inhibitors; ARB = angiotensin II receptor blockers; ARN = angiotensin II receptor blocker neprilysin inhibitors; ECMO = extracorporeal membrane oxygenation; IABP = intra-aortic balloon pump; ISDN = isosorbide dinitrate; LVOTO = left ventricular outflow tract obstruction.