What is the treatment for severe hypokinesis?

Treatment of Severe Hypokinesis

The treatment of severe hypokinesis should target the underlying cause while optimizing cardiac function through a combination of medications including ACE inhibitors/ARBs or ARNI, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, with consideration for device therapy in patients with persistent LVEF ≤35% despite optimal medical therapy. 1

Understanding Hypokinesis in Cardiovascular Context

• Hypokinesis refers to reduced contractility of the myocardium, which can be regional or global, and is often characterized by reduced left ventricular ejection fraction (LVEF) 1
• Severe hypokinesis is associated with significantly impaired cardiac function and may lead to heart failure symptoms 1
• Right ventricular (RV) hypokinesis can be a sign of pulmonary embolism, with the McConnell sign (severe hypokinesia of the mid-free wall with normally contracting RV apex) being highly specific for acute PE 2

Diagnostic Approach

• Echocardiography is the primary diagnostic tool to assess hypokinesis, evaluating:
  • Extent of hypokinesis (regional vs. global) 2
  • Ejection fraction measurement (severely depressed if <30%) 1
  • Right ventricular function (RV hypokinesis may indicate pulmonary embolism) 2
• Doppler echocardiography helps assess diastolic function and filling patterns, which may be abnormal in patients with hypokinesis 2

Treatment Based on Etiology

For Heart Failure with Reduced Ejection Fraction (HFrEF)

• First-line pharmacological therapy includes:
  • ACE inhibitors/ARBs or preferably ARNI (angiotensin receptor-neprilysin inhibitor) 1
  • Beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) 1
  • Mineralocorticoid receptor antagonists (spironolactone or eplerenone) 1
  • SGLT2 inhibitors 1
  • Diuretics for symptom relief in fluid overload 1

For Pulmonary Embolism with RV Hypokinesis

• Anticoagulation is the mainstay of treatment 2
• For submassive PE with RV hypokinesis (considered a marker of increased severity):
  • Heparin anticoagulation is the primary treatment 2
  • Consider fibrinolytic therapy if there is evidence of shock, respiratory failure, or moderate to severe RV strain 2
  • Alteplase 100 mg over 2 hours IV is recommended in patients with no contraindications to fibrinolysis 2

For Stress-Induced Cardiomyopathy

• Conventional therapy with ACE inhibitors, beta-blockers, aspirin, and diuretics if hemodynamically stable 1
• Most patients recover normal ventricular function within 1-4 weeks 1

Device Therapy Considerations

• Cardiac resynchronization therapy (CRT) should be considered in patients who require ventricular pacing or have left bundle branch block 1
• Implantable cardioverter-defibrillator (ICD) is recommended for primary prevention in patients with persistent LVEF ≤35% despite optimal medical therapy 1

Special Considerations

• Avoid long-term use of positive inotropic drugs except as palliation for end-stage disease 1
• For dynamic left ventricular outflow tract (LVOT) obstruction with hypokinesis, beta-blockers and intravenous fluids may be more appropriate than inotropes 2
• In cases of severe hypokinesis with hypotension, careful assessment is needed to differentiate cardiogenic shock from other forms of shock that may require different management 2

Monitoring and Follow-up

• Serial echocardiography is recommended to assess improvement in ventricular function 1
• Adjustment of medications based on clinical response and side effects 1
• Monitor for development of complications such as thrombus formation 1

Pitfalls and Caveats

• Misdiagnosis of the underlying cause can lead to inappropriate treatment (e.g., administering inotropes instead of beta-blockers in dynamic LVOT obstruction) 2
• In patients with PE and RV hypokinesis, failure to recognize the severity may lead to inadequate treatment and worse outcomes 2
• Neurological causes of hypokinesis (such as parkinsonism) require entirely different treatment approaches and should not be confused with cardiac hypokinesis 3, 4