What causes global myocardial hypokinesis?

Causes of Global Myocardial Hypokinesis

Global myocardial hypokinesis results from diverse etiologies including dilated cardiomyopathy, stress-induced cardiomyopathy, myocarditis, toxic exposures (especially chemotherapy and alcohol), infiltrative diseases, septic shock, and—less commonly than expected—multivessel coronary artery disease. 1, 2

Primary Cardiac Causes

Cardiomyopathies

• Dilated cardiomyopathy is the most common structural cause, characterized by ventricular dilatation with reduced ejection fraction and both systolic and diastolic dysfunction 1
• Approximately 50% of nonischemic dilated cardiomyopathy cases are idiopathic, typically affecting younger patients 3
• Stress-induced (Takotsubo) cardiomyopathy produces reversible global systolic dysfunction with characteristic apical ballooning, often triggered by acute illness or emotional stress 4, 1
• Hypertrophic cardiomyopathy can present in late stages with dilated, hypokinetic left ventricle and wall thinning 3

Ischemic Heart Disease

• Coronary artery disease remains the leading cause of left ventricular systolic dysfunction in adults, though global hypokinesis shows a possible inverse correlation with triple-vessel disease 1, 2
• Hibernating myocardium (chronically hypoperfused but viable tissue) manifests as hypokinetic segments that can improve after revascularization, even with ejection fractions as low as 15-20% 1, 5
• Myocardial stunning from intermittent ischemia causes reversible ventricular dysfunction 1
• Critical finding: A recent study demonstrated no positive association between global hypokinesis and triple-vessel CAD, suggesting that heart failure and other diagnoses have stronger effects on global hypokinesis than multivessel coronary disease 2

Infectious and Inflammatory Causes

• Myocarditis (viral, bacterial, fungal) can produce both regional and global hypokinesis with myocardial edema mimicking hypertrophic cardiomyopathy 3, 1
• Acute rheumatic fever affects ventricular function 1
• Cardiac sarcoidosis produces segmental hypokinesis with ventricular septal thickening in acute phase, but thinning with global dysfunction in chronic phase 3, 1
• Systemic sclerosis and collagen vascular disorders (lupus, rheumatoid arthritis, polyarteritis nodosa) cause ventricular dysfunction through vasculitis and direct myocardial infiltration 3, 1

Toxic and Metabolic Causes

Cardiotoxic Agents

• Chemotherapeutic agents, particularly anthracyclines (doxorubicin), tyrosine kinase inhibitors, trastuzumab, and interferons induce cardiomyopathy with higher risk at cumulative doses 3, 1
• Alcoholic cardiomyopathy occurs in heavy drinkers with genetic susceptibility, most common in men aged 30-55 years 3, 1
• Cocaine, heroin, and amphetamines cause direct cardiotoxicity 1
• Chronic use of anabolic steroids, tacrolimus, and hydroxychloroquine can cause left ventricular hypertrophy and dysfunction 3, 1

Metabolic Derangements

• Protein, thiamine, and selenium deficiencies 1
• Electrolyte abnormalities: hypocalcemia, hypophosphatemia, hyponatremia, hypokalemia 1
• Endocrine disorders: diabetes mellitus, hypothyroidism, hyperthyroidism 1

Infiltrative Disorders

• Amyloidosis produces characteristic basal-predominant hypokinesis with preserved apical function ("apical sparing" pattern) despite normal ejection fraction 1
• Relative apical sparing of longitudinal strain ≥1.0 has 93% sensitivity and 82% specificity for distinguishing cardiac amyloidosis from controls 3
• Hemochromatosis and storage diseases cause restrictive patterns with associated hypokinesis 1

Acute Hemodynamic and Systemic Causes

Septic Shock

• Global left ventricular hypokinesia occurs in 60% of adult septic shock patients, with 39% presenting at admission (primary) and 21% developing after 24-48 hours of norepinephrine support (secondary) 6
• This reversible dysfunction is usually corrected by adding inotropic agents and is not associated with worse prognosis 6

Pulmonary Embolism

• Acute massive pulmonary embolism causes right ventricular hypokinesis with characteristic apical sparing (McConnell sign) 1
• In severe cases, global dysfunction can occur indicating submassive PE with higher mortality 4

Arrhythmia-Related Causes

• Tachycardia-induced cardiomyopathy from incessant supraventricular tachyarrhythmias or atrial fibrillation with rapid ventricular rates produces reversible global hypokinesis 1

Valvular and Structural Heart Disease

• Chronic aortic stenosis and mitral regurgitation produce progressive ventricular dysfunction through pressure and volume overload 1
• Valvular disease is highly prevalent in heart failure patients: 21% in HFrEF/HFmrEF and 28% in HFpEF 3

Special Populations

• Peripartum cardiomyopathy develops in late pregnancy or first 5 months postpartum, occurring in 1 in 2,500-4,000 births in the United States 3, 1
• Risk factors include age >30 years, nonwhite background, multiparity, hypertension, and preeclampsia 3
• Chagas disease remains the most common cause of nonischemic heart failure in South America 3, 1

Critical Diagnostic Pitfalls

• The designation "idiopathic dilated cardiomyopathy" should only be applied after excluding all specific etiologies through appropriate evaluation 1
• Wall motion abnormalities extending beyond single coronary territories suggest non-ischemic etiologies 3, 1
• Regional wall motion abnormalities can be caused by acute infarction, old infarction, acute ischemia, stunning, hibernation, or non-ischemic conditions like cardiomyopathy and inflammatory diseases 3
• Global hypokinesis shows positive association with heart failure diagnosis but possible inverse correlation with triple-vessel CAD, meaning other causes should be strongly considered 2