ICU · Cardiovascular
Sepsis-induced myocardial dysfunction (septic cardiomyopathy)
Also known as Septic cardiomyopathy · Sepsis-induced cardiomyopathy · SICM · Septic myocardial depression · Myocardial dysfunction in sepsis
Sepsis-induced cardiomyopathy (SICM): reversible, biventricular myocardial dysfunction arising during septic shock and NOT explained by ischaemia, infarction, or pre-existing structural heart disease. Presents: NEW LV systolic dysfunction (reduced EF), RV dysfunction, and diastolic dysfunction superimposed on a vasoplegic (distributive) shock state. Mechanism: circulating myocardial depressant substances (TNF-α, IL-1β, IL-6), nitric oxide/iNOS overproduction, mitochondrial dysfunction with impaired oxidative phosphorylation, beta-adrenergic receptor downregulation/desensitisation, and coronary microcirculatory dysfunction. Diagnosis: echocardiography (reduced EF, LV dilatation, RV dysfunction, abnormal global longitudinal strain, diastolic impairment) supported by elevated troponin and BNP/NT-proBNP; cardiac MRI for atypical/persistent cases. Treatment: treat sepsis (source control, antibiotics), fluid resuscitation guided by fluid-responsiveness testing, vasopressors (noradrenaline first-line), inotropes if low cardiac output (dobutamine, milrinone; levosimendan NOT routinely recommended — LeoPARDS). REVERSIBLE — EF usually recovers within 10 days in survivors.
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Target exams
Red flags
- New LV dysfunction in septic shock — SICM (not necessarily ischaemic — troponin may be elevated)
- Low cardiac output in septic shock — add inotrope (dobutamine/milrinone), not just vasopressor
- RV dysfunction in sepsis — may need pulmonary vasodilator, volume management
- SICM is REVERSIBLE — EF usually recovers within 10 days (if patient survives sepsis)
- Persistent LV dysfunction beyond 10 days — reconsider ischaemia, myocarditis, takotsubo, pre-existing cardiomyopathy
- Elevated troponin in sepsis is usually type 2 MI / cytokine injury — do NOT reflexively coronary angiogram
Meet the patient
It is 3am. A 64-year-old man is in septic shock from a perforated sigmoid diverticulum. He has had his 30 mL/kg of crystalloid and sits on noradrenaline 0.35 mcg/kg/min for a MAP of 62. The bedside echo shows a globally hypokinetic, dilated LV with an EF of 25% and a TAPSE of 14 mm; troponin T is 480 ng/L, NT-proBNP 6800, lactate 4.2. The ECG has no ST changes.[1][11][12]
The registrar's first reflex is to reach for the cath lab: "Is this his MI?" The consultant's question — and the one this whole topic answers — is sharper: this is the septic heart. Reversible, cytokine-driven, and treated by draining the abdomen, not by stenting a coronary.[3][5]
Three words to carry through every section: reversible, global, biventricular. Hold those and the management writes itself.[1]
- Recognise — septic shock with cardiac dysfunction (new LV dysfunction, elevated troponin, BNP)
- Echocardiography — assess: LV systolic function (EF), LV dilatation, RV function, diastolic function, cardiac output, global longitudinal strain. Compare to baseline (if available)
- Distinguish from cardiogenic shock — SICM: WARM shock (vasoplegic), high lactate (sepsis), source of infection, REVERSIBLE. Cardiogenic: COLD shock, elevated filling pressures, ischaemic cause
- Treat sepsis — antibiotics within 1h, source control, fluid resuscitation (30 mL/kg crystalloid — but titrate to fluid responsiveness, avoid overload)
- Vasopressors — noradrenaline FIRST-LINE (alpha vasoconstriction + modest beta). Target MAP ≥65. Add vasopressin if escalating noradrenaline requirement
- Inotropes if low cardiac output — dobutamine (beta-1, increases contractility) or milrinone (PDE inhibitor, reduces afterload, pulmonary vasodilator). Use if: low cardiac output despite adequate volume + vasopressor, ongoing hypoperfusion (lactate, oliguria, mottled skin). Levosimendan NOT routinely recommended (LeoPARDS — no outcome benefit)
- Monitor — echocardiography (serial — assess recovery), troponin/BNP trend, lactate clearance, urine output, clinical perfusion
- Expect recovery — SICM typically REVERSES within 10 days (if sepsis controlled). Persistent dysfunction: consider alternative diagnosis (ischaemia, myocarditis, takotsubo, pre-existing cardiomyopathy)
References20ShowHide
- [1]Hollenberg SM, Singer M Pathophysiology of sepsis-induced cardiomyopathy Nat Rev Cardiol, 2021.PMID 33473203
- [2]Hunter JD, Doddi M Sepsis and the heart Br J Anaesth, 2010.PMID 19939836
- [3]Parrillo JE, Burch C, Shelhamer JH, et al A circulating myocardial depressant substance in humans with septic shock. Septic shock patients with a reduced ejection fraction have a circulating factor that depresses in vitro myocardial cell performance J Clin Invest, 1985.PMID 4056039
- [4]Sato R, Nasu M A review of sepsis-induced cardiomyopathy J Intensive Care, 2015.PMID 26566443
- [5]Parrillo JE, Parker MM, Natanson C, et al Septic shock in humans. Advances in the understanding of pathogenesis, cardiovascular dysfunction, and therapy Ann Intern Med, 1990.PMID 2197912
- [6]Kakihana Y, Ito T, Nakahara M, et al Sepsis-induced myocardial dysfunction: pathophysiology and management J Intensive Care, 2016.PMID 27011791
- [7]Kumar A, Thota V, Dee L, et al Tumor necrosis factor alpha and interleukin 1beta are responsible for in vitro myocardial cell depression induced by human septic shock serum J Exp Med, 1996.PMID 8642298
- [8]Hasegawa D, Ishisaka Y, Sato R, et al Prevalence and Prognosis of Sepsis-Induced Cardiomyopathy: A Systematic Review and Meta-Analysis J Intensive Care Med, 2023.PMID 37272081
- [9]De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock N Engl J Med, 2010.PMID 20200382
- [10]Antcliffe DB, Santhakumaran S, Orme RML, et al. Levosimendan in septic shock in patients with biochemical evidence of cardiac dysfunction: a subgroup analysis of the LeoPARDS randomised trial Intensive Care Med, 2019.PMID 31428804
- [11]Evans L, Rhodes A, Alhazzani W, et al Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 Intensive Care Med, 2021.PMID 34599691
- [12]Sheyin O, Davies O, Duan W, Perez X The prognostic significance of troponin elevation in patients with sepsis: a meta-analysis Heart Lung, 2015.PMID 25453390
- [13]Monnet X, Marik P, Teboul JL Passive leg raising for predicting fluid responsiveness: a systematic review and meta-analysis Intensive Care Med, 2016.PMID 26825952
- [14]Pandompatam G, Kashani K The role of natriuretic peptides in the management, outcomes and prognosis of sepsis and septic shock Rev Bras Ter Intensiva, 2019.PMID 31618357
- [15]Muehlberg F, Blaszczyk E, Will K, et al. Characterization of critically ill patients with septic shock and sepsis-associated cardiomyopathy using cardiovascular MRI ESC Heart Fail, 2022.PMID 35587684
- [16]Hare JM, Colucci WS Role of nitric oxide in the regulation of myocardial function Prog Cardiovasc Dis, 1995.PMID 7568904
- [17]Parker MM, McCarthy KE, Ognibene FP, et al Right ventricular dysfunction and dilatation, similar to left ventricular changes, characterize the cardiac depression of septic shock in humans Chest, 1990.PMID 2295231
- [18]Parker MM, Shelhamer JH, Bacharach SL, et al Profound but reversible myocardial depression in patients with septic shock Ann Intern Med, 1984.PMID 6703540
- [19]Gajardo AIJ, Ferrière-Steinert S, Valenzuela Jiménez J, et al Early high-sensitivity troponin elevation and short-term mortality in sepsis: a systematic review with meta-analysis Crit Care, 2025.PMID 39953561
- [20]De Backer D, Cecconi M, Chew MS, et al A plea for personalization of the hemodynamic management of septic shock Crit Care, 2022.PMID 36457089