Septic Cardiomyopathy: Occult Myocardial Depression Within a Hyperdynamic Circulatory State. A Narrative Review

Abstract

Septic cardiomyopathy is an acute and potentially reversible cardiovascular dysfunction associated with sepsis. It may remain clinically concealed by vasoplegia, which reduces afterload and may preserve a normal or hyperdynamic ejection fraction despite underlying depression of myocardial contractility. Its pathophysiology involves systemic inflammation, mitochondrial dysfunction, oxidative and nitrosative stress, endothelial and glycocalyx injury, disturbances in intracellular calcium handling, and β-adrenergic desensitisation. It may present as left ventricular hyperdynamic function, systolic or diastolic dysfunction, right ventricular injury, or biventricular involvement. Ejection fraction alone is insufficient for diagnosis. Assessment should integrate loading conditions, stroke volume, left ventricular outflow tract velocity–time integral, tissue Doppler imaging, global longitudinal strain, right ventricular function, and haemodynamic evolution. Cardiac troponins and natriuretic peptides provide prognostic information but lack diagnostic specificity. Septic cardiomyopathy therefore requires serial, multiparametric assessment. Management should be individualised according to the predominant cardiovascular phenotype, prioritising infection control, adequate tissue perfusion, and the judicious use of fluids, vasopressors, and inotropes.