Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Pathophysiology of stunned or hibernating myocardium

David M Shavelle, MD
Section Editors
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Jeroen J Bax, MD, PhD
Deputy Editor
Gordon M Saperia, MD, FACC


Left ventricular (LV) dysfunction, an important consequence of coronary artery disease, can result from myocardial ischemia or myocardial infarction [1,2]. In some patients, transient ischemia can lead to a period of persistent dysfunction after the restoration of flow while in others persistent, asymptomatic ischemia produces LV dysfunction that can mimic nonischemic causes of heart failure. The former phenomenon is referred to as myocardial stunning and the latter as hibernating myocardium.

The definitions and pathophysiology of myocardial stunning and hibernation will be reviewed here. The approach to diagnosis and therapy of hibernation, the clinical syndromes associated with stunned or hibernating myocardium, the role of nuclear imaging, dobutamine echocardiography, and cardiac magnetic resonance imaging to assess myocardial viability are discussed elsewhere. (See "Evaluation of hibernating myocardium" and "Clinical syndromes of stunned or hibernating myocardium" and "Assessment of myocardial viability by nuclear imaging in coronary heart disease" and "Dobutamine stress echocardiography in the evaluation of hibernating myocardium".)


Hibernating myocardium must be distinguished from the stunned myocardium and from transient left ventricular (LV) dysfunction that is a result of ischemia induced by stress (eg, exercise, dobutamine). However, hibernating myocardium can coexist with both conditions.

Stunned myocardium — “Stunned myocardium” was the term initially used to describe a condition demonstrated in the laboratory in which total coronary artery occlusion lasting only 5 to 15 minutes (a period not associated with cell death) produced an abnormality in regional LV wall motion that persisted for hours or days following reperfusion [3-7]. Thus, the key elements of the stunned myocardium are:

Short-term, total, or near total reduction of coronary blood flow

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Dec 05, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Rahimtoola SH. The hibernating myocardium in ischaemia and congestive heart failure. Eur Heart J 1993; 14 Suppl A:22.
  2. Opie LH. The ever expanding spectrum of ischemic left ventricular dysfunction. Cardiovasc Drugs Ther 1994; 8 Suppl 2:297.
  3. Heyndrickx GR, Millard RW, McRitchie RJ, et al. Regional myocardial functional and electrophysiological alterations after brief coronary artery occlusion in conscious dogs. J Clin Invest 1975; 56:978.
  4. Heyndrickx GR, Baig H, Nellens P, et al. Depression of regional blood flow and wall thickening after brief coronary occlusions. Am J Physiol 1978; 234:H653.
  5. Braunwald E, Kloner RA. The stunned myocardium: prolonged, postischemic ventricular dysfunction. Circulation 1982; 66:1146.
  6. Marban E. Myocardial stunning and hibernation. The physiology behind the colloquialisms. Circulation 1991; 83:681.
  7. Bolli R. Myocardial 'stunning' in man. Circulation 1992; 86:1671.
  8. Gerber BL, Wijns W, Vanoverschelde JL, et al. Myocardial perfusion and oxygen consumption in reperfused noninfarcted dysfunctional myocardium after unstable angina: direct evidence for myocardial stunning in humans. J Am Coll Cardiol 1999; 34:1939.
  9. Braunwald E, Rutherford JD. Reversible ischemic left ventricular dysfunction: evidence for the "hibernating myocardium". J Am Coll Cardiol 1986; 8:1467.
  10. Rahimtoola SH. The hibernating myocardium. Am Heart J 1989; 117:211.
  11. Schulz R, Guth BD, Pieper K, et al. Recruitment of an inotropic reserve in moderately ischemic myocardium at the expense of metabolic recovery. A model of short-term hibernation. Circ Res 1992; 70:1282.
  12. Bolukoglu H, Liedtke AJ, Nellis SH, et al. An animal model of chronic coronary stenosis resulting in hibernating myocardium. Am J Physiol 1992; 263:H20.
  13. Schulz R, Rose J, Martin C, et al. Development of short-term myocardial hibernation. Its limitation by the severity of ischemia and inotropic stimulation. Circulation 1993; 88:684.
  14. Downing SE, Chen V. Acute hibernation and reperfusion of the ischemic heart. Circulation 1992; 85:699.
  15. Bristow JD, Arai AE, Anselone CG, Pantely GA. Response to myocardial ischemia as a regulated process. Circulation 1991; 84:2580.
  16. Selvanayagam JB, Jerosch-Herold M, Porto I, et al. Resting myocardial blood flow is impaired in hibernating myocardium: a magnetic resonance study of quantitative perfusion assessment. Circulation 2005; 112:3289.
  17. Tillisch J, Brunken R, Marshall R, et al. Reversibility of cardiac wall-motion abnormalities predicted by positron tomography. N Engl J Med 1986; 314:884.
  18. Cabin HS, Clubb KS, Vita N, Zaret BL. Regional dysfunction by equilibrium radionuclide angiocardiography: a clinicopathologic study evaluating the relation of degree of dysfunction to the presence and extent of myocardial infarction. J Am Coll Cardiol 1987; 10:743.
  19. Knight C, Fox K. The vicious circle of ischemic left ventricular dysfunction. Am J Cardiol 1995; 75:10E.
  20. Bortman G, Sellanes M, Odell DS, et al. Discrepancy between pre- and post-transplant diagnosis of end-stage dilated cardiomyopathy. Am J Cardiol 1994; 74:921.
  21. Gerber BL, Rousseau MF, Ahn SA, et al. Prognostic value of myocardial viability by delayed-enhanced magnetic resonance in patients with coronary artery disease and low ejection fraction: impact of revascularization therapy. J Am Coll Cardiol 2012; 59:825.
  22. Marinho NV, Keogh BE, Costa DC, et al. Pathophysiology of chronic left ventricular dysfunction. New insights from the measurement of absolute myocardial blood flow and glucose utilization. Circulation 1996; 93:737.
  23. Vanoverschelde JL, Wijns W, Depré C, et al. Mechanisms of chronic regional postischemic dysfunction in humans. New insights from the study of noninfarcted collateral-dependent myocardium. Circulation 1993; 87:1513.
  24. Vanoverschelde JL, Wijns W, Borgers M, et al. Chronic myocardial hibernation in humans. From bedside to bench. Circulation 1997; 95:1961.
  25. Shivalkar B, Flameng W, Szilard M, et al. Repeated stunning precedes myocardial hibernation in progressive multiple coronary artery obstruction. J Am Coll Cardiol 1999; 34:2126.
  26. Fallavollita JA, Canty JM Jr. Differential 18F-2-deoxyglucose uptake in viable dysfunctional myocardium with normal resting perfusion: evidence for chronic stunning in pigs. Circulation 1999; 99:2798.
  27. Kim SJ, Peppas A, Hong SK, et al. Persistent stunning induces myocardial hibernation and protection: flow/function and metabolic mechanisms. Circ Res 2003; 92:1233.
  28. Ross J Jr. Myocardial perfusion-contraction matching. Implications for coronary heart disease and hibernation. Circulation 1991; 83:1076.
  29. Gallagher KP. Myocardial hibernation in terms of the flow-function relationship. Basic Res Cardiol 1995; 90:12.
  30. Geft IL, Fishbein MC, Ninomiya K, et al. Intermittent brief periods of ischemia have a cumulative effect and may cause myocardial necrosis. Circulation 1982; 66:1150.
  31. Ausma J, Cleutjens J, Thoné F, et al. Chronic hibernating myocardium: interstitial changes. Mol Cell Biochem 1995; 147:35.
  32. Ausma J, Fürst D, Thoné F, et al. Molecular changes of titin in left ventricular dysfunction as a result of chronic hibernation. J Mol Cell Cardiol 1995; 27:1203.
  33. Borgers M, Thone F, Wouters L, et al. Structural correlates of regional myocardial dysfunction in patients with critical coronary artery stenosis: Chronic hibernation. Cardiovasc Pathol 1993; 2:237.
  34. Depré C, Vanoverschelde JL, Melin JA, et al. Structural and metabolic correlates of the reversibility of chronic left ventricular ischemic dysfunction in humans. Am J Physiol 1995; 268:H1265.
  35. Ausma J, Schaart G, Thoné F, et al. Chronic ischemic viable myocardium in man: Aspects of dedifferentiation. Cardiovasc Pathol 1995; 4:29.
  36. Schwarz ER, Schaper J, vom Dahl J, et al. Myocyte degeneration and cell death in hibernating human myocardium. J Am Coll Cardiol 1996; 27:1577.
  37. Scognamiglio R, Ponchia A, Fasoli G, et al. Exercise-induced left ventricular dysfunction in coronary heart disease. A model for studying the stunned myocardium in man. Eur Heart J 1991; 12 Suppl G:16.
  38. Kloner RA, Allen J, Cox TA, et al. Stunned left ventricular myocardium after exercise treadmill testing in coronary artery disease. Am J Cardiol 1991; 68:329.
  39. Homans DC, Laxson DD, Sublett E, et al. Cumulative deterioration of myocardial function after repeated episodes of exercise-induced ischemia. Am J Physiol 1989; 256:H1462.
  40. Murry CE, Jennings RB, Reimer KA. Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium. Circulation 1986; 74:1124.
  41. Ito BR. Gradual onset of myocardial ischemia results in reduced myocardial infarction. Association with reduced contractile function and metabolic downregulation. Circulation 1995; 91:2058.
  42. Thielmann M, Kottenberg E, Kleinbongard P, et al. Cardioprotective and prognostic effects of remote ischaemic preconditioning in patients undergoing coronary artery bypass surgery: a single-centre randomised, double-blind, controlled trial. Lancet 2013; 382:597.
  43. Hoole SP, Heck PM, Sharples L, et al. Cardiac Remote Ischemic Preconditioning in Coronary Stenting (CRISP Stent) Study: a prospective, randomized control trial. Circulation 2009; 119:820.
  44. Chen C, Ma L, Linfert DR, et al. Myocardial cell death and apoptosis in hibernating myocardium. J Am Coll Cardiol 1997; 30:1407.
  45. Elsässer A, Schlepper M, Klövekorn WP, et al. Hibernating myocardium: an incomplete adaptation to ischemia. Circulation 1997; 96:2920.
  46. Kaprielian RR, Gunning M, Dupont E, et al. Downregulation of immunodetectable connexin43 and decreased gap junction size in the pathogenesis of chronic hibernation in the human left ventricle. Circulation 1998; 97:651.
  47. Schwarz ER, Schoendube FA, Kostin S, et al. Prolonged myocardial hibernation exacerbates cardiomyocyte degeneration and impairs recovery of function after revascularization. J Am Coll Cardiol 1998; 31:1018.
  48. Anversa P, Zhang X, Li P, Capasso JM. Chronic coronary artery constriction leads to moderate myocyte loss and left ventricular dysfunction and failure in rats. J Clin Invest 1992; 89:618.
  49. Capasso JM, Jeanty MW, Palackal T, et al. Ventricular remodeling induced by acute nonocclusive constriction of coronary artery in rats. Am J Physiol 1989; 257:H1983.
  50. Schulz R, Heusch G. Characterization of hibernating and stunned myocardium. Eur Heart J 1995; 16 Suppl J:19.
  51. Heusch G, Rose J, Skyschally A, et al. Calcium responsiveness in regional myocardial short-term hibernation and stunning in the in situ porcine heart. Inotropic responses to postextrasystolic potentiation and intracoronary calcium. Circulation 1996; 93:1556.
  52. Shimonagata T, Nanto S, Kusuoka H, et al. Metabolic changes in hibernating myocardium after percutaneous transluminal coronary angioplasty and the relation between recovery in left ventricular function and free fatty acid metabolism. Am J Cardiol 1998; 82:559.
  53. Schulz R, Rose J, Post H, Heusch G. Regional short-term myocardial hibernation in swine does not involve endogenous adenosine or KATP channels. Am J Physiol 1995; 268:H2294.
  54. Shan K, Bick RJ, Poindexter BJ, et al. Altered adrenergic receptor density in myocardial hibernation in humans: A possible mechanism of depressed myocardial function. Circulation 2000; 102:2599.