ADM and Tako-tsubo cardiomyopathy: ,47 Elevated dipeptidyl dipeptidase-3 and adrenomedullin are associated with impaired cardiac contractility and worse outcomes in patients with CS and sepsis; these biomarkers could contribute to mixed shock and have been proposed as targets for therapy.52, 53, 54, 55 Stress-induced cardiomyopathy (eg, apical ballooning or takotsubo syndrome) can occur during the course of any acute illness, resulting in ventricular systolic dysfunction and a risk of LVOT obstruction.49