A Broken Heart
Happy Valentine’s Day to all of our readers. Did you lavish your sweetheart with flowers, candies, and romantic trinkets? Did you buy her that diamond necklace she’s secretly wanted? Did you surprise him with a romantic candlelight dinner?
As if you didn’t already have enough guilt heaped on you during this highly commercialized holiday, here’s something to add to the list: broken heart syndrome. Yep, you heard right—fail to live up to your romantic obligations and you might just trigger a legitimate cardiac syndrome in your significant other.
Let’s consider an otherwise healthy lady I met last year who came to the emergency department after a day of weakness, increasing shortness of breath, and dull, aching chest discomfort. Her EKG showed changes consistent with a possible heart attack and her initial set of cardiac enzymes was elevated. The ER staff wasted no time transferring her to the cardiac catheterization lab where, to the surprise of all involved, she was found to have normal coronary arteries with no hint of blockage. Injection of the dye into the left ventricle showed poor heart strength with apparent lack of contraction of the lower half of the ventricular chamber.
Because there was no blockage, no stents were needed. Further questioning revealed that the patient’s mother— to whom she was very close — had just passed away and that she had spent the morning attending the funeral. With the constellation of chest pain, normal coronary arteries, and weakening of the heart muscle, a final diagnosis was reached: takotsubo cardiomyopathy, or broken heart syndrome.
Despite the fact that it sounds like I’m making this up, there is indeed a condition where the heart suffers damage from emotional stress. Talk to any cardiologist and he or she will share similar stories of takotsubo cardiomyopathy arising in people after various tragedies: deaths in the family, loss of employment, divorce, bankruptcy. The pattern of apparent heart attack with normal coronary arteries has been around for a while but only recently has this scenario been characterized as a well-described clinical entity.
Numerous terms have been applied to this condition—two variants are apical ballooning syndrome and stress cardiomyopathy—but they all imply the same illness. The term tako tsubo means “octopus trap” in Japanese and was attached to this syndrome when it was first described in 1991, apparently because of the resemblance of the poorly functioning ventricle to submersible traps used to ensnare the eponymous sea life.
The idea that emotional stress can wreak havoc on the cardiovascular system is not new, although scientific evidence to support this notion has been around only recently. A prominent example of the emotion-heart connection is depression, which is known to be a risk factor for heart attacks. What isn’t clear about this relationship is whether treatment for depression provides any protective benefit—most studies on the matter have been disappointingly unfruitful.
Thanks to large databases and mass calamities we know that sudden surges in anxiety can act as an acute trigger of heart attacks. Consider the following (as cited on UpToDate.com):
- During the five days after the 1981 Athens earthquake, the incidence of cardiac deaths rose from the normal average of 2.6 deaths per day to an average of 5.4, with a peak of 8 deaths per day.
- An increased risk of heart attack (nearly two and a half times normal) and cardiovascular death was observed after the 1994 Los Angeles earthquake, which occurred in the early morning, compared to the week before the disaster.
- During the initial eight days after six blizzards in Massachusetts from 1974 to 1978, a 22 percent increase in cardiac deaths per day was reported.
- During the six weeks immediately following the Hanshin-Awaji, Japan earthquake there were 10 cardiovascular or sudden deaths compared to three during the same period in the previous year.
- During the first week of Iraqi missile attacks on Israel in 1991, 20 civilians suffered a heart attack in the area served by one hospital, compared to only eight during a control period.
None of these observational studies were conclusive in themselves, but taken together there appears to be a pretty clear picture that events that increase your level of emotional stress can tax the health of your heart. Most recently a study was published that suggested that even a nail-biter of a Superbowl game can trigger heart attacks in ardent fans. An article in the Omaha World-Herald reminded us of the “perfect storm” of Superbowl Sunday: fatty, salty foods; gallons of beer; a couple hours of screaming and hair pulling (although, admittedly, most championship games I’ve seen were snoozers). A caveat to this report, however, was that the so-called expert quoted in the story is known to have parceled out misleading information on several other occasions.
Of course, there must be an underlying predisposition among people who suffer stress-induced heart attacks—these are patients who are destined to have a coronary event at some point and simply do so in response to whatever activity happens to result in the biggest rise in adrenalin.
Takotsubo cardiomyopathy, on the other hand, can strike apparently healthy people. Why this is the case is not known. It can’t just be the stress alone—if it were, the whole state of Nebraska would be showing up in the emergency room every time the Huskers play Texas. At this point we can only speculate who might be at risk of having their heart assume the shape of an octopus trap whenever tragedy hits. Thankfully, patients with takotsubo generally enjoy a full recovery on appropriate medications and the rate of recurrence is low.
So, do your best not to break any hearts this Valentine’s Day. We’ll all get enough stress once the Husker football season rolls around again.
Very interesting! I worked many years in the ER. and this certainly explains the number of Heart related illness we saw when pts. were under severe emotional duress. Thanks! ... Love your articles!
Dr. Van De Graaff
LKO, Good question. No one knows the answer to your question about the possible link between increased levels of generalized anxiety and future occurrence of takotsubo cardiomyopathy. This abnormality is uncommon enough that it is difficult to draw conclusions about baseline risk factors. Just bear in mind that your chance of suffering this is extremely remote (extremely extremely remote). Hopefully my reassurance will give you one less thing to worry about. Good luck with everything and thanks for the question. Dr. VDG
I am 40 and have coped with Generalized Anxiety Disorder since I was 10. Is there a greater chance of people with GAD experiencing Takotsubo due to the long term stress associated with GAD? Thank you
Dr. Van De Graaff
Vicki, Your story of having this happen twice is pretty disconcerting. I, too, would be concerned about any surgery in the furture. The problem, of course, is that you may not necessarily be able to avoid the need for operations as you age through life. I wouldn't be able to guess what the likelihood is that this would recur but I'd have to assume that the chance is higher in you than in others. I suppose if I were you I'd avoid any non-necessary surgeries (there are a few of those out there) and for any operations I couldn't avoid I'd seek cardiology assessment prior to the OR date. Your doctor may want to minimize your chance of takotsubo by pre-emptively putting you on medications like beta-blockers and ACE-inhibitors. Good luck! Dr. VDG
I followed the link to article of the "so-called expert" that was quoted in the Omaha World Herald. Boy did that make me giggle!! Enjoy reading your blog every week!
I have experienced this condition twice. Both times after surgery. The second time muscle around my heart valve was effected so the recovery was slower. An MRI six weeks after the onset confirmed that their was no damage to the heart muscle. Several cardiologists were consulted the second time. Some doctors were familiar with the condition and some did not believe that it existed. The research on this is limited because it is rare and rarely reoccures. The question for me is if it will happen if I have surgery again. There was no emotional trigger for my occurances. The surgery seemed to be the contributing factor.
Takotsubo...very interesting and i have a great new word for my scrabble repertoire!
Thank you for the good adivice. The beta-blockers and ACE inhibitors are what my cardiologist and internist suggest. Trust me. I will think twice about surgery.
John C. Estabrook
This is a rarefied "Renaissance Man" that dignifies his talents for writing on a regular basis. I refer you to his 11/15/2010 blog that is a LOL moment, that I can't get out of my mind. Given his many talents as a clinician in his field, he is an accomplished Pianist and Cyclist. I know that I am missing something.