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Broken Heart Syndrome

Cara DiMasi, NP

Ahhh February, the month of love!  And with love, occasionally comes heartbreak. With February being American Heart Month, it’s a perfect time to discuss “Broken Heart Syndrome,” also known as Takotsubo Cardiomyopathy (TCM).

Takotsubo Cardiomyopathy (also referred to as stress cardiomyopathy and apical ballooning syndrome, in addition to broken heart syndrome), is a temporary condition where the heart’s left ventricle (main pumping chamber) changes shape and gets larger, leaving the heart muscle weaker and unable to pump blood as efficiently.  This usually occurs in the setting of emotional or physical stress.

This syndrome was first described in Japan by Dote and company around 1990.  The term “takotsubo” refers to a Japanese fishing pot with a narrow-neck used to catch octopus.  Takotsubo is used due to the similarities in the shape of the fishing pot and the shape the left ventricle takes on with TCM [1].

Stressors

Stressors that can induce TCM are vast.  Personally, I have seen triggers range from the death of a husband, to a fierce argument, to the death of a beloved pet.  Other stressors can include serious illness, surgery, severe pain, domestic violence, receiving devastating news (i.e. cancer diagnosis), accident, financial loss, etc.  Stressors aren’t always necessarily bad. Think news that you just won the lottery or walked into a surprise party thrown for you.  Sometimes there is no particular stressor identified at all [9].

What causes TCM?

The exact cause of TCM is unknown, but experts theorize that surging stress hormones responsible for the “fight or flight response” can "stun" the heart.  This stunning causes changes in the heart muscle that prevent the left ventricle from squeezing effectively [6]. 

Who gets it?

Around 90% of cases occur in post-menopausal women (age range 58-75).  Research shows that up to 5% of women who are initially thought to be having a heart attack instead have TCM.  Studies have shown that Takotsubo occurs in about 28% of ICU patients due to severe physical stress [5].  Interestingly, in Japan, this syndrome is more common in men, which usually develops following physical stress [4].

Recently, Cleveland Clinic researchers performed a study which found a significant increase in TCM during the COVID-19 pandemic, showing an incidence of 7.8% compared with pre-pandemic incidence of 1.7%.  All of the patients diagnosed with Takotsubo in this study tested negative for COVID-19 [3]. This shows that the pandemic has taken a toll on the population, not just due to the infection of COVID-19 itself, but due to the pandemic’s increase of  multiple stressors ranging from financial stress to emotional stress, and isolation, just to name a few. 

Symptoms & Presentation

The presentation of TCM is almost identical to a heart attack.  The most common symptoms on presentation include chest pain, shortness of breath, and dizziness.  Complaints of weakness also occur, along with reports of syncope (passing out). 

ECGs can show changes that include ST-segment elevation, T-wave inversion, and/or prolongation of the QT interval, although these findings can vary.  There can be a normal ECG on presentation up to 15% of the time [10]. Lab work can show elevated levels of cardiac biomarkers (troponin, BNP). 

An echocardiogram (ultrasound of the heart), can show decreased function of the heart (ejection fraction), with movement abnormalities of the heart walls of the left ventricle.  The typical pattern is apical ballooning of the left ventricle, but there are also variant patterns (mid-ventricular, basal, focal, and global). There are reports that the right ventricle can also be affected [6].

Diagnosis

Diagnostic criteria for TCM was initially introduced by Mayo Clinic researchers in 2004 (later updated to the Revised Mayo Clinic diagnostic criteria).  In order for a definitive diagnosis to occur, patients are brought to the cardiac catheterization lab, where a coronary angiography is performed.  If there is no evidence of blockages in the coronary arteries or plaque rupture, along with other evidence that includes elevated cardiac biomarkers, ECG changes, abnormal echocardiogram imaging, and no evidence of myocarditis (inflammation of the heart muscle) or pheochromocytoma (rare tumor of the adrenal gland); the suspicion for TCM can be confirmed.  We need to keep in mind that newer international diagnostic criteria has been developed   (International Takotsubo Diagnostic Criteria) that notes significant coronary artery disease is not necessarily a contradiction to the diagnosis of TCM [4].

Treatment

Because TCM presents so similar to a heart attack, it’s usually treated as such until proven otherwise.  Once the diagnosis is made, treatment is mainly supportive.  Since there’s no standard treatment for TCM, therapy is adapted to the patient’s clinical presentation.  Clinicians typically recommend standard heart failure medications, like beta blockers, ACE inhibitors, and diuretics.  ECGs are monitored for QT prolongation, along with stopping all QT prolonging medications and repleting electrolytes, as this could trigger a bad heart rhythm.  “Blood thinners” (warfarin, coumadin, etc.) are used in patients with left ventricular thrombus (clot) or in patients with severely reduced heart function at risk for a thrombus [11].

Approximately 5-10% of patients develop cardiogenic shock, requiring ICU level of support with specialized monitoring, medication drips (inotropes or vasopressors), or even mechanical circulatory support (balloon pump) [7].

One of the most important parts of treatment is removing the emotional or physical stressor that triggered the syndrome.  A follow-up echocardiogram is performed to confirm the resolution of heart muscle abnormalities. Regarding long term medical therapy, there’s not much evidence available at this time that provides guidance on how long to continue or when to stop medicines.

Prognosis

Ready for some good news? 95% of patients recover full heart function within several weeks, with most of the abnormalities clearing up in one to four weeks, and with full recovery within two months [11].

On the flip side, TCM can happen again, with some studies showing a recurrence rate of 4% [2].  Despite the typical recovery of heart function, recent research has shown that TCM can have a poor outcome.  Heart failure occurs in about 20% of patients, with more rare complications including abnormal heart rhythms, obstruction of blood flow from the left ventricle, and rupture of the heart wall [8].  Although death is rare, mortality rates have been shown to be similar to those in patients suffering from heart attacks [9]. 

Relax. Slow down. Take a deep breath.

As we move through American Heart Month this February, remember that it is just as important to learn how to reduce stress in our everyday lives.  This rings especially true over the past year, where the pandemic has loomed over our heads every single day.  Take time to reduce stress and find balance in your personal lives, work lives, and help decrease stress in the lives of your friends or family.  Exercise, meditate, find safe ways to socialize, and remember to take time for yourself.  When you need help or feel overwhelmed, reach out to others for assistance.  We need self-care more than ever during these challenging days.  Unplug. Unwind. Stay positive. Keep that heart healthy.   

Resources:

1. Akashi, Y.J., Goldstein, D.S., Barbaro, G., Ueyama,T. Takotsubo Cardiomyopathy A New Form of Acute, Reversible Heart Failure. Circulation. 2008;118:2754-2762. 

https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.108.767012#:~:text=Researchers%20at%20the%20Mayo%20Clinic,beyond%20a%20single%20epicardial%20vascular

2. El‐Battrawy, I.,Santoro, F., Stiermaier, T., Möller, C., Guastafierro, F., Novo, G., et al. (2019, May 3). Incidence and Clinical Impact of Recurrent Takotsubo Syndrome: Results From the GEIST Registry. Journal of the American Heart Association, 8 (9). https://www.ahajournals.org/doi/10.1161/JAHA.118.010753

3. Jabri, A., Kalra, A., Ashish, K.,  et al. (2020). Incidence of Stress Cardiomyopathy During the Coronavirus Disease 2019 Pandemic. JAMA Network Open, 3 (7): e2014780 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2768093

4. Ghadri JR, Wittstein IS, Prasad A, et al. (2018, June 7). International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology, European Heart Journal, Volume 39, Issue 22, Pages 2032–2046, https://academic.oup.com/eurheartj/article/39/22/2032/5025412

5. Park JH, Kang SJ, Song JK, et al. (2005). Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU. Chest, 128:296-302. https://pubmed.ncbi.nlm.nih.gov/16002949/

6. Reeder, G. & Prasad, A. (2019).Clinical manifestations and diagnosis of stress (takotsubo) cardiomyopathy. In W.J. McKenna & S. B. Yeon (Eds.). UpToDate. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-stress-takotsubo-cardiomyopathy#H4

7. Reeder, G. & Prasad, A. (2020).Management and prognosis of stress (takotsubo) cardiomyopathy. In W.J. McKenna & S. B. Yeon (Eds.). UpToDate. https://www.uptodate.com/contents/management-and-prognosis-of-stress-takotsubo-cardiomyopathy?search=takotsubo%20cardiomyopathy&source=search_result&selectedTitle=2~105&usage_type=default&display_rank=2#H607855250  

8. Takotsubo cardiomyopathy (broken-heart syndrome). (2020, January 29). https://www.health.harvard.edu/heart-health/takotsubo-cardiomyopathy-broken-heart-syndrome

9. Templin, C., Ghadri, J. R., Diekmann, J., Napp, L.C., Bataiosu, D. R., Jaguszewski, M., et al. (2015, September 3). Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. New England Journal of Medicine,  2015; 373:929-938 DOI: https://www.nejm.org/doi/full/10.1056/nejmoa1406761

10. Tomich, E.B. (2019, July 31). What is the role of ECG in the diagnosis of takotsubo (stress) cardiomyopathy (broken heart syndrome)? E.D. Schraga (Ed.). Medscape. https://www.medscape.com/answers/1513631-56498/what-is-the-role-of-ecg-in-the-diagnosis-of-takotsubo-stress-cardiomyopathy-broken-heart-syndrome

11. Webb, S. R. (2020, March 30). Takotsubo Cardiomyopathy. American College of Cardiology. https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2020/03/30/12/17/takotsubo-syndrome