Takotsubo Cardiomyopathy: Broken-Heart Syndrome

We've all probably heard the story of a couple, married many decades, one dies and within days the other dies - death by heartbreak. I wrote about heartbreak and the phenomenon of it causing quite literal physical pain within the body, so that Ibuprofen can help relieve grief. What is a rather new concept to me though is Takotsubo Cardiomyopathy, which is actual electrocardiogram abnormalities and abnormalities in the left ventricle as a result of heartbreak.

This diagnosis is almost exclusive to women, with 90 percent happening to women who are beyond menopause (Prasad et al., 2008). Years of gender-based research has taught us that when it comes to heart health, sex differences matter. One striking example is the temporary heart condition known as takotsubo cardiomyopathy, also known as broken-heart syndrome, first described in 1990 in Japan. More than 90 percent of reported cases are in women ages 58 to 75. Research suggests that up to 5 percent of women suspected of having a heart attack actually have this disorder, which is indistinguishable from a myocardial infarction. Most people recover with no long-term heart damage.

Takotsubo cardiomyopathy is a weakening of the left ventricle, the heart's main pumping chamber, usually as the result of severe emotional or physical stress, such as a sudden illness, the loss of a loved one, a serious accident, or a natural disaster such as an earthquake. The main symptoms are chest pain and shortness of breath after severe stress (emotional or physical), but as mentioned, abnormalities that mimic a heart attack can be seen on an electrocardiogram (Prasad et al., 2008). This is acute systolic heart failure. There is no evidence of coronary artery obstruction, but there is movement abnormalities in the left ventricle and ballooning of the left ventricle. There may also be rales in the lungs, a S3 gallop in the heart, venous distention in the jugulars, an elevated heart rate, low blood pressure, narrow pulse pressure, and a systolic ejection murmur. Elevation in cardiac biomarkers can also be seen, such as with the troponin, creatine kinase-myocardial band, and B-type natriuretic peptide. Typically these individuals are fully recovered within a month's time.

Not just hysteria anymore. Serious illnesses, surgery, severe pain, a sudden drop in blood pressure, an asthma attack - all potential scenarios that may instigate broken-heart syndrome. Domestic violence as well, an unexpected loss, a fierce argument, significant financial loss, and even receiving devastating news are other causes. Yes, even public speaking, a surprise birthday part, or an intense fear can create that initial trigger. More recently, case reports have also described women with Takotsubo cardiomyopathy associated with levothyroxine over-replacement, which unfortunately many utilize to increase weight loss (Balsa et al., 2017).

Seemingly an Acute Myocardial Infarction

This diagnosis is often made when an individual with suspected acute myocardial infarction is found at cardiac catheterization to have no coronary blockage (Prasad et al., 2008). Symptoms are similar to a MI, with positive cardiac biomarkers and an abnormal electrocardiogram, but even after admission and monitoring in the intensive care unit, no coronary blockage is identified.

Initially, women should be treated as if this is an acute coronary event, with management directed towards the treatment of myocardial ischemia with continuous ECG monitoring, administration of aspirin, intravenous heparin, and beta-blockers (Prasad et al., 2008). Treatment is usually provided inpatient via cardiology and is typically supportive until function spontaneously returns, but that may take 21 to 30 days. Diuretics and vasodilators are often utilized for pulmonary congestions, and ACE inhibitors, angiotensin II receptor blockers or beta-blockers are used to reduce workload and to control blood pressure. Once the diagnosis is made, aspirin can be discontinued unless there is coexisting coronary atherosclerosis.

This is such a uniform finding that an alternative diagnosis should be considered in those whose cardiomyopathy does not resolve (Prasad et al., 2008). Generally though, prognosis is very good, and this scenario repeats in less than 10%.

And now you know.

References

Balsa, A. M., Ferreira, A. R., Alves, M., & Guimaraes, J. (2017). Takotsubo cardiomyopathy associated with levothyroxine over-replacement. European Endocrinology, 13(1), 30-32.

Prasad. A., Lerman, A., & Rihal, C. S. (2008). Apical ballooning syndrome (tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. American Heart Journal, 155(3), 408-417.