Suffering from a broken heart


Broken Heart Syndrome is an uncommon condition of the heart that can mimic a heart attack.

Can you die from a broken heart? The short answer is yes. The longer answer is that it is very unlikely. Is it common? No, but the actual frequency of this condition probably lies somewhere between rare and uncommon.

Our story begins rather interestingly with a reported case in Japan by Y. J. Akashi of a 70-year-old woman who continued to have chest pain two hours after a particularly emotional quarrel with her neighbours and was subsequently admitted to a hospital.

She presented with symptoms not unlike a heart attack complicated by heart failure. At the emergency room, she was breathless and very anxious. Her heart was going like a freight train. Like most people at this age, she had hypertension and high cholesterol. However, this was the first time she had such chest pains. She did not have any family history of heart disease either, and no one in the family had died suddenly from a heart attack. Her annual medical checkup was normal (she had the usual electrocardiogram).

This is what happened when she was admitted. Her ECG showed that she had some changes suggestive of lack of oxygen to the heart muscle and an echocardiogram (showing the movement of the heart on television) showed that its contraction was weaker in some areas.

At this point, the most obvious diagnosis would be an early heart attack. She quickly underwent a coronary angiogram and surprisingly, had essentially normal coronary vessels. However, the left heart wall was not contracting as well as it should.

During her hospital stay, the patient continued to have chest pain and one day suddenly lost consciousness. Her blood pressure dropped to unrecordable levels and an echocardiogram showed evidence of a ruptured wall of the heart.

This is a grave complication and emergency surgery was performed immediately whereupon the rupture of the cardiac wall was identified. Unfortunately, all efforts at resuscitation were unsuccessful. The patient died three days after admission. This was an actual case reported in a peer-reviewed journal.

Not common

Remember, this is a rare condition, but by all accounts to die from such a rare condition is even more unlikely.

However, it demonstrates a dramatic presentation of this condition. Cardiologists have given it various names, which have included “Transient Left Ventricular Ballooning” (the left ventricle being the main chamber of the heart), “Cardiac Syndrome X”, “Ampulla Cardiomyopathy” and most dramatically “Broken Heart Syndrome” (BHS).

It was first described in 1991 in Japan and it was called “Takotsubo Syndrome” (tako – octopus; tsubo – trap). Some believe that it is not a new disease but that recognition and diagnosis of this condition has increased because of the greater use and availability of cardiac investigations such as echocardiography and coronary angiography, together with biochemical tests.

Elsewhere in the world, various similar cases have been reported as early as the mid-80s. The total number of cases so far number less than 500. A takotsubo is a pot with a round bottom and a narrow neck used for trapping octopus in Japan. The syndrome is called this, because in this condition, the front part, or the apex of the heart, tends to balloon out abnormally, much like the bottle used for catching octopus. The other commonly used terms for this are stress-induced cardiomyopathy (SICM) and apical ballooning syndrome (ABS). It is often only temporary.

Generally this condition tends to occur in women in the older age group (80% are post menopausal). However, it has been recently reported in a paediatric journal as occurring in a 17-year-old girl following a heated argument with her boyfriend. She experienced chest pains two hours after the quarrel and was admitted but was discharged well after one week.

About 90% of all reported cases have been in women and the average age ranges from 58 to 75 years. Only less than 3% of cases are below 50 years of age.

It is still unclear why it mainly affects women but some suggest that lower oestrogen (female hormone) levels, which occurs with menopause, may contribute to this illness.

Usually, the women also have other risk factors for coronary heart disease; in particular hypertension and diabetes. Many of them are short in stature (less than 150 cm) and have a small body surface area (less than 1.9 square metres).

It has also been found to be confined particularly to certain ethnic groups, in particular in Mediterranean as well as in Asian and Jewish groups. A number of cases have been reported in Japan.

The clinical presentation in most patients cannot be distinguished from an early heart attack. About 50 to 60% present with chest pains which have an angina-like quality. Breathlessness may also be the first presenting complaint. A drop in blood pressure may occur because the heart is unable to contract properly.

In 20% of patients, they present with heart failure. About two-thirds of patients have a preceeding emotional or physically stressful event.

Fortunately, this condition generally has a good outcome and only 1 – 2% die from it. After the initial period of heart failure, the patient usually recovers.

Complete recovery is seen in virtually all patients by four to eight weeks. In fact, if the heart failure does not resolve by then, other possible diagnoses should be looked for.

Underlying cause

What causes this condition? Let’s discuss it. It’s called or stress-induced cardiomyopathy or simply stress cardiomyopathy not without a reason. There have been several suggested mechanisms. It is thought that this condition is due to a sudden surge in stress hormones. It is likely there are multiple factors causing and contributing to this condition, one of which may be coronary artery spasm or narrowing.

The other is an abnormality involving the function of the microvessels. Another possible cause is the somewhat abnormal response of the heart muscle and its vessels to increasing levels of stress hormones such as adrenaline and noradrenaline, which may result in “stunning” of the heart muscle.

Stress hormones have evolved over millennia to help us adapt to changing bodily demands. They increase the heart rate and contraction of the heart many times over and pump blood with increased oxygen levels to vital organs including the brain, kidneys and the heart itself. They are important for survival. Their levels fluctuate at various times of the day, gradually rising in the early morning to prepare the body before it wakes up. They also rise during the day in response to anger and pain and any form of stress.

As has been reported above, it can occur after a violent quarrel, during natural disasters and devastating financial losses. Clearly, too much of a good thing is bad. In patients with BHS, this excessive stress hormone surge can also occur because of severe emotional stress such as the death of a loved one, and because of this, it is known as the Broken Heart Syndrome. Some studies have shown that in these patients, the hormone levels may be 20 times higher than those in normal individuals.

What follows is a sudden temporary weakening of the heart muscle. Patients may have chest pain and some ECG changes – not necessarily the typical ECG changes of coronary heart disease. Sometimes, the ECG changes may suggest lack of oxygen to the heart muscle and this is what can confuse the diagnosis.

Patients also have breathlessness and some elevation of cardiac enzymes to suggest a degree of heart muscle damage.

However, classically, the diagnosis of Broken Heart Syndrome must demonstrate the presence of normal or near-normal coronary vessels. There is no evidence of cardiac vessel narrowing or damage.

Despite the dramatic clinical presentation, almost all patients recover fully and the left ventricle contraction, though very poor at presentation, will improve rapidly within a period of days to weeks. The left ventricle function continues to improve over two months.

However, a third of patients have no preceeding stressful event. Again they have normal coronary vessels on investigation. Where then does that leave us? What does this condition teach us and what can we learn from it?

For one thing, in medicine, there are a lot more things that we are still beginning to understand. Coronary artery disease is by far, still the commonest cause of heart failure and heart attacks. My lecturer once said that if there is a bird on a roof-top, it is most likely a crow rather than an eagle; implying that you should make a diagnosis based on a common cause rather than the rare ones. Medical students tend to be fixated on the exotic diagnoses at the expense of the mundane yet commoner ones!

The treatment for Takotsubo cardiomyopathy or Broken Heart Syndrome is generally supportive in nature. Initial management when patients present for the first time to any emergency department with chest pain should be directed towards treating coronary artery disease first as this is invariably the most common diagnosis. They should be treated in the hospital and observed closely with continous ECG monitoring. They are given appropriate lifesaving drugs such as aspirin, heparin, and betablockers, which are drugs used to slow down the heart rate.

Individuals with low blood pressure need drugs to increase the blood pressure and sometimes a small balloon may be inserted into the aorta, called an “intra-aortic balloon pump” to improve the circulation to the heart for a few days. Often the condition gradually improves.

On a lighter note, it would appear that this condition has not escaped the imagination of Hollywood script writers and novelists alike, not least because it is related to stressful, often unexpected bad news! It was mentioned in Wikipedia that in season six, episode four of the television series Scrubs entitled My House, there was a dramatisation about a case of a person who presented with heart failure after her husband’s death and was diagnosed to have Broken Heart Cardiomyopathy!

There is also reference in various literary works related to this condition; for example in Midsomer Murders, one of the characters dies of a (Broken Heart) after six months following news that her son committed suicide.

It is also mentioned in a classic ghost story, The Woman in Black, by Susan Hill, now a famous West End play, where one of the characters dies prematurely soon after the death of her child.

Alas, no one is immune to grief and without doubt, it will continue to exact more of a toll on human emotion rather than human life. Fortunately, for most of us, this is a condition we need not worry about. We first have to stay healthy as best we can.

So, friends, “How do you mend a broken heart?” as the song goes? My parting comment is, if you can’t mend your own, at least try not to break that of your loved ones with your unhealthy lifestyle!


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