Can You Die of a Broken Heart?

You've probably heard stories about dying of a broken heart, but is there any truth to them?

You’ve probably heard stories about dying of a broken heart, but is there any truth to them? As it turns out, there is. It’s called takotsubo cardiomyopathy (TCM), and its death rates are similar to those for heart attacks.1

Background

Named after a Japanese word for an octopus trap, TCM is a type of nonischemic cardiomyopathy. Affected patients experience transient weakening of the heart wall, resulting in left ventricular dysfunction and symptoms closely resembling myocardial infarction. Interestingly, TCM can be triggered by emotional stress, earning it the nickname broken-heart syndrome.2

TCM is often characterized by left ventricular apical ballooning upon angiography. Although ST-segment elevation and chest pain are common initial manifestations, TCM is unlike acute coronary syndromes (ACS) in that patients typically present without significant coronary artery disease (CAD).

TCM occurs in approximately 1% to 2% of patients with suspected troponin-positive or ST-segment elevated ACS.2 Furthermore, in a study of 1750 patients, 90% of TCM cases occurred in postmenopausal women.3

TCM (A) versus a normal heart (B)

TCM was first studied in Japan in 1990. Despite numerous case studies describing the condition, it wasn’t considered an established type of cardiomyopathy in the West until 2005.2

Signs and Symptoms

Patients with TCM often present similarly to those with an ACS, making diagnosis challenging. Common symptoms include chest pain (75.9%), dyspnea (46.9%), and syncope (7.7%).3

Because more than 80% of patients with TCM also have elevated troponin and signs of myocardial ischemia on initial electrocardiography, early coronary angiography is necessary to rule out an ACS. Although TCM is considered unrelated to CAD, 15.3% of TCM patients also have evidence of CAD on angiography.3

Cause

Despite being recognized more than 25 years ago, the cause of TCM still isn’t fully understood. One popular theory is that stress induces excessive catecholamine release, resulting in myocardial toxicity or stunning. However, catecholamine excess isn’t uniform across studies. Other theories include microvascular dysfunction and multivessel coronary artery spasm.2

It’s believed TCM is preceded by emotional and physical triggers, but there have been instances of patients without any evident triggers. Despite its nickname, one study showed physical triggers were actually a more common cause of TCM.3

TCM Triggers3

Treatment

To my knowledge, no prospective, randomized, controlled trials have analyzed the therapeutic management of TCM.

Unlike ACS, treatment of TCM is largely supportive in nature. In the emergency department setting, however, it’s recommended that patients be treated as having an ACS until a diagnosis is made.4

Patients presenting with acute congestive heart failure will often receive diuretics, while those with cardiogenic shock often receive inotropes and IV fluids. Intra-aortic balloon pumps have also been used for resuscitation. Beta-blockers and calcium channel blockers may be beneficial in an acute setting, as well.

Although beta-blockers have been used as long-term therapy after TCM episodes, one study reported no survival benefit after 1 year in patients treated with a beta-blocker. However, improved survival at 1 year was seen with angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers.3

Much is still unknown about TCM, and it will be interesting to see how our understanding of this condition evolves in the coming years.

References

  • Bhatt D. “Stress” cardiomyopathy: A different kind of heart attack. Harvard Health Publications. health.harvard.edu/blog/stress-cardiomyopathy-a-different-kind-of-heart-attack-201509038239. Updated October 29, 2015.
  • Reeder G, Prasad A. Clinical manifestations and diagnosis of stress (takotsubo) cardiomyopathy. UptoDate. uptodate.com/contents/clinical-manifestations-and-diagnosis-of-stress-takotsubo-cardiomyopathy. Updated February 4, 2016.
  • Templin C, Ghadri JR, Diekmann J, et al. Clinical features and outcomes of Takotsubo (stress) cardiomyopathy. N Engl J Med. 2015;373(10):929-938.
  • Kurisu S, Inoue I, Kawagoe T, Ishihara M, Shimatani Y, Nakama Y. Incidence and treatment of left ventricular apical thrombosis in takotsubo cardiomyopathy. Int J Cardiol. 2009.
  • Singh K, Carson K, Usmani Z, et al. Systematic review and meta-analysis of incidence and correlates of recurrence of takotsubo cardiomyopathy. Int J Cardiol. 2014;174(3):696-701.
  • Kawai S, Kitabatake A, Tomoike H. Guidelines for diagnosis of takotsubo (ampulla) cardiomyopathy. Circ J. 2007;71(6):990-992.
  • Boland TA, Lee VH, Bleck TP. Stress-induced cardiomyopathy. Crit Care Med. 2015;43 (3):686-693.