A 70-year-old female presents to the emergency department with chest pain. Her husband of 50 years died suddenly earlier in the day. Her pain is described as “severe and intermittent” and is isolated below the sternum. She has no other symptoms and has a normal physical exam. Her work-up revealed an abnormal ECG and significantly elevated troponin, implying injury to the tissues of the heart.
Her initial treatment is focused on intervention for a heart attack, though the ultrasound of her heart and cardiac catheterization show something else.
Takotsubo cardiomyopathy, or “stress-induced cardiomyopathy,” is often referred to as “broken heart syndrome.” The name Takotsubo comes from the Japanese term for “octopus trap,” which resembles the shape of the heart during contraction in those with this condition. On an echocardiogram, the left lower chamber of the heart is seen to balloon out, while the upper chamber remains narrow, creating a shape similar to the pot used in traditional Japanese fishing.
Lots of songs have been written about broken hearts, but new research is showing us how a broken heart can be much more serious than you think. On Valentine’s Day, right in the middle of American Heart Month, we explore the links between emotional health and physical health, and understand the biological underpinnings of how emotional stressors like the loss of a loved one can lead to significant heart disease.
What causes Takotsubo cardiomyopathy?
While the exact cause of Takotsubo cardiomyopathy is not fully understood, the implication for a surge of stress hormones remains strong. Epinephrine (adrenaline), for example, begins a fight-or-flight response following an intense emotional experience and may temporarily stun the heart muscle, leading to dysfunction.
Research into Takotsubo cardiomyopathy suggests additional mechanisms, such as dysregulation of glucose and lipid metabolic pathways, and the existence of a potential genetic link, which remains a focal point for future research.
Emotional stressors, like grief, anxiety, or intense fear can directly influence the activity of the autonomic nervous system, which is responsible for regulating involuntary bodily functions, like heart rate and blood pressure. When the brain perceives a stressful situation, such as the death of a loved one, it triggers the release of stress hormones, which can have a profound effect on the cardiovascular system.
With Takotsubo cardiomyopathy, the brain-heart connection is particularly evident when triggered by strong emotions. The emotional centers in the brain, known as the amygdala and prefrontal cortex, play crucial roles in processing and responding to stress. When activated by an intense emotion, they can send signals to the autonomic nervous system, affecting the heart.
Studies have shown that the brain’s response to stress may also impact the structure and function of the heart over time. Chronic stress, for example, has been associated with an increased risk of developing cardiovascular diseases such as high blood pressure, coronary artery disease, and certain arrhythmias. A constant activation of the stress response leads to inflammation, oxidative stress, and changes in functionality of blood vessels, all of which contribute to heart disease.
The science of a broken heart
The presentation of Takotsubo cardiomyopathy is very similar to acute coronary syndrome and is frequently misdiagnosed. Mayo Clinic’s diagnostic criteria includes a transient regional left ventricle wall dysfunction, new ST changes on ECG or a troponin elevation, the absence of coronary obstruction or angiographic evidence of plaque, and absence of myocarditis or pheochromocytoma, hypertrophic cardiomyopathy, and a recent significant head injury.
Over 90% of reported cases involve women, ages 58 to 75. Research reports that it may be present in 5-7% of postmenopausal women presenting with acute coronary symptoms. In Japan most cases have been diagnosed in men, following physical stress.
Interestingly, Takotsubo cardiomyopathy has increased since the start of the Covid-19 pandemic, reminding us of the heart’s vulnerability not just in matters of health but also relationships. The stress related to social isolation, diagnosis, or as a direct complication of infection are thought to be potential triggers. With a 4-5-fold rise in incidence, the identification of prognostic biomarkers has taken on a renewed interest. The use of biomarkers in chronic cases of Takotsubo syndrome include elevation in Troponin-I, BNP, IL-6, and IL-8, with detectable levels of troponin and BNP being associated with a poorer prognosis in patients with existing heart disease.
There is no specific treatment for broken heart syndrome, and the focus is on managing symptoms such as controlling blood pressure, fluid in the lungs (as a result of transient heart failure), and stress. Initial treatment includes medical therapy with beta-blockers, ACE inhibitors, angiotensin receptor blockers, statins, and antiplatelet medications.
Most of the changes seen on ultrasound will clear up in 1-4 weeks, and those with a complete recovery during this time are at a low risk for recurrence.
American Heart Month
Heart health starts with everyday, proactive actions such as minimizing stressors and taking care of one’s overall physical health. The American Heart Association reminds that “positive psychological health is associated with a lower risk of heart disease and death.” Learn more about biotech advances in heart health, including a promising oral pill from Merck designed to lower bad cholesterol which helps prevent heart disease.
