What is Mid-Ventricular Takotsubo Cardiomyopathy (Broken Heart Syndrome)?
Takotsubo Cardiomyopathy is a treatable heart condition, first discovered in Japan in the 1990s. It affects mainly women after menopause who have experienced severe emotional or physical stress. People with this disease present symptoms similar to a heart attack, such as chest pain. However, an examination of the arteries using angiography (imaging to see blood vessels) shows no blockages, which are common in actual heart attacks.
This condition can take on different forms over time and is often categorized into two categories.
Typical Variant:
This is the most common form of Takotsubo Cardiomyopathy, which involves the lower part or ‘apex’ of the left ventricle – the main pumping chamber of the heart, stretching at the time of contraction. This expanding or ‘ballooning’ happens while the upper or ‘basal’ parts of the heart likely contract too much.
Atypical Variants:
This form involves various parts of the heart including the basal, ‘mid-ventricular’ (middle heart chambers), ‘biventricular’ (both left and right ventricles), and ‘global’ variants. In these forms, other parts stretch at contraction instead of just the apex of the left ventricle.
What Causes Mid-Ventricular Takotsubo Cardiomyopathy (Broken Heart Syndrome)?
Mid-ventricular Takotsubo cardiomyopathy is a heart condition that can be sparked off by a variety of causes. However, the exact way this works is still not completely understood. Currently, there are two major categories of triggers: physical and emotional, both of which contribute to the development of this heart condition.
Here are some examples of these triggers:
Emotional triggers can be events that cause extreme stress, like:
- The death of a family member
- Sudden bankruptcy
- Going through a divorce
- Losing a job
On the other hand, physical triggers can be severe health events, such as:
- A stroke
- Sepsis, which is a serious infection that affects your whole body
- Giving birth vaginally
- Receiving chemotherapy treatment for cancer
Risk Factors and Frequency for Mid-Ventricular Takotsubo Cardiomyopathy (Broken Heart Syndrome)
Takotsubo cardiomyopathy, a heart condition, is estimated to be the reason behind 2% of ST-elevation myocardial infarction — a type of severe heart attack — patients. This condition tends to predominantly impact post-menopausal women, making up about 90% of these cases. The death rate for patients of this heart condition while in hospital is about 1.1%, and a recurrence of the condition is seen in about 3.5% of these patients. The mid-ventricular form of Takotsubo cardiomyopathy, which is a rarer variation that causes the middle section of the heart to balloon and the tip/bottom parts to overwork is found in about 14.6% of patients with this condition.
Signs and Symptoms of Mid-Ventricular Takotsubo Cardiomyopathy (Broken Heart Syndrome)
Mid-ventricular Takotsubo cardiomyopathy, a variant of Takotsubo syndrome, often presents in the same way as a heart attack. Symptoms can include chest pain, changes visible on an electrocardiogram (ECG), and elevated heart enzymes indicating damage to the heart muscle. This condition is often prompted by a high-stress event in the person’s life.
An accurate account of recent events in the patient’s life is crucial, as stressors such as the death of a family member, a natural disaster, discovering a new medical condition, divorce, significant gambling loss, or bankruptcy could trigger this syndrome.
In studies from the International Takotsubo Registry, about 28% of patients suffering from this kind of Takotsubo cardiomyopathy or any related variant reported some kind of emotional triggering event. In contrast, about 36% experienced a physical trigger like an infection or respiratory failure. Interestingly, approximately 8% reported both physical and emotional triggers, and around 28.5% did not identify any specific emotional or physical triggering event.
Testing for Mid-Ventricular Takotsubo Cardiomyopathy (Broken Heart Syndrome)
When testing for a specific type of heart condition called stress cardiomyopathy, doctors typically use a test called an electrocardiogram. The electrocardiogram looks for something called “ST-segment elevation.” This condition, which most often affects the front part of your heart, is found in about 44% of patients with any kind of Takotsubo cardiomyopathy. Other, less common findings may include ST-segment depression, abnormal waves, and T wave inversion.
It’s also typical to see a change in what are called cardiac enzymes. These enzymes, which can be measured with a simple blood test, can help doctors diagnose and monitor heart conditions. Most patients with this condition have higher than normal amounts of these enzymes.
There was a case where a seventy-seven-year-old woman came to the hospital with chest pain. Changes in her electrocardiogram suggested that there was a lack of oxygen in the front, left part of her heart. Additionally, her cardiac enzyme levels were high. She went through two more tests: a left heart catheterization, which checks for heart problems by looking at blood in the arteries, and a transthoracic echocardiogram, which uses sound waves to create a picture of the heart. Both tests showed patterns consistent with mid-ventricular takotsubo cardiomyopathy, a type of heart muscle disease.
Treatment Options for Mid-Ventricular Takotsubo Cardiomyopathy (Broken Heart Syndrome)
Takotsubo cardiomyopathy is a temporary heart condition that we typically manage with supportive care. The first step in treating this condition involves reducing both physical and emotional stress, as these lead to your symptoms. In some cases, the condition can escalate to cause acute congestive heart failure, and in severe cases, cardiogenic shock, which is a state where your heart can’t pump enough blood to meet your body’s needs. At this point, we follow standard treatment guidelines for heart failure and shock.
In these serious situations, it is crucial to check if there is any obstruction in the left ventricular outflow tract (LVOT), a pathway from which blood exits the heart. An obstruction here could worsen the patient’s condition, and hence, we aim to avoid therapies that can decrease the amount of blood in your vessels or widen them, as these can increase the chances of LVOT obstruction. To identify any obstruction early on, we perform a non-invasive heart imaging test called a transthoracic echocardiogram.
A subtype of this condition, mid-ventricular Takotsubo cardiomyopathy, presents an additional risk of forming a blood clot within the heart chambers due to severe dysfunction of the left ventricle, a key pumping chamber in the heart. Approximately 1% to 1.5% of individuals with any type of stress-induced heart conditions, including mid-ventricular cardiomyopathy, were found to have a blood clot in the left ventricle in a significant study. To manage patients with blood clots in this region, warfarin, an anticoagulant or blood-thinning medication, is generally used for about three months. The duration of this treatment can vary depending on how quickly the left ventricle’s function improves and the blood clot dissolves.
What else can Mid-Ventricular Takotsubo Cardiomyopathy (Broken Heart Syndrome) be?
If a mid-ventricular Takotsubo cardiomyopathy is suspected in a patient, the first step is to confirm it’s not a heart disease – known as acute coronary syndrome – by conducting a coronary angiography test. This test gives a picture of the heart’s arteries and can reveal any significant diseases impacting the heart’s walls. Occasionally, the test might show some obstructive coronary artery disease, which isn’t responsible for the heart’s abnormal movement.
The other medical conditions that should be considered in such patients are:
- An acute coronary syndrome triggered by use of cocaine
- Myocarditis – an inflammation of the heart muscle
- An acute brain injury incident in patients with pheochromocytoma – a rare tumour of adrenal gland tissue
A comprehensive medical history, physical exam, and toxicology tests can help point to a correct diagnosis. Myocarditis, for instance, can be diagnosed using a cardiac magnetic resonance imaging test that shows inflammation and scar on the heart muscle. In pheochromocytoma, patients typically show symptoms like rapid heartbeat, high blood pressure, excessive sweating, and headaches.
What to expect with Mid-Ventricular Takotsubo Cardiomyopathy (Broken Heart Syndrome)
Patients who have a condition known as mid-ventricular Takotsubo cardiomyopathy usually get better through careful management and attention to their health. In case you’re wondering, this condition affects a part of the heart known as the left ventricle. If patients make it through the initial stage of the syndrome, they typically regain normal heart function, specifically measured by the left ventricle ejection fraction, within a month.
Possible Complications When Diagnosed with Mid-Ventricular Takotsubo Cardiomyopathy (Broken Heart Syndrome)
Patients with a heart condition called mid-ventricular Takotsubo cardiomyopathy have about the same risk of complications while in the hospital as those suffering from acute coronary syndrome, another heart issue. These complications can include the need for CPR, ventilatory therapy (breathing assistance), shocks to the heart, and receiving adrenaline-like medication, collectively, these complications are experienced by approximately 19% of these patients.
Main Complications:
- Need for CPR
- Requiring ventilatory therapy (help with breathing)
- Cardiogenic shock (when your heart can’t pump enough blood)
- Requirement to receive adrenaline-like medication
Preventing Mid-Ventricular Takotsubo Cardiomyopathy (Broken Heart Syndrome)
If possible, patients should be given educational materials that they are comfortable with, such as online resources or informational booklets. This way they can better understand their condition and treatment.
