What is Takotsubo Cardiomyopathy (Broken Heart Syndrome)?
Takotsubo cardiomyopathy, also known as transient apical ballooning syndrome, stress-induced cardiomyopathy, or even “broken heart syndrome”, is a unique type of non-blood flow related heart muscle disease. It is mainly seen in women who have gone through menopause. This condition is defined by a temporary change in the normal pumping function of a part of the left main heart chamber (ventricle) due to stress and without a blockage of the heart arteries.
Unlike other heart diseases, in most cases of takotsubo cardiomyopathy, the unusual pumping function isn’t limited to the area supplied by one specific heart artery, it goes beyond. Takotsubo is actually a Japanese word for an octopus trap, and it’s named that way because the left ventricle of the heart changes into a similar shape during the peak of this disease.
What Causes Takotsubo Cardiomyopathy (Broken Heart Syndrome)?
The exact cause of a condition called takotsubo cardiomyopathy is not entirely clear. There are many theories about what might cause it, including too much activity in the part of the nervous system that controls things like heartbeat and blood pressure, spasm in the blood vessels that supply the heart, problems with tiny blood vessels in the heart, low levels of the hormone estrogen, inflammation, or problems with the way the heart uses fat for energy.
There are several risk factors that can increase the possibility of developing takotsubo cardiomyopathy. These can include being a victim of domestic abuse, experiencing the death of a loved one, natural disasters, accidents or major trauma, fights or arguments, financial or gambling losses, being diagnosed with a serious health problem, or using stimulant drugs such as cocaine or amphetamines. Interestingly, even happy events can sometimes lead to this condition, in what’s been named the ‘happy heart syndrome.’
Risk Factors and Frequency for Takotsubo Cardiomyopathy (Broken Heart Syndrome)
The exact number of cases of takotsubo cardiomyopathy, also known as broken heart syndrome, is unclear. It accounts for 1 to 2% of patients who are thought to have acute coronary syndrome, a term for situations where blood supplied to the heart muscle is suddenly blocked. In one study of 3265 patients with blood markers indicating they might have acute coronary syndrome, 1.2% had takotsubo cardiomyopathy.
Another study showed that of patients suspected to have a heart attack, 1.7 to 2.2% actually had takotsubo cardiomyopathy. The condition is seen much more frequently in post-menopausal women, but when it does occur in men, the outcomes may be worse.
- Of 1750 patients with takotsubo cardiomyopathy studied in an international research project, 88.9% were women.
- The average age of the patients in the study was 66.4 years.
Signs and Symptoms of Takotsubo Cardiomyopathy (Broken Heart Syndrome)
Takotsubo cardiomyopathy, often referred to as “broken heart syndrome”, normally presents similarly to a heart attack and is usually brought on by severe emotional or physical stress. Examples of such triggers include sudden death in the family, domestic abuse, a major confrontation, a medical diagnosis, a natural disaster, or a financial crisis. Common symptoms include chest pain, shortness of breath, and fainting. In some cases, patients may also display symptoms of heart failure, irregular heartbeat, sudden cardiac arrest, or serious mitral valve leak. After a medical examination, a late-peaking heart murmur can often be heard due to a blockage in the passageway leading out of the heart. Additionally, some may also present symptoms similar to those of a mini-stroke or a stroke due to a blood clot being dislodged from the heart and blocking blood flow to the brain. Sadly, about 10% of people with this condition may develop cardiogenic shock, a condition in which the heart is unable to pump sufficient blood to the body.
- Severe emotional or physical stress
- Chest pain
- Shortness of breath
- Fainting
- Heart failure symptoms
- Irregular heartbeat
- Sudden cardiac arrest
- Serious mitral valve leak
- Late-peaking heart murmur
- Stroke-like symptoms
- Cardiogenic shock (in about 10% of cases)
Testing for Takotsubo Cardiomyopathy (Broken Heart Syndrome)
Stress cardiomyopathy, also known as takotsubo cardiomyopathy, is typically diagnosed in adults, particularly postmenopausal women, who show signs of heart problems such as acute coronary syndrome. This condition might be suspected if the patient’s symptoms and abnormalities on an electrocardiogram (a test that measures the electrical activity of the heartbeat) don’t match up with the results from cardiac biomarkers (a type of heart disease test).
However, it’s really important to understand that stress cardiomyopathy can only be definitely diagnosed after a person has undergone a coronary angiography (a medical imaging technique that involves injecting a contrasting agent into the coronary arteries to visualize the blood flow to the heart). This is because its features can look really similar to acute coronary disease.
Several diagnostic criteria have been suggested to help doctors identify stress cardiomyopathy, some of which include the Mayo Clinic criteria and the International Takotsubo Diagnostic Criteria. Most doctors tend to use the Mayo Clinic diagnostic criteria, which consist of five main features that need to be fulfilled for the condition to be diagnosed:
1. Changes in the function or movement within certain parts of the left ventricle (the heart’s main pumping chamber), which might include a lack of movement or abnormal movement.
2. The presence of a stressful trigger, which could have resulted in the abnormalities in the left ventricle.
3. The absence of any blockages in the coronary artery or evidence of acute plaque rupture (which could lead to a heart attack).
4. New electrocardiogram abnormalities or a modest rise in cardiac troponin (a substance that is released into the blood when the heart muscle has been damaged).
5. The absence of other medical conditions, such as pheochromocytoma (a rare tumor that produces excess adrenaline) and myocarditis (inflammation of the heart muscle).
In addition to the Mayo Clinic criteria, several other diagnostic tests can help identify stress cardiomyopathy:
– Electrocardiogram: Patients with this condition often showcase a series of changes on this test similar to those seen during pericarditis (inflammation of the pericardium, the sac that surrounds your heart).
– Laboratory findings: Tests that measure cardiac biomarkers, such as troponins and CK-MB (enzymes released when the heart muscle is damaged), show a mild elevation. Furthermore, levels of brain natriuretic peptide (BNP) or N-terminal pro-BNP are higher in most patients with stress cardiomyopathy compared to those in patients with acute coronary syndrome.
– Transthoracic echocardiography: This test uses sound waves to produce images of the heart and helps to categorize the abnormalities seen within its walls.
– Cardiovascular magnetic resonance imaging: This test uses a magnetic field and radio waves to create detailed pictures of the heart and can be particularly useful in identifying stress cardiomyopathy when other tests are inconclusive.
– Cardiac catheterization: This is preferred when stress cardiomyopathy presents as ST-elevation acute coronary syndrome or troponin-positive acute coronary syndrome. It’s an invasive procedure where a thin plastic tube is inserted into an artery or vein in the arm or leg, and guided to the heart.
Treatment Options for Takotsubo Cardiomyopathy (Broken Heart Syndrome)
Takotsubo cardiomyopathy, often thought of as a mild condition, may in fact be more serious than previously suspected. This condition, which temporarily weakens your heart, has recently been linked to the same levels of heart failure and death rates as acute coronary syndrome, a sudden and severe blockage of the heart’s blood supply. As a result, doctors are focusing on identifying and monitoring patients who are at risk for more serious complications.
The outcomes of a patient’s hospital stay can be negatively affected by factors like physical triggers, acute neurologic or psychiatric diseases, high levels of a cardiac biomarker called troponin, and lower than normal heart pumping function measured as “left ventricular ejection fraction” less than 45%. It has also been found that men with Takotsubo cardiomyopathy have up to three times higher death rate and major heart and brain events, which is mainly due to higher number of additional existing health problems.
The management of this condition still lacks specific guidelines because there’s a lack of direct, carefully controlled research data. Therefore, the current treatment strategies are primarily based on clinical experience and expert consensus. As the initial symptoms of Takotsubo cardiomyopathy can mimic an acute coronary syndrome (like a heart attack), the initial treatment often includes aspirin, a type of medication called beta-blockers, ACE inhibitors (which lower blood pressure), lipid-lowering agents, and a procedure called coronary angiography (which checks the blood flow in your heart’s arteries).
The treatment plan usually depends on each patient’s unique health status and stability. Feeling good and stable patients may be advised to take cardioselective beta-blockers and ACE inhibitors for a short period of about 3 to 6 months, with regular heart imagining to monitor the condition progress or improvement. A type of medication called anticoagulants, used to prevent blood clots, is usually reserved for patients showing evidence of blood clots in the heart’s chamber or those who have experienced embolic events (a sudden interruption of blood flow to an organ), which occurs in 5% of patients with this condition.
For the patients who have unstable conditions or are experiencing heart failure in the absence of heart’s blood flow obstruction, medications to stimulate or support the heart’s activity may be needed. For some, mechanical aids such as an intra-aortic balloon pump or at times, left ventricular assist devices might be beneficial. However, if obstruction of blood flow from the heart is present along with the heart failure, certain medications like inotropes should be avoided, and drugs like phenylephrine (a blood pressure boosting agent) are the preferred choice, often combined with beta-blockers.
What else can Takotsubo Cardiomyopathy (Broken Heart Syndrome) be?
When experiencing heart-related symptoms, doctors need to rule out the following conditions:
- Acute Coronary Syndrome: a condition marked by sudden, reduced blood flow to the heart.
- Cocaine-Related Coronary Syndrome: heart problem caused by cocaine use.
- Coronary Artery Spasm: temporary tightening of the muscles in the wall of an artery.
- Esophageal Spasm: painful contractions in the tube transporting food from the mouth to the stomach.
- Myocarditis: inflammation of the heart muscle.
- Pericarditis: inflammation of the lining surrounding the heart.
- Pheochromocytoma: a rare tumor of adrenal gland tissue leading to excessive adrenaline production.
What to expect with Takotsubo Cardiomyopathy (Broken Heart Syndrome)
Takotsubo cardiomyopathy (a temporary heart condition often brought on by stress) is typically recoverable, but the risk of complications for hospitalized patients is similar to those of an acute myocardial infarction (heart attack). The reported death rate among patients with takotsubo cardiomyopathy varies from 0 to 8%, with a 4.1% overall death rate noted in a key international study.
The prognosis (anticipated course or outcome) for takotsubo cardiomyopathy depends largely on what caused it, and this condition is divided into primary and secondary forms. Primary takotsubo cardiomyopathy is brought on by emotional or psychological stressors, while secondary forms happen due to physical issues in a hospital setting, like sepsis (a life-threatening response to infection), trauma, surgery, or other critical illnesses. Secondary takotsubo cardiomyopathy is often linked to worse outcomes both in the hospital and in the long term.
While takotsubo cardiomyopathy incidents in males are lower, they often have a worse prognosis. This could be due to higher rates of acute critical illnesses among males, which cause elevated levels of catecholamines (stress hormones), potentially leading to a higher death rate within the hospital.
Possible Complications When Diagnosed with Takotsubo Cardiomyopathy (Broken Heart Syndrome)
The main complications after surviving a heart event often include blockage in the left ventricular outflow tract, life-threatening irregular heart rhythms, sporadic or persistent irregular heartbeats originating in the atria (top chambers of the heart), low blood pressure, poor cardiac performance also known as low output syndrome, cardiogenic shock (a condition where the heart can’t pump enough blood to meet the body’s needs), heart failure, and blood clots, also known as thromboembolism.
After surviving the initial event, about 5% of patients may have a second event. The second event often happens anywhere between three weeks to 3.8 years after the first one.
Main Complications:
- Blockage in the left ventricular outflow tract
- Life-threatening irregular heart rhythms
- Sporadic or persistent irregular heartbeats
- Low blood pressure
- Poor cardiac performance (low output syndrome)
- Cardiogenic shock
- Heart failure
- Blood clots (thromboembolism)
Preventing Takotsubo Cardiomyopathy (Broken Heart Syndrome)
People generally recover well from a takotsubo event, an unexpected weakening of the heart muscle, but not everyone recovers at the same pace. While some people may fully recover within weeks or a few months, there’s still ongoing research into long-term effects of this condition. Hence, it’s important for each person to follow a recovery rhythm that best suits their individual circumstances.
To aid in recovery, there are also support groups available for people with takotsubo syndrome. Additionally, a heart care nurse is able to guide patients to heart rehabilitation classes that can be particularly helpful during the recovery process.
