What is broken heart syndrome

Broken heart syndrome is a condition in which extreme stress can lead to heart muscle failure. The heart failure is severe, but often short-term.

In people with a broken heart syndrome, extreme emotional or physical stress (i.e. intense grief, anger, surprise, illness or surgery) can lead to heart muscle failure. Signs and symptoms of the condition mimic those of a heart attack and may include sudden chest pain, shortness of breath, and an irregular heartbeat. The cause of broken heart syndrome is not completely understood. Some researchers believe that it may occur when certain hormones released during times of stress temporarily affect the heart’s ability to pump blood throughout the body. Treatment is available to manage the symptoms of the condition. Fortunately, most affected people have a full and quick recovery with no permanent damage to the heart muscle ¹.

Post-menopausal women are more likely than men to have broken heart syndrome ². Women have a 9-fold higher risk of broken heart syndrome compared to men ³. Women > 55 years have about 5-fold higher risk than women < 55 years ³. Broken heart syndrome recurrence has been reported in greater than 10% of the patients in the first four years ⁴. Researchers are just starting to explore what causes this disorder and how to diagnose and treat it.

Most people who experience broken heart syndrome think they may be having a heart attack, a more common medical emergency caused by a blocked coronary (heart) artery. The two conditions have similar symptoms, including chest pain and shortness of breath. However, there’s no evidence of blocked coronary arteries in broken heart syndrome, and most people have a full and quick recovery.

• All chest pain should be checked by a doctor.

Broken heart syndrome is a recently recognized heart problem. It was originally reported in the Asian population in 1991 and named Takotsubo (“tako tsubo” is the term for a traditional Japanese octopus trap, whose shape resembles the bulging appearance of the heart during this condition) cardiomyopathy ⁵. In 1991, cardiologists from Hiroshima, Japan were the first to report a cardiac syndrome with female preponderance exhibiting transient left ventricular apical ballooning, transient left ventricular systolic dysfunction, electrocardiographic changes, and minimal myocardial enzymatic release mimicking acute myocardial infarction without significant epicardial coronary artery disease ⁶. Based on the first series of 30 patients from this group, published ten years later, they believed that simultaneous multivessel coronary spasm was one of the main causes ⁷. Of note, in their series of 30 patients acute coronary angiography revealed no coronary artery disease in 25 patients, and only moderate single coronary artery disease in five patients. Three patients showed spontaneous multivessel coronary spasm. In ten patients, coronary spasm could be provoked by either ergonovine or acetylcholine ⁷. Vasospastic ischemia is supposed to be more common in Japan than in the rest of the world ⁵.

In this condition, the heart is so weak that it assumes a bulging shape. Cases have since been reported worldwide, and the first reports of broken heart syndrome in the United States appeared in 1998. The condition also is commonly called stress-induced cardiomyopathy.

The cause of broken heart syndrome is not fully known. In most cases, symptoms are triggered by extreme emotional or physical stress, such as intense grief, anger, or surprise. Researchers think that the stress releases hormones that “stun” the heart and affect its ability to pump blood to the body. (The term “stunned” is often used to indicate that the injury to the heart muscle is only temporary.)

People who have broken heart syndrome often have sudden intense chest pain and shortness of breath. These symptoms begin just a few minutes to hours after exposure to the unexpected stress. Many seek emergency care, concerned they are having a heart attack. Often, patients who have broken heart syndrome have previously been healthy.

Physical and mental stressors are recognized as the leading causes of broken heart syndrome ⁸. With the increasing pressure of work and life in modern society, the morbidity of broken heart syndrome in large cities is gradually increasing. Broken heart syndrome has drawn increased attention as a new mechanism of sudden cardiac death ⁹. Among the 12 million people who die from cardiovascular disease worldwide each year, half die of sudden cardiac death. Under these circumstances, an early diagnosis and the administration of appropriate and timely treatment may avoid unnecessary coronary angiography, avert fatal complications, and improve the survival rates of sudden cardiac death patients ¹⁰. Although many countries have reported cases of broken heart syndrome in last 10 years ¹¹, ¹², ¹³, including Japan, Korea, America, and Australia.

Other names for broken heart syndrome

• Apical ballooning syndrome
• Stress cardiomyopathy
• Stress-induced cardiomyopathy
• Takotsubo cardiomyopathy
• Transient left ventricular apical ballooning syndrome

Types of broken heart syndrome

Four different morphotypes of broken heart syndrome have been described: (1) Classical – apical ballooning with basal hyperkinesis; (2) Mid-ventricular – basal hyperkinesis, mid-ventricular hypokinesis and normal or hyperkinetic apex; (3) Basal (inverted) – basal and mid-ventricular hypokinesis with apical hyperkinesis; and (4) Focal – hypokinesis of a focal myocardial segment ³. Broken heart syndrome predominantly affects the left ventricle but right ventricular (RV) involvement with a more malignant course has been described as well ¹⁴. The classic type characterized by basal hyperkinesis is often associated with left ventricular outflow tract (LVOT) obstruction and shock ¹⁵. Significant reversible mitral regurgitation (MR) and higher brain natriuretic peptide (BNP) levels related to the ventricular dilation have been described in the classic form. The inverted (basal) form seems to have higher levels of troponin and lower levels of BNP as well as lower incidence of LVOT obstruction and MR ¹⁵.

Broken Heart Syndrome Vs Heart Attack

Symptoms of broken heart syndrome can look like those of a heart attack.

Most heart attacks are caused by blockages and blood clots forming in the coronary arteries, which supply the heart with blood. If these clots cut off the blood supply to the heart for a long enough period of time, heart muscle cells can die, leaving the heart with permanent damage. Heart attacks most often occur as a result of coronary heart disease, also called coronary artery disease.

Broken heart syndrome is quite different. Most people who experience broken heart syndrome have fairly normal coronary arteries, without severe blockages or clots. The heart cells are “stunned” by stress hormones but not killed. The “stunning” effects reverse quickly, often within just a few days or weeks. In most cases, there is no lasting damage to the heart.

Because symptoms are similar to a heart attack, it is important to seek help right away. You, and sometimes emergency care providers, may not be able to tell that you have broken heart syndrome until you have some tests.

All chest pain should be checked by a doctor. If you think you or someone else may be having heart attack symptoms or a heart attack, don’t ignore it or feel embarrassed to call for help. Call your local emergency number for emergency medical care. In the case of a heart attack, acting fast at the first sign of symptoms can save your life and limit damage to your heart.

Prognosis of a broken heart syndrome

Research is ongoing to learn more about broken heart syndrome and its causes.

The symptoms of broken heart syndrome are treatable, and most people who experience it have a full recovery, usually within days or weeks. The heart muscle is not permanently damaged, and the risk of broken heart syndrome happening again is low.

More than 95% of patients with broken heart syndrome have favorable prognoses that entail the full recovery of left ventricle function; however, serious complications such as heart failure, malignant arrhythmia and death have also been reported ¹⁶, ¹⁷. As catecholamine-mediated cardiotoxicity is widely accepted as the primary pathophysiological mechanism of broken heart syndrome ¹⁸, ¹⁹, ²⁰, beta receptor blockers and angiotensin-converting enzyme inhibitors (ACEI) are commonly chosen to treat the disease rather than thrombolytic agents, coronary artery stents, coronary bypass, or long-term antiplatelet or lipid-lowering drugs ²¹.

Complications of of broken heart syndrome

Broken heart syndrome can be life threatening in some cases. It can lead to serious heart problems such as:

• Heart failure, a condition in which the heart can’t pump enough blood to meet the body’s needs
• Heart rhythm problems that cause the heart to beat much faster or slower than normal
• Heart valve problems
• In rare cases, broken heart syndrome is fatal.

The good news is that most people who have broken heart syndrome make a full recovery within weeks. With medical care, even the most critically ill tend to make a quick and complete recovery.

Broken heart syndrome symptoms

All chest pain should be checked by a doctor. Because symptoms of broken heart syndrome are similar to those of a heart attack, it is important to seek help right away. Your doctor may not be able to diagnose broken heart syndrome until you have some tests.

Common Signs and Symptoms of broken heart syndrome

The most common symptoms of broken heart syndrome are sudden, sharp chest pain and shortness of breath. Typically these symptoms begin just minutes to hours after experiencing a severe, and usually unexpected, stress.

Because the syndrome involves severe heart muscle weakness, some people also may experience signs and symptoms such as fainting, arrhythmias (fast or irregular heartbeats), cardiogenic shock (when the heart can’t pump enough blood to meet the body’s needs), low blood pressure, and heart failure.

Differences From a Heart Attack

Some of the signs and symptoms of broken heart syndrome differ from those of a heart attack. For example, in people who have broken heart syndrome:

• Symptoms (chest pain and shortness of breath) occur suddenly after having extreme emotional or physical stress.
• EKG (electrocardiogram) results don’t look the same as the results for a person having a heart attack. An EKG is a test that records the heart’s electrical activity.
• Blood tests show no signs or mild signs of heart damage.
• Tests show enlarged and unusual movement of the lower left heart chamber (the left ventricle).
• Tests show no signs of blockages in the coronary arteries.
• Recovery time is quick, usually within days or weeks (compared with the recovery time of a month or more for a heart attack).

Broken heart syndrome causes

The cause of broken heart syndrome isn’t fully known. However, extreme emotional or physical stress is believed to play a role in causing the temporary disorder.

Although symptoms are similar to those of a heart attack, what is happening to the heart is quite different. Most heart attacks are caused by near or complete blockage of a coronary artery. In broken heart syndrome, the coronary arteries are not blocked, although blood flow may be reduced.

Potential Triggers

In most cases, broken heart syndrome occurs after an intense and upsetting emotional or physical event. Some potential triggers of broken heart syndrome are:

• Emotional stressors—extreme grief, fear, or anger, for example as a result of the unexpected death of a loved one, financial or legal trouble, intense fear, domestic abuse, confrontational argument, car accident, public speaking, or even a surprise party.
• Physical stressors—an asthma attack, serious illness or surgery, or exhausting physical effort.

It’s also possible that some drugs, rarely, may cause broken heart syndrome by causing a surge of stress hormones. Drugs that may contribute to broken heart syndrome include:

• Epinephrine (EpiPen, EpiPen Jr.), which is used to treat severe allergic reactions or a severe asthma attack
• Duloxetine (Cymbalta), a medication given to treat nerve problems in people with diabetes, or as a treatment for depression
• Venlafaxine (Effexor XR), which is a treatment for depression
• Levothyroxine (Synthroid, Levoxyl), a drug given to people whose thyroid glands don’t work properly.

Potential Causes

Researchers think that sudden stress releases hormones that overwhelm or “stun” the heart. (The term “stunned” is often used to indicate that the injury to the heart muscle is only temporary.) This can trigger changes in heart muscle cells or coronary blood vessels, or both. The heart becomes so weak that its left ventricle (which is the chamber that pumps blood from your heart to your body) bulges and cannot pump well, while the other parts of the heart work normally or with even more forceful contractions. As a result the heart is unable to pump properly.

Researchers are trying to identify the precise way in which the stress hormones affect the heart. Broken heart syndrome may result from a hormone surge, coronary artery spasm, or microvascular dysfunction.

Hormone Surge

Intense stress causes large amounts of the “fight or flight” hormones, such as adrenaline and noradrenaline, to be released into your bloodstream. The hormones are meant to help you cope with the stress. Researchers think that the sudden surge of hormones overwhelms and stuns the heart muscle, producing symptoms similar to those of a heart attack.

Coronary Artery Spasm

Some research suggests that the extreme stress causes a temporary, sudden narrowing of one of the coronary arteries as a result of a spasm. The spasm slows or stops blood flow through the artery and starves part of the heart of oxygen-rich blood.

Microvascular Dysfunction

Another theory that is gaining traction is that the very small coronary arteries (called microvascular arteries) do not function well due to low hormone levels occurring before or after menopause. The microvascular arteries fail to provide enough oxygen-rich blood to the heart muscle.

Risk Factors for broken heart syndrome

Broken heart syndrome affects women more often than men. Often, people who experience broken heart syndrome have previously been healthy. Research shows that the traditional risk factors for heart disease may not apply to broken heart syndrome.

People who might be at increased risk for broken heart syndrome include:

• Women who have gone through menopause, particularly women in their sixties and seventies
• People who often have no previous history of heart disease
• Asian and White populations
• A history of a neurological condition. People who have neurological disorders, such as a head injury or a seizure disorder (epilepsy) have a greater risk of broken heart syndrome.
• A previous or current psychiatric disorder. If you’ve had disorders, such as anxiety or depression, you probably have a higher risk of broken heart syndrome.

Although these are the characteristics for most cases of broken heart syndrome, the condition can occur in anyone.

Research is ongoing to learn more about broken heart syndrome and its causes.

Prevention of a broken heart syndrome

Researchers are still learning about broken heart syndrome, and no treatments have been shown to prevent it. For people who have experienced the condition, the risk of recurrence is low. Many doctors recommend long-term treatment with beta blockers or similar medications that block the potentially damaging effects of stress hormones on the heart.

An emotionally upsetting or serious physical event can trigger broken heart syndrome. Learning how to manage stress, relax, and cope with problems can improve your emotional and physical health.

Having supportive people in your life with whom you can share your feelings or concerns can help relieve stress. Physical activity, medicine, and relaxation therapy also can help relieve stress. You may want to consider taking part in a stress management program.

Also, some of the ways people cope with stress—such as drinking, smoking, or overeating—aren’t healthy. Learning to manage stress includes adopting healthy habits that will keep your stress levels low and make it easier to deal with stress when it does happen. A healthy lifestyle includes following a healthy diet, being physically active, maintaining a healthy weight, and quitting smoking.

Broken heart syndrome diagnosis

Because the symptoms are similar, at first your doctor may not be able to tell whether you are experiencing broken heart syndrome or having a heart attack. Therefore, the doctor’s immediate goals will be:

• To determine what’s causing your symptoms
• To determine whether you’re having or about to have a heart attack

Your doctor will diagnose broken heart syndrome based on your signs and symptoms, your medical and family histories, and the results from tests and procedures.

Your doctor may refer you to a cardiologist. A cardiologist is a doctor who specializes in diagnosing and treating heart diseases and conditions.

Physical Exam and Medical History

Your doctor will do a physical exam and ask you to describe your symptoms. He or she may ask questions such as when your symptoms began, where you are feeling pain or discomfort and what it feels like, and whether the pain is constant or varies.

To learn about your medical history, your doctor may ask about your overall health, risk factors for coronary heart disease (coronary artery disease) and other heart disease, and family history. Your doctor will ask whether you’ve recently experienced any major stresses.

Diagnostic Tests and Procedures

No single test can diagnose broken heart syndrome. The tests and procedures for broken heart syndrome are similar to those used to diagnose coronary artery disease or heart attack. The diagnosis is made based on the results of the following standards tests to rule out heart attack and imaging studies to help establish broken heart syndrome.

Standard Tests and Procedures

EKG (Electrocardiogram)

An EKG is a simple, painless test that detects and records the heart’s electrical activity. The test shows how fast your heart is beating and whether its rhythm is steady or irregular. An EKG also records the strength and timing of electrical signals as they pass through each part of the heart.

The EKG may show abnormalities in your heartbeat, a sign of broken heart syndrome as well as heart damage due to coronary artery disease.

Blood Tests

Blood tests check the levels of certain substances in your blood, such as fats, cholesterol, sugar, and proteins. Blood tests help greatly in diagnosing broken heart syndrome, because certain enzymes (proteins in the blood) may be present in the blood to indicate the condition.

Imaging Procedures

Echocardiography

Echocardiography (echo) uses sound waves to create a moving picture of your heart. The test provides information about the size and shape of your heart and how well your heart chambers and valves are working. Echo also can show areas of heart muscle that aren’t contracting well because of poor blood flow or previous injury.

The echo may show slowed blood flow in the left chamber of the heart.

Chest X Ray

A chest x ray is a painless test that creates pictures of the structures in your chest, such as your heart, lungs, and blood vessels. Your doctor will need a chest x ray to analyze whether your heart has the enlarged shape that is a sign of broken heart syndrome.

A chest x ray can reveal signs of heart failure, as well as lung disorders and other causes of symptoms not related to broken heart syndrome.

Cardiac MRI

Cardiac magnetic resonance imaging (MRI) is a common test that uses radio waves, magnets, and a computer to make both still and moving pictures of your heart and major blood vessels. Doctors use cardiac MRI to get pictures of the beating heart and to look at its structure and function. These pictures can help them decide the best way to treat people who have heart problems.

Coronary Angiography and Cardiac Catheterization

Your doctor may recommend coronary angiography if other tests or factors suggest you have coronary artery disease. This test uses dye and special x rays to look inside your coronary arteries.

To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization. A thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck. The tube is threaded into your coronary arteries, and the dye is released into your bloodstream.

Special x rays are taken while the dye is flowing through your coronary arteries. The dye lets your doctor study the flow of blood through your heart and blood vessels.

Because broken heart syndrome often mimics the signs and symptoms of a heart attack, a coronary angiogram may be done quickly to rule out a heart attack. People with broken heart syndrome often don’t have any blockages in the blood vessels, while people who’ve had a heart attack usually have a blockage that is visible on an angiogram.

Once it’s clear you’re not having a heart attack, your doctor will check to see if your signs and symptoms were caused by broken heart syndrome.

Ventriculogram

Ventriculogram is another test that can be done during a cardiac catheterization that examines the left ventricle, which is the heart’s main pumping chamber. During this test, a dye is injected into the inside of the heart and x ray pictures are taken. The test can show the ventricle’s size and how well it pumps blood. It also shows how well the blood flows through the aortic and mitral values.

Broken heart syndrome treatment

Even though broken heart syndrome may feel like a heart attack, it’s a very different problem that needs a different type of treatment.

Procedures that are often used to treat a heart attack, such as balloon angioplasty and stent placement, or even surgery, aren’t helpful in treating broken heart syndrome. These procedures treat blocked arteries, which are not the cause of broken heart syndrome. But, coronary angiography can be used to diagnose the cause of the chest pain.

The good news is that broken heart syndrome is usually treatable and most people make a full recovery. Most people who experience broken heart syndrome stay in the hospital for a few days to a week.

Once it’s clear that broken heart syndrome is the cause of your symptoms, your doctor will likely prescribe heart medications for you to take while you’re in the hospital, such as angiotensin-converting enzyme (ACE) inhibitors, beta blockers or diuretics. These medications help reduce the workload on your heart while you recover and may help prevent further attacks.

Initial treatment is aimed at improving blood flow to the heart, and may be similar to that for a heart attack until the diagnosis is clear. Further treatment can include medicines and lifestyle changes.

Medicines

Doctors may prescribe medicines to relieve fluid buildup, treat blood pressure problems, prevent blood clots, and manage stress hormones. Medicines are often discontinued once heart function has returned to normal.

Your doctor may prescribe the following medicines:

• ACE inhibitors (or angiotensin-converting enzyme inhibitors), to lower blood pressure and reduce strain on your heart
• Beta blockers, to slow your heart rate and lower your blood pressure to decrease your heart’s workload
• Diuretics (water or fluid pills), to help reduce fluid buildup in your lungs and swelling in your feet and ankles
• Anti-anxiety medicines, to help manage stress hormones

Take all of your medicines as prescribed. If you have side effects or other problems related to your medicines, tell your doctor. He or she may be able to provide other options.

Many patients make a full recovery within a month or so. Ask your doctor how long you will need to continue taking these medications once you recover, as most can be stopped within three to six months.

Treatment of Complications

Broken heart syndrome can be life threatening in some cases. Because the syndrome involves severe heart muscle weakness, patients can experience shock, heart failure, low blood pressure, and potentially life-threatening heart rhythm abnormalities.

The good news is that this condition improves very quickly, so with proper diagnosis and management, even the most critically ill tend to make a quick and complete recovery.

Lifestyle Changes

To stay healthy, it’s important to find ways to reduce stress and cope with particularly upsetting situations. Learning how to manage stress, relax, and cope with problems can improve your emotional and physical health.

Having supportive people in your life with whom you can share your feelings or concerns can help relieve stress. Physical activity, medicine, and relaxation therapy also can help relieve stress. You may want to consider taking part in a stress management program.

Treatments Not Helpful for Broken Heart Syndrome

Several procedures used to treat a heart attack are not helpful in treating broken heart syndrome. These procedures—percutaneous coronary intervention (sometimes referred to as angioplasty), stent placement, and surgery—treat blocked arteries, which is not the cause of broken heart syndrome.

Living with a broken heart syndrome

Most people who have broken heart syndrome make a full recovery within weeks. The risk is low for a repeat episode of this disorder.

Ongoing medical care and adopting a healthy lifestyle can help speed recovery and contribute to a long, healthy life.

Medicines

Some doctors recommend long-term treatment with beta blockers or similar medicines to block the effects of stress hormones on the heart.

Regular Checkups

To check your heart health, your doctor may recommend echocardiography about a month after you’re diagnosed with broken heart syndrome. Talk with your doctor about how often you should schedule follow-up visits.

Managing Stress

Learning how to manage stress, relax, and cope with problems can improve your emotional and physical health. Having supportive people in your life with whom you can share your feelings or concerns can help relieve stress. Physical activity, medicine, and relaxation therapy also can help relieve stress. You may want to consider taking part in a stress management program.

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