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What's the Real Story Behind the "Broken Heart" Syndrome?

The facts behind stress cardiomyopathy - and its broader implications

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Updated October 27, 2013

Each year, near Valentine's Day, newspapers around the country run stories on "Broken Heart Syndrome," a condition in which people (usually postmenopausal women) experience severe, acute cardiac symptoms following an episode of extreme emotional stress.

Broken Heart Syndrome (BHS), also called stress cardiomyopathy, is triggered by extreme and sudden emotional trauma. Reported triggers have included unexpected news of a death, domestic abuse, armed robbery, and even a surprise party. The condition manifests with symptoms suggesting an acute heart attack (severe pressure-like chest pain, shortness of breath, and a sense of impending doom).

When first evaluated, patients with BHS are initially thought to be having massive heart attacks. However, the changes on their ECGs are not typical for a heart attack, and the cardiac enzyme tests that are supposed to confirm a heart attack are found not to be significantly elevated. Furthermore, when taken to the catheterization laboratory, their coronary arteries are found to be normal (whereas in true heart attacks, one of the coronary arteries would have been occluded). And finally, many of these patients are found to have a peculiar type of heart muscle weakness (cardiomyopathy) on echocardiography, where a portion of their left ventricle "balloons" outward in an unusual and distinctive fashion.

Many patients with BHS are initially in severe heart failure, and require aggressive and intensive cardiac care. With appropriate care, however, not only do they survive, but also their cardiomyopathy usually completely resolves within a few days to weeks.

The unique features of BHS are that it occurs suddenly in otherwise healthy patients (usually women); it immediately follows an episode of severe emotional stress; the presenting symptoms strongly suggest a heart attack; and, while victims are at first critically ill with cardiomyopathy, with appropriate care they most often survive and the cardiomyopathy almost always disappears entirely.

The cause of BHS is unknown, but most experts blame it on an unusual response to stress hormones (such as adrenaline) after emotional trauma. The condition may be related to Cardiac Syndrome X, which is caused by constriction of microvessels (tiny blood vessels) within the heart muscle.

BHS has been written about for many years in Japan (where it is called "octopus trap cardiomyopathy" because of the peculiar shape of the ballooning heart muscle), but until relatively recently it has been poorly recognized in the rest of the world.

A Comment on BHS:

The term "broken heart syndrome" may not be the best name for this syndrome, as one typically thinks of a broken heart as something that occurs after receiving a Dear John letter, rather than something that happens after seeing a loaded .44 magnum shoved in one's face. Nonetheless, this terminology has resulted in lots of publicity, and the knowledge of this new syndrome consequently has been rapidly and widely disseminated. And that widespread awareness is good.

The symptoms of BHS are so severe that it is nearly inconceivable that anyone who develops it will fail to seek medical help; and the physical manifestations of the condition are so obvious that no doctor who sees one of these women could fail to realize that something serious is going on. So, as bad as BHS is, at least there is little danger it will be ignored either by its victims or by medical personnel.

This stands in stark contrast to several other cardiac conditions experienced by women that are far more frequent than stress cardiomyopathy. Chief among these are angina and heart attacks - conditions that are as frequent and as dangerous in women as in men, but that often present with "atypical" symptoms. So, women who suffer from coronary artery disease often fail to seek help, and when they do seek help they often fail to get it from their doctors.

Perhaps the publicity around this "broken heart syndrome" will draw women's and doctors' attention to the general fact that heart disease in women is different from heart disease in men - but is no less frequent and no less lethal. If so, the inaccurate terminology used throughout the mass media will turn out to have been a good thing.

Sources:

Sharkey, SW, Lesser, JR, Zenovich, AG, et al. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation 2005; 111:472.

Tsuchihashi, K, Ueshima, K, Uchida, T, et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigations in Japan. J Am Coll Cardiol 2001; 38:11.

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