A Broken Heart From Stress
A Broken Heart From Stress
Stress can cause a 'Broken Heart' but usually we recover.
“Is stress bad for your heart?”
I get this question all the time.
Usually, it doesn’t come from the patient but from the person sitting beside them.
Our response to stress varies, and a little stress is usually a good thing resulting in improvements in performance. Not enough stress often leaves us unprepared; too much stress can cause us to shut down completely.
This is known as the stress response curve
.
Constant background stress has been shown to increase rates of heart disease and stroke
.But what about when we take the stress levels out to the extreme and do so abruptly?
We find that when exposed to these levels of sudden stress, the heart can ‘break’, and it’s something we have only known about for the last 30 years.
In the early 1990s, Dr Hikaru Sato, a Japanese physician, described a phenomenon whereby a patient with a suspected heart attack after a major stressful event did not have any blockages of their coronary arteries but did have a very unusual pattern of heart muscle damage.
In these cases, the left ventricle, which is the heart's main pumping chamber, ‘ballooned’ out at the apex or the tip of the left ventricle. This is not a pattern we see with a heart attack.
The pattern appeared quite similar to a Japanese fishing vessel used to catch octopus called a Takotsubo
.
Since this patient had a reduced heart function, also known as cardiomyopathy, the term Takotsubo Cardiomyopathy was coined.
More than 30 years later, we know a lot more about this mysterious condition, but in many ways, we are still in the dark.
Many more cases were identified after the condition came to light, usually following major emotional triggers.
Cases of Takotsubo Cardiomyopathy tend to spike following major events, such as those seen after the Niigata Chuetsu earthquake in Japan in 2004 and New Zealand in 2011.
The emotional triggers that precipitate Takotsubo Cardiomyopathy have been described following a range of different events, including:
Death of a loved one
Assault
Major Argument
Divorce
Job loss
Physical stressors can also precipitate the condition, the most common being an intracranial bleed
.
In about 25% of cases, however, there is no major trigger.
The condition is rare, accounting for about 2% of all patients who are initially hospitalised for a suspected heart attack.
Over 90% of cases, however, occur in females, the majority of which are post menopausal
.Interestingly, however, in Japan, it mainly occurs in males.
The Cause
We do not have a clear explanation as to what causes Takotsubo Cardiomyopathy, but there are some theories.
The most likely explanation relates to excess stress hormones called catecholamines, the fight-of-flight hormones that ramp up sympathetic activity.
Higher levels of catecholamines are seen in those with Takotsubo Cardiomyopathy, and the condition can also be induced by infusing large amounts of catecholamines
.Patients who present with the condition often report a ‘sudden rush’, possibly suggesting a sudden release of stress hormones.
Some studies have suggested a variety of genetic markers that might put people at higher risk, but the research here is still unclear
.Why Post-Menopausal Females?
The short answer is we do not know.
The most likely answer is that there is a relationship with reduced circulating estrogen levels, which play an important role in catecholamine signalling. Animal studies have shown that the likelihood of Takotsubo Cardiomyopathy can be reduced with estrogen therapy.
Although many mechanisms have been proposed ranging from catecholamine surges to microvascular dysfunction, we do not have a clear explanation for its cause.
Is it dangerous?
Most patients presenting with Takotsubo Cardiomyopathy recover quickly and require limited treatment.
About 5% of patients die due to complications, so although usually self-limiting, it can be fatal.
Stress hormones tightly regulate the autonomic nervous system, which in turn regulates heart rate etc., and many patients have impaired heart rate variability many months after their admission.
Did it just appear in the 1990s?
Takotsubo Cardiomyopathy is almost certainly not a new phenomenon. Only the name is new.
Lady Montague, the mother of Romeo in Shakespeare’s ‘Romeo and Juliet’ died after her son was exiled from Verona. Maybe Shakespeare didn’t know it, but he might have been the author of the first documented case of ‘dying from a broken heart’.
Work done in the 1980s on homicide victims who died after an assault but did not sustain life-threatening injuries revealed autopsy findings suggesting they may have died due to a stress-induced cardiomyopathy
.Acute emotional stressors have been around for as long as humanity, and I suspect so too has Takotsubo Cardiomyopathy.
Takeaway
Takotsubo Cardiomyopathy is rare, usually self-limiting but can be fatal.
However, it does highlight a crucial point.
The emotional events we encounter in life can affect our cardiovascular health.
Usually, these impacts result from slow, constant background stressors, but when emotional stressors are sudden and significant….
Hearts can break.
But they usually get better.
https://mi-psych.com.au/what-is-stress/
Psychosocial Risk Factors and Cardiovascular Disease and Death in a Population-Based Cohort From 21 Low-, Middle-, and High-Income Countries. JAMA Netw Open. 2021;4(12):e2138920.
Takotsubo cardiomyopathy: Review of broken heart syndrome. JAAPA. 2020 Mar;33(3):24-29.
Lyon A, Citro R, Schneider B, et al. Pathophysiology of Takotsubo Syndrome. J Am Coll Cardiol. 2021 Feb, 77 (7) 902–921.
Takotsubo cardiomyopathy: Review of broken heart syndrome. JAAPA 33(3):p 24-29, March 2020. | DOI: 10.1097/01.JAA.0000654368.35241.fc
Takotsubo cardiomyopathy: Review of broken heart syndrome. JAAPA 33(3):p 24-29, March 2020. | DOI: 10.1097/01.JAA.0000654368.35241.fc
Takotsubo cardiomyopathy: Review of broken heart syndrome. JAAPA. 2020 Mar;33(3):24-29.
Human stress cardiomyopathy. Myocardial lesions in victims of homicidal assaults without internal injuries. Hum Pathol. 1980 Mar;11(2):123-32.