In 1897, recently released from prison, the author Oscar Wilde wrote to a close friend, “My desire to live is as intense as ever, and though my heart is broken, hearts are made to be broken: that is why God sends sorrow into the world. The hard heart is the evil thing of life and of art.” Heartbreak, Wilde seemed to imply, wasn’t just an inevitability of life; it was an affirmation of it.
Nearly a hundred years later, doctors in Japan reported that heartbreak could endanger life, too. Takotsubo cardiomyopathy (named after the Japanese term for an octopus trap, which the ballooning heart resembles), also commonly referred to as broken heart syndrome, is a form of acute heart failure that, while often temporary and benign, can also result in significant morbidity and even death. Nine out of ten afflicted individuals are women, and emotional events – a breakup, the death of a loved one, the loss of a job — are classically blamed as triggers.
But broken heart syndrome is more complicated, and less well understood, than its evocative name might suggest. Sometimes the trigger is physical, rather than emotional; traumatic injuries, surgeries, strokes, and asthma attacks are just some of the inciting events that have been reported. Other times, there is no satisfactory explanation for why the condition develops. The near- and long-term health consequences of Takotsubo also haven’t been clearly defined.
To help shed light on these issues, the International Takotsubo Registry was created, and data on seventeen hundred fifty patients afflicted by the condition were collected and studied. The results of the analysis, published this week in NEJM are surprising. Physical triggers were actually more common than emotional ones (36% versus 28%), and in many patients, there was no identifiable trigger (29%). Severe complications during hospitalization were just as likely as with acute coronary syndrome (19% for both) and included death in almost 4% of cases. Long-term complications were also significant, with major adverse cardiac or cardiovascular events occurring in 10% per patient-year, and death from any cause occurring in close to 6% per patient-year.
Takotsubo cardiomyopathy can often be difficult to distinguish from acute coronary syndrome. Notable similarities in an age- and sex-matched comparison included an elevated troponin and evidence of myocardial ischemia on initial EKG (seen in 80% of Takotsubo patients), suggesting that these characteristics aren’t useful for distinguishing between the two conditions. There were, however, a few salient differences. Those with Takotsubo were more likely to demonstrate a reduced left ventricular ejection fraction (87% versus 54%). They were also more likely to have an acute neurological or psychiatric illness (56% versus 26%), suggesting that a connection between the heart and brain could be contributing to the disease process.
The use of an angiotensin converting enzyme inhibitor or angiotensin receptor blocker was linked to improved one-year survival, while beta-blockers, which were previously thought to be protective, didn’t demonstrate a survival benefit. In fact, a third of patients developed Takotsubo cardiomyopathy while on a beta-blocker, and half of patients who suffered a recurrence (a 2% per patient-year risk) were on a beta-blocker at the time of the second event.
“Our data demonstrate that the spectrum of Takotsubo cardiomyopathy is wide and ranges from low to very high risk in the acute phase,” the authors write. A young man who develops the condition after being in a car accident, for instance, has a very different risk profile from an elderly woman whose husband has just passed away.
Perhaps it’s fitting that broken heart syndrome, like heartbreak itself, should be less than straightforward. It blurs the line between the physical and emotional; it implicates the mind in matters of the heart; it sometimes defies reason; and even with our best efforts to comprehend it, it remains, in many ways, a mystery.