If this Valentine’s Day, you’re looking for some romance tinged with tragedy, look no further than the Celtic legend of Tristan and Isolde, star-crossed lovers who predated Romeo and Juliet by several centuries. Things don’t end happily (spoiler alert): Tristan dies a mortal wound, and Isolde dies beside him, of a broken heart.
The legend may be a myth, but broken hearts are a real phenomenon. Broken Heart Syndrome is an actual condition, different from a heart attack, which is often caused by acute stress or grief. It doesn’t cause instant death, however, and in the majority of cases it is a temporary condition that can be reversed. The regular heartache we feel after a big emotional loss is real, too: it’s caused by reduced blood flow to the heart. Broken Heart Syndrome, however, is a specific diagnosis, and much more painful. Without tests, its symptoms look just like a heart attack.
Also known as stress cardiomyopathy, or by its Japanese name, Takotsubo Cardiomyopathy, Broken Heart Syndrome is a rare but serious health issue, affecting thousands of patients worldwide each year. While researchers are still investigating the causes and effects of this mysterious condition, Broken Heart Syndrome is far from a romantic myth.
Lovelorn
A real case goes more like this: Linda, 47 years old and in very good health, went to visit an ill friend in the hospital, who unexpectedly died during the visit. 20 minutes later, a grief-stricken Linda clutched her heart, seized with sudden, acute chest pain. Still in the hospital, doctors rushed her to the ER for an angiogram, suspecting a heart attack.
Instead, Linda was diagnosed with TTS, Takotsubo Syndrome. (The community of patients who’ve had this condition prefer the term Takotsubo, arguing that “Broken Heart Syndrome” diminishes the clinical credibility of the issue, and isn’t an accurate description for all cases.) Linda spent six days in the hospital; by the time she was released, her heart had normalized again.
Linda’s story – one of many shared on the Takotsubo support network’s website – is precisely the kind of case that inspired medical researchers to investigate this mysterious condition, which causes chambers of the heart to balloon in shape, weakening the muscles that pump blood. That ballooning reminded the Japanese team that first identified the condition of the shape of a rounded octopus trap called a takotsubo, and assigned it that clinical name in a paper they published in 1990.
The symptoms of Takotsubo are very similar to a heart attack, including chest pain, breathlessness, and/or collapse, so doctors only diagnose Takotsubo after an electrocardiogram (ECG) and blood tests have ruled out a heart attack.
Despite those outward symptoms, heart attacks and Takotsubo differ considerably. Heart attacks are caused by plaque ruptures in the heart’s arteries, causing blood clots that permanently damage the heart tissue. With Takotsubo, an excess of stress hormones is released into the bloodstream, flooding the heart and triggering a series of mechanisms that temporarily impede the heart’s ability to pump properly.
“It’s a stunning of the heart muscle,” explains Dr. Ilan S. Wittstein, a cardiologist at Johns Hopkins University School of Medicine, who published the first U.S. study on the condition in 2005. “In a heart attack, at least some of the heart muscle is permanently killed. In Takotsubo, while the heart can look very weak on day one, it gets better, because the heart muscle is stunned and not killed.”
Most cases – though not all – are caused by an identifiable stress trigger. Emotional events like the loss of a loved one or a frightening robbery can cause Takotsubo, along with physical stressors, such as a stroke, overexertion, or exposure to extreme heat. In one of the first Takotsubo cases Dr. Wittstein saw, a woman developed acute chest pain after her own surprise birthday party.
While about 96% of patients make a full recovery from Takotsubo, Dr. Wittstein notes that the outcome depends on a variety of factors, from age to genetics, but also the type of stress event that triggered the syndrome. “It’s kind of hard to compare somebody who had a surprise birthday party and someone who had a massive stroke,” Dr. Wittstein explains. In some cases, there is no stress trigger at all, leading some researchers to call for more diagnostic specificity within the umbrella of Takotsubo Syndrome, in order to better understand causation and prognosis.
The link to women
About 90% of Takotsubo Syndrome patients are post-menopausal women, a link that may be caused by declining estrogen levels. But this link, like much about Takotsubo, is still heavily debated. As more case studies emerge, researchers have raised new questions about the mysterious syndrome. In a 2020 paper in European Heart Journal, for instance, researchers critiqued the current prevailing belief that Takotsubo syndrome and coronary artery disease, which causes heart attacks, are mutually exclusive, citing a new study that found they coincide more frequently than previously thought.
Much is still unknown about Takotsubo Syndrome, including why these stress events lead to heart muscle weakness, and why thirty percent of cases have no identifiable stress trigger at all. That’s partly because Takotsubo was only discovered recently, a lag resulting from the long history of gender bias in medical research. Echocardiography – heart ultrasound technology – became widespread in the 1970s, greatly advancing our understanding of the human heart, but centuries of cardiology research focused on male patients, often overlooking issues more common in women.
The issue persists today: the British Heart Foundation found that, while heart disease is the leading cause of death for women worldwide, women are 50% more likely than men to be misdiagnosed. “If you are a woman, the odds are stacked differently,” Dr. Sonya Babu-Narayan, associate medical director of the BHF, says in a statement on the organization’s website.
Since Takotsubo Cardiomyopathy was first identified, researchers have gathered larger patient samples to better understand the condition and how to care for it. Treating the immediate symptoms is critical, because in most cases, once the heart has stabilized, it will return to normal on its own, says Dr. Malissa Wood, co-director of the Corrigan Women’s Heart Health Program at Massachusetts General Hospital Heart Center.
“First we make sure the diagnosis is correct, and that it’s not a heart attack,” Dr. Wood said. “Then we’ll use beta blockers and ACE inhibitors,” which promote heart muscle recovery by relaxing the veins and arteries and lowering blood pressure. “If they’re having rhythm problems, or heart failure, chest pain…we’ll treat that – we really respond to the problem the patient is having.”
For most patients, Takotsubo only occurs once, but some individuals have experienced multiple episodes. Doctors still aren’t sure how to prevent it from recurring, but, as Dr. Wood notes, “the good news is it very rarely does.”
After recovery, Dr. Wood adds, managing stress through meditation, mindfulness, and other relaxation techniques is an important long-term priority – something everyone should do, whether they’ve had heart trouble or not.
And, she added, all the regular advice for heart health applies here, too: 150 minutes of heart-pumping exercise every week, eating a healthy diet, and limiting sodium, carbohydrates, and sugar. “All of the general recommendations for heart health, and managing stress – that’s really important,” Dr. Wood explains.
Takotsubo cardiomyopathy is quite rare, so even if you’ve had an acutely stressful or traumatizing experience, it’s not likely your heart will give you trouble. But Dr. Wood says that anyone experiencing a symptom they haven’t felt before, such as chest tightness or difficulty breathing, should get it checked out.
Whether it’s the real Broken Heart Syndrome, or garden-variety sadness, Dr. Wittstein notes, “the heart truly does ache.” Luckily, with some tender care (and perhaps just a little bit of dark chocolate), your heart will begin to mend.