Broken Hearts

We’ve spent the last few months talking about stress and how it can harm your sleep, health, safety, and decision-making. It’s not like you need any more reasons to get the stress in your day under control but just in case, let’s talk about some other bad things stress can do to your health. 

Common song lyrics and poetic verses always seem to have something, or everything, to do with lost lovers and broken hearts—metaphorically, that is. That old band Yes makes the case with their song about broken hearts, “Owner of a lonely heart; owner of a broken heart.” Also on the list might be a little verse with an aviation slant from Jean De La Fontaine, a popular 17th-century French poet, who penned a more optimistic line about his own broken heart and lost love, “Sadness flies away on the wings of time.” That might be wishful thinking in poems and songs, but in real life stress and sadness don’t usually just fly away; there’re consequences. Modern medical understanding of the pathology of stress and diseases is finding out that you really can die of a broken heart.

About 30 years ago a Japanese group headed by cardiologist Dr. Hikaru Sato published an article on a series of heart failure patients who all suffered a disease that they called the “broken heart syndrome.” Much to his credit, Dr. Sato didn’t name the new disease after himself as most innovators usually do. The name comes from the characteristic shape of a centuries-old traditional Japanese octopus trap known as a “takotsubo.” When Dr. Sato studied his ailing patients he found they all shared a unique ballooning shape of the left ventricle on an angiogram that gives the heart the same appearance as the old octopus trap and hence the name, Takotsubo syndrome (TTS). The trap pot has a narrow neck and a relatively wide base just like the shape of the “broken hearts” he found in his patients. The shape lets octopuses enter but not leave, appropriately like letting stress into your life and not letting it leave.

Takotsubo syndrome isn’t all that common, but not unheard of. I had a patient on my service last week with this diagnosis and a recent study identified over 115,000 patients in one clinic over ten years with the disease that added up to just over 2% of admissions for acute chest pain syndromes. The causes are all the same, acute emotional stress, and their data reinforce my theme of the last few posts that stress can be really bad for you and can affect your health in all kinds of adverse ways. Take a look at the events precipitating the “broken heart syndrome” the authors listed in their review: domestic abuse or relationship conflict, sudden loss of a loved one, natural disasters, accident or major trauma, fierce argument, financial or gambling losses, unexpected surprise (a patient cited in the paper had a large lottery winning), public speaking, and extreme fright.

With advancements in real-time computer-enhanced imaging we’ve learned a lot about acutely stressed hearts. Although there are a few details of Dr. Sato’s syndrome that still need to be worked out, the most plausible cause responsible for Takotsubo syndrome is the sudden release of stress hormones, such as norepinephrine, epinephrine, and dopamine, causing cardiac stunning. Huge elevations in the levels (two to threefold) of these plasma stress hormones have been found in patients with Takotsubo syndrome. This huge chemical spike causes vasoconstriction of all the arteries in the body (that’s why stress raises your blood pressure), especially spasm of the coronary arteries, leading to acute stunning of the heart muscles. Spasm in these arteries restricts coronary blood flow just like a clot or atherosclerosis blocks perfusion during a heart attack. Subsequent muscle failure from this sudden lack of blood and oxygen is the central cause of heart failure in TTS. And just like its evil twin brother, acute coronary syndrome (heart attack), TTS can be fatal. There are recent reports showing a similar incidence of severe complications and mortality with the two diseases.

Since coronary spasm leads to lack of cardiac blood flow, the symptoms are just like the common “heart attack,” and the clinical presentation of Takotsubo syndrome is the same as that of patients with acute coronary syndromes. Chest pain and dyspnea (shortness of breath) are the most common symptoms, but other symptoms like nausea, palpitations, syncope, and vomiting can also happen. Also in both diseases patients often describe a physical or an emotionally stressful event before the onset of symptoms. Unlike acute coronary syndromes that usually present during the early morning hours, Takotsubo syndrome tends to present in the mid to late afternoon. Without making any potentially politically incorrect assertions, it’s been shown in all the reviews that 85%–90% of the TTS patients are women. With too quick a reaction you might be tempted to think that it’s just that women are more emotional than men, but that’s not true and also unrelated to TTS. The reason is that the incidence of coronary atherosclerosis, literally “hardening of the arteries,” has the opposite male/female ratio and ranges around 75–85 % in men. It turns out that stiff, hard arteries just can’t spasm as opposed to softer, more normal, arteries found in most women.Recent studies published in the European Heart Journal theorize that atherosclerotic coronary artery disease modulates and physically opposes obstruction during spasm and likely explains the lower incidence of TTS in men.

There are tests that can induce coronary spasm in the cardiac catheterization lab to help identify patients who are having symptoms and see if it is due to TSS. It’s important to identify and treat TTS especially because of the condition’s markedly increased incidence over the last few years, likely related to all the stresses we’ve experienced during the ongoing COVID-19 pandemic and its consequences. The treatments of TTS vary depending on the severity and all involve a combination of blood thinners to prevent clot and agents like beta-blockers to relax the spasm. Clearly behavioral counseling to help with a healthier way to deal with stress is an integral part of any treatment plan. Time is the best treatment so supportive care during the worst of the effects is given with the expectation that the disease is self-limited and will improve over time.

If all that isn’t enough to make my point about stress, there’s another cardiac disease that’s also stress related known as “Spontaneous Coronary Artery Dissection syndrome(SCAD).” As in TSS this syndrome also occurs predominantly in women and a key factor is also environmental stress that’s implicated in over 50% of cases. SCAD accounts for about 1/3 of heart attacks in women and the most common cardiac condition during pregnancy. The underlying similarity with TSS is that huge spikes in stress hormones lead to arterial muscle spasm that rockets up the blood pressure and can actually tear (dissect) the inside of coronary arteries. Also as in TSS, women are more likely to suffer from this, as their soft arteries are more prone to shearing injuries from stress-induced arterial spasm.

Stress has been known for decades to be one of the leading causes of cardiac disease and none of this is meant to imply that men are any less likely to suffer stress-related cardiac illnesses (or any stress-related disease for that matter); there are just different manifestations of the same problem because of our inborn anatomical and hormonal differences. Adding it all up as we’ve seen over the last months, stress and its impacts on our health and safety is a huge issue for all of us. Control the stress in your life—relax, get good, restful nights of sleep, and as always, fly safe!

Kenneth Stahl, MD, FACS
Kenneth Stahl, MD, FACS is an expert in principles of aviation safety and has adapted those lessons to healthcare and industry for maximizing patient safety and minimizing human error. He also writes and teaches pilot and patient safety principles and error avoidance. He is triple board-certified in cardiac surgery, trauma surgery/surgical critical care and general surgery. Dr. Stahl holds an active ATP certification and a 25-year member of the AOPA with thousands of hours as pilot in command in multiple airframes. He serves on the AOPA Board of Aviation Medical Advisors and is a published author with numerous peer reviewed journal and medical textbook contributions. Dr. Stahl practices surgery and is active in writing and industry consulting. He can be reached at [email protected].

Related Articles