|
Takotsubo Cardiomyopathy
Takotsubo cardiomyopathy, also known as broken heart syndrome, is a form of stress-induced cardiomyopathy. It is a rare condition where the patient’s left ventricle (the heart’s main pumping chamber) weakens, usually due to severe emotional or physical stress such as sudden illness, the loss of a loved one, a serious accident, or a natural disaster like an earthquake.
First described by Dr Hikaru Sato in 1991, the term ‘Takotsubo’ describes the resemblance of the image of the left ventricle to an earthen pot with a narrow neck and bulbous body used historically by the Japanese to catch octopus.
Symptoms
The condition presents symptoms and signs suggestive of a heart attack:
- Chest pain
- Shortness of breath
- Cold sweat
- Nausea/dizziness
- Fainting spells
- Electrocardiographic changes
- Abnormal blood test results
To differentiate Takotsubo cardiomyopathy from a heart attack, a coronary angiography and left ventriculography (a contrast imaging of the left heart chamber) must be performed during the acute stage.
The biggest difference between Takotsubo cardiomyopathy and a classic heart attack is that there is no obstruction of the coronary arteries when coronary angiography is performed. In Takotsubo cardiomyopathy, blood flow to heart muscles is reduced due to spasms in heart arteries instead of a blockage, resulting in chest pain and shortness of breath.
Causes
Takotsubo cardiomyopathy stems from a specific trigger, either emotional or physical.
- Emotional triggers are mostly negative. It could be the death of a loved one, being in a fierce argument or fear.
About 4% of cases were triggered by pleasant events such as winning the jackpot or witnessing a good win from a favourite sports team. But this is rare, and it occurs mainly in men.
- Physical triggers could include going for major surgery, a stroke attack, or even severe respiratory illnesses like COVID-19 infection. A very rare percentage of patients after COVID-19 pneumonia can actually develop Takotsubo cardiomyopathy and suffer the consequence of it.
This is not a very well-recognised condition until the last one or two decades. The National University Hospital reported its first case in 2005, and about two to three cases per year among the 600 heart attack cases at NUH thereafter. The incidence rate has remained steady.
Cases were mainly related to domestic disputes. A patient developed Takotsubo cardiomyopathy after being scammed and losing money; one was frightened by a barking dog in the neighbourhood. A patient also suffered Takotsubo cardiomyopathy while undergoing cataract surgery due to fear of the operation. These patients have all survived.
How does Takotsubo cardiomyopathy happen
The cause mechanism is not fully known. It is postulated to be a massive surge of adrenaline in the body during a stress state, affecting the small arteries instead of the big vessels. That is why we see clear open arteries on an angiogram, but there may be microvascular involvement.
When Takotsubo cardiomyopathy occurs:
- There is a temporary loss of contractile functions of the left ventricle, a part of our left heart chamber.
- The left heart chamber suddenly expands and enlarges with the weakening of the left ventricular muscle.
- Patients experience symptoms that resemble a heart attack, and there are ECG abnormalities that resemble a heart attack.
However, to differentiate between a heart attack and Takotsubo cardiomyopathy, it is necessary to perform coronary angiography and left ventriculography, which is a contrast imaging of the left heart chamber during the acute stage.
- When a coronary angiogram is done, there is no blockage in the coronary artery, which is unlike the usual heart attack. In Takotsubo cardiomyopathy, blood flow to heart muscles is reduced due to spasms in heart arteries.
Complication
In severe cases (about 20%), patients can go into a heart failure state where they have water in the lungs and need to be supported with medicine and machine. 5% of them will die.
This mortality rate is comparable to the usual heart attack.
Who are at risk
- Postmenopausal Women
80-90% of the affected people are women above age 50 (average age 70), with a history of a preceding emotional event which serves as a trigger in 30% of these patients. - Patients with an underlying psychiatric history
Besides age and gender, up to 40% of patients have some underlying psychiatric history, e.g. mood problem and anxiety disorder.
Treatment
Treatment of Takotsubo cardiomyopathy is largely supported with medications, e.g. pain relievers for pain symptoms.
If patients go into shock, anti-failure treatment will be performed, but mostly they can do with a temporary course of medicine, e.g. beta-blocker, used to treat a heart attack.
But certainly, they do not require blood-thinning or cholesterol-lowering medicine like usual heart attack patients.
The majority of patients will recover within 2 to 4 weeks and can lead a normal lifestyle thereafter. However, it is important for them to manage stress and control their moods well. Some form of psychiatric support may be necessary for people with anxious personalities.
Takotsubo cardiomyopathy cannot be prevented, but a greater awareness may lead to earlier diagnosis, intervention and possibly improved outcomes.
Article contributed by Prof Tan Huay Cheem, Chairman, Singapore Heart Foundation; Senior Consultant Cardiologist, National University Hospital.
