Broken heart syndrome during COVID-19 pandemic?

The frequent portrayal in TV dramas and movies of a character collapsing and dying when he encounters an extremely emotional situation such as grief or anger may seem cliché, but the truth is – based on medical facts, there is such an occurrence. This is known originally as the ‘broken heart syndrome’ or Takotsubo syndrome (TTS), which we now refer to as stress cardiomyopathy or transient left ventricular apical ballooning syndrome.

First described by Dr Hikaru Sato in 1991, this is a rare condition characterised by the patient presenting with symptoms and signs suggestive of a heart attack, i.e. chest pain, shortness of breath, fainting spell, electrocardiographic changes and abnormal blood test results.

A unique feature of TTS is that it occurs mostly in postmenopausal women between ages 60 to 70, with the history of a preceding emotional event which serves as a trigger in 30% of these patients. This is often a negative life stressor event, such as the death of a loved one, extreme fear or anger. In a minority of cases, it can also be preceded by a pleasant event such as winning the jackpot, a wedding or even the excitement of witnessing a good win by a favourite sports team.

Physiologic triggers such as severe respiratory illnesses, e.g. COVID-19 infection, strokes, surgeries etc have also been identified to precipitate TTS. At the National University Hospital, 10 patients were diagnosed with this condition over a 7-year period (2000-2006) and the incidence has remained steady.

While there is growing evidence of myocardial injury that accompanies COVID-19 infection based on biomarker and imaging studies, the mechanisms remain poorly understood. TTS could certainly be one of the causes, developing from catecholamine-induced microvascular dysfunction secondary to the metabolic, inflammatory, and emotional distress associated with COVID-19. An overseas study found TTS in small minority of 4% among COVID patients who had ultrasound scan studies of their heart. These patients were all males at median age of 66 years with mortality rate higher than those without myocardial injury on their scans.

To differentiate TTS from heart attack (myocardial infarction), it is necessary to perform coronary angiography and left ventriculography (contrast imaging of the left heart chamber) during the acute stage. 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. The biggest difference between TTS and classic heart attack is that there is no obstruction of the coronary arteries when coronary angiography is performed.

Although TTS has long been considered a benign disease with a good prognosis, the acute stage of the disease still constitutes a life-threatening condition with a mortality rate of 5%, comparable to that of heart attack. These patients will still warrant close monitoring in the Coronary Care Unit (CCU) for complications such as heart failure, cardiogenic shock, and malignant heart rhythms etc. Survivors of TTS have universal recovery of heart function, but recurrence is possible.

Treatment of TTS is largely supportive with medications and long-term prognosis is still uncertain. One cannot prevent this condition but a greater awareness and vigilance about this disease entity by both doctors and the public may lead to earlier diagnosis, intervention, and possibly improved outcomes.

Symptoms of broken heart syndrome are like heart attack:

Article is contributed by Prof Tan Huay Cheem, Chairman of Singapore Heart Foundation; Senior Consultant, Department of Cardiology and Director of National University Heart Centre, Singapore.

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