**EP49: Takotsubo or Broken Heart Syndrome**
**Dr. Warwick:** Welcome to Dr. Warwick's podcast channel. I am Warwick, a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. I believe educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love.
My name's Dr. Warwick Bishop, and I'd like to welcome you to my consulting room. Today, I'm going to discuss a condition called Takotsubo Syndrome. Now, that's a heck of a mouthful. It's spelled T-A-K-O, Tako, T-S-U-B-O, T-S-U-B-O. It's a Japanese word, and I'll tell you more about it in a second. The same condition is also called Broken Heart Syndrome.
This is a discussion today about the emotional stress that can impact your heart. I've done other podcasts on stress and the heart, but this is a very particular situation where stress gives rise to severe crushing chest pain. In fact, it's a situation almost indistinguishable from a normal heart attack.
What we see with this condition called Takotsubo syndrome is a significant emotional challenge in about 70% of people who present with this condition. It may be a fight, it may be some very distressing circumstance in someone's life. It can even occur as people are preparing for surgery, particularly if they're scared. Occasionally, it can even occur during soccer games where there's a lot of emotion involved.
Most commonly, the condition affects middle-aged women. That's most common, but it can affect men, though far less frequently. The condition is characterized by a significant emotional event followed by distressing and unpleasant pain in the chest, as one might imagine from a heart attack. So, these people do present to the hospital, and they do get checked out for a possible problem with blocked coronary arteries.
The syndrome is hard to discern from blocked coronary arteries because the patients have changes on their ECG, which could look like a heart attack. They also have changes in their blood test—the blood test that gives us an indication as to whether there is any damage to the heart. I may have mentioned that blood test before; it's called a troponin. So, these people have chest pain with ECG changes and a positive troponin, and for all the world, they look like they could be having a heart attack. They need to be separated out from that group.
What the condition is, is a significant outpouring of nervous activity and hormones produced from the adrenal glands that seem to impact the way the muscle of the heart works. What is absolutely characteristic about this condition is that it is the nervous input and the hormonal impact on the heart that causes a problem and reduces the way the heart functions.
Importantly, this condition is diagnosed by the presence of all the features of a heart attack without any blocked arteries. So, it is really a diagnosis of exclusion. The name of the condition, Takotsubo, I don't need to explain to any Japanese because they will know that it means octopus pot. That is a descriptive term to try and give us an idea of what the heart looks like when this condition occurs.
Now, it turns out that a Japanese octopus pot has a ring at the top and a bulbous part at the bottom where obviously the body of the octopus sits. It turns out that the heart of Takotsubo is characterized by the proximal parts of the heart looking to work okay, but the distal part, or the apex of the heart, balloons out like a balloon. So, you can imagine a tight collar and a bulbous end. Instead of the heart being a nice bullet-shaped structure, it's a collar with a bulb at the end, and that is very characteristic.
It also occurs in all territories from the apex. One would normally expect, if it were coronary artery disease, for a problem in the function of the heart to be localized to the area that is supported or supplied by that single coronary artery. So, the condition is relatively rare, but it does occur with some frequency—probably up to 5 or 10% of people presenting with what appeared to be a myocardial infarction or heart attack.
Pleasingly, it is very uncommon for this condition to actually kill someone. It is important to understand that most of these patients do recover. It takes several months, and if the patient doesn't recover, that would be uncommon and would certainly prompt a requirement to look for other causes or other diagnoses. I think about 10% of patients can have a second episode, but a second episode is generally fairly uncommon.
Treatment is with the sort of treatments we use for a heart when it's not pumping properly. I've told you already that the apex of the heart, the distal part of the heart, balloons out and doesn't contract properly. So, we treat it as if there's a component of cardiac failure. We also use beta blockers, which block some of the autonomic nervous system—the outpouring of the nervous system that's probably caused the problem in the first place.
The diagnosis is really important, and most of these patients will have an invasive coronary angiogram where we stick a tube inside the arteries and squirt dye directly down the arteries to see the health of the arteries. If there is a narrowing or a blockage, it's very hard to make the diagnosis of Takotsubo because it's really a diagnosis that we can make as an exclusion. Remember, coronary artery disease could exist in coexistence with this condition.
My habit is often to also use, or to use instead of invasive angiography, a CT coronary angiogram so that we can get a good look at not only the inside of the artery to see if there's a narrowing or a blockage, but also to look at the health of the artery just in case there is plaque in those artery walls that could be a problem for that individual down the line.
My general practice is to bring these people back in about three months for a follow-up ultrasound of the heart to make sure that everything's gone back to normal and to follow up with an ECG so we have a documented baseline again should there be any problems in the future.
So, Takotsubo syndrome, broken heart syndrome, apical ballooning syndrome—closely linked with emotion, women more than men, very uncommon for people to die from the condition. It is a diagnosis of exclusion and looks a lot like a heart attack. It is infrequent, but it occurs often enough that we do need to be aware of it, probably representing up to 10% of people who present with features of a heart attack.
And there is some treatment, and we do follow up to make sure everything goes back to normal. Well, now you know what an octopus pot is. Try not to get too emotional watching the football or the soccer. I hope you've enjoyed that. If you have any other ideas for podcasts, please let us know. I'd be happy to try and help out. I hope you found today's podcast informative and educational, and thank you for joining me. Bye for now.
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