What Is Broken Heart Syndrome?

Overview 

‘Broken heart syndrome’ is the term commonly used to refer to Takotsubo Cardiomyopathy, a condition whereby the heart muscle becomes suddenly weakened resulting in acute heart failure. It usually results from severe stress, either emotional or physical. It nearly always affects those assigned “female” at birth, especially those that are post-menopause.¹ 

The condition was first identified in Japan during the 1990s and was named after the shape of an ancient octopus trap (a takotsubo), the structure of which is similar to the hearts of affected individuals.²

There are several different names used when referring to this syndrome:

• Broken heart syndrome
• Stress-induced cardiomyopathy
• Apical ballooning syndrome 
• Takotsubo syndrome

The condition causes the left ventricle of the heart to change shape and get larger. The left ventricle is the main powerhouse of the heart, when it contracts, oxygenated blood is pushed through the aorta and around the body.³

Types of broken heart syndrome

Apical

This is the most common type of Broken heart syndrome making up around 80% of cases. During contraction of the heart muscle, the midsection and tip (apex) of the left ventricle balloon out whilst the above area of the ventricle (the base) contracts normally. This is called apical ballooning.⁴ The resulting shape of the ventricle is similar to that of the octopus trap from which takotsubo syndrome takes its name. 

Mid ventricular

Mid ventricular broken heart syndrome is rare. It is presented as abnormalities in the middle section of the left ventricle. The area affected looks like it has a belt wrapped around it with the areas above and below the belt still functioning correctly.⁵

Basal

The affected area looks again like a belt has been wrapped around it, but in basal broken heart syndrome, the belt is higher up than in mid-ventricular.⁶

Focal

Focal takotsubo cardiomyopathy is rare, accounting for 1.5% of all cases. ⁷ The area that is affected sticks out like a bulge from the rest of the heart muscle.⁸

Causes of broken heart syndrome

Unlike some other cardiac conditions such as hypertrophic cardiomyopathy, takotsubo cardiomyopathy is not an inherited condition. It is triggered by extreme emotional or physical stress. Examples of stressful events that have triggered the condition are normally negative experiences, including but not limited to:⁹

• Grief and bereavement 
• Abuse
• Assault
• Severe illness and/or recent surgery 
• Financial issues and worries
• Experiencing a disaster such as an earthquake or violent incident

A small number of patients experience symptoms after a happy event such as a wedding or after receiving good news. When this occurs, it is called ‘happy heart syndrome’ and is more common in those assigned male at birth compared to broken heart syndrome which almost always occurs in people assigned female at birth.¹⁰

Although it is rare, certain drugs can lead to broken heart syndrome. These include:¹¹

• Anxiety medications
• Nasal sprays used to treat a stuffy nose
• Medicines used in an emergency to treat severe asthma attacks or allergic reactions
• Cocaine and methamphetamines

A small number of people experiencing broken heart syndrome cannot pinpoint a particular stressor that has caused their condition.¹²

The exact reason why some people respond in this way to stressful events is not fully clear. It’s thought that surging stress hormones, such as adrenaline might be implicated in the condition. Research carried out by scientists at Imperial College London discovered that increased levels of microRNAs -16 and -26a increase the chance of developing broken heart syndrome. MicroRNAs are small molecules involved in the regulation of gene expression.¹³ When the researchers examined heart cells of rats that had increased levels of these types of microRNA, the cells were more sensitive to adrenaline and were more likely to develop contraction issues. The microRNAs studied (-16 and -26a) are already linked to anxiety and depression and an increase in levels of stress. This research provides an insight into the harmful effects of chronic stress on the cardiovascular system and highlights a potential link between chronic stress and takotsubo syndrome.¹⁴

Signs and symptoms of broken heart syndrome

The British Heart Foundation lists the signs and symptoms of Takotsubo Cardiomyopathy. They are similar to that of a heart attack:

• Sudden, severe chest pain
• Shortness of breath
• Nausea
• Vomiting
• Heart palpitations- these can be felt as a fluttering or pounding sensation in the chest and/or neck

It’s important to take action very quickly and call the emergency services if you experience these symptoms because they could be caused by a serious cardiac condition, including a heart attack. 

Signs of broken heart syndrome that a medical professional will look for: 

• A weakened heart muscle that isn’t pumping blood properly
• A change in the shape of their patients’ left ventricle

Management and treatment for broken heart syndrome

There’s ongoing research to determine the best way to treat the condition but medications are often used with the aim of supporting the heart as the patient recovers. These medications are often prescribed for heart failure as well as broken heart syndrome:¹⁵

• Diuretics

Promote urine output and reduce the build-up of fluids. 

• Beta-blockers 

Block the release of stress hormones adrenaline and noradrenaline. This slows the heart rate and therefore reduces the pressure on the heart. 

• ACE inhibitors

Lower blood pressure by widening the blood vessels will result in less strain on the heart whilst it’s recovering. 

• Blood thinning medications

Prescribed if the patient is at risk of developing a blood clot. 

Most people recover from broken heart syndrome with no long-term damage to the heart muscle. Unfortunately, in a small number of patients, the change in heart shape is permanent. They may experience long-term symptoms of fatigue and chest pain. 

According to the British Heart Foundation, around 10% of patients will go on to develop the condition again in the future. 

Diagnosis of broken heart syndrome

Before a diagnosis of Takotsubo syndrome is made, other medical conditions need to be ruled out. Medical professionals must be sure that the patient is not suffering from an acute myocardial infarction (a heart attack) which has similar symptoms to broken heart syndrome. 

The doctor will also ask the patient about their medical history and will ask if they have experienced any stressful events recently. 

Tests carried out include: 

• An electrocardiogram (ECG) 

A simple test whereby sticky pads are placed on the chest and torso of the patient. The electrical activity of the heart is recorded. Patterns of electrical activity in patients with broken heart syndrome can be similar to that of myocardial infarction. 

• Blood tests

If it is suspected that a patient might be suffering from a heart attack, blood tests are carried out to detect levels of cardiac enzymes. Troponin is one such protein that becomes elevated in response to heart damage. Other blood tests to determine overall health might also be carried out. 

• An echocardiogram

A scan of the heart using soundwaves (like a pregnancy ultrasound) to look at its structures and the way in which blood is moving through the heart. The abnormal movements of the left ventricle associated with broken heart syndrome can be observed during this test. The ballooning of the ventricle should also be visible in patients with the condition. 

• A cardiac MRI scan

Another scanning method that shows a more detailed picture of the structure of the heart. 

• An angiogram

This is a type of X-ray using contrast to look at the arteries that supply the heart with blood. During this test, a small catheter (plastic tubing) is passed through the wrist or groin and directed up the heart. There should be no blockages in the coronary arteries of a patient with takotsubo syndrome.¹⁶
The aim of all of these tests is to get to the root cause of the cardiac symptoms a patient is experiencing. It might not be necessary to have all of the tests listed, it depends on the individual patient and which symptoms they present. 

Complications

It is rare, but the condition can cause death in some cases. 

Complications include:¹⁷

• Low blood pressure
• Persistent irregular heartbeats and rhythms
• Heart failure
• Blood clots within the heart
• Pulmonary oedema- the abnormal build-up of fluid within the lungs

FAQs

How can I prevent broken heart syndrome

As chronic stress is associated with broken heart syndrome, trying to lower emotional stress levels is a good way to reduce your risk of many diseases and maintain good heart health.  

If a patient has already had an episode, following their doctor’s advice and continuing with the medications is the best way to reduce the chances of another episode.  

How common is broken heart syndrome

Around 2% of people that are assessed for a heart attack are actually suffering from takotsubo cardiomyopathy.¹⁸

What kind of emotion can trigger broken heart syndrome

Broken heart syndrome can be triggered by both positive and negative emotions. As mentioned earlier in this article, events causing major stress such as experiencing bereavement or abuse can trigger the condition. It is less common for a positive emotion to be the trigger, but cases have occurred and this is known as ‘happy heart syndrome’. 

When should I see a doctor

If a patient is experiencing any symptoms of Takotsubo cardiomyopathy, they should dial 999 immediately as the symptoms can mimic a heart attack. 

Summary

Broken heart syndrome is a cardiac condition, characterised by the enlargement of the left ventricle. It mostly affects those assigned “female” at birth aged 50 and over. The condition is usually caused by experiencing high levels of stress and is mostly associated with negative emotions such as being severely unwell or suffering a bereavement. Medications such as beta blockers can take the pressure off the heart muscle whilst it recovers. Luckily, patients often make a full recovery.