The Achy Breaky Heart

Author: Klein Matt, MD (EM Resident Physician, PGY-2, NUEM) // Edited by: Michael Macias, MD (EM Resident Physician, PGY-3, NUEM) 

Citation: [Peer-Reviewed, Web Publication] Klein M, Macias M (2016, February 14). The Achy Breaky Heart. [NUEM Blog]. Retrieved from http://www.nuemblog.com/blog/achy-breaky-heart/

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In 1990, only two years before singer Billy Ray Cyrus revealed his cardiac myocytes to be “achy breaky,” Japanese scientists first described a pathophysiologic mechanism for a common condition which has, for centuries, plagued philosophers and poets, cardiologists and lyricists alike: the broken heart.

Takotsubo cardiomyopathy, also known as stress cardiomyopathy or broken heart syndrome, is  an increasingly recognized clinical entity that mimics the features of acute coronary syndrome (ACS). Patients with takotsubo present with new EKG changes or troponin elevation, but without obstructive coronary disease or acute plaque rupture. Thus, symptoms result not from a total eclipse of the heart, but rather apical ballooning of the left ventricle, the shape of which resembles the Japanese octopus pot known as takotsubo.

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Triggering Factors Of Takotsubo Cardiomyopathy

The most common triggers for takotsubo cardiomyopathy were physical or emotional triggers with a smaller fraction of patients who had both. In 28.5% of all takotsubo cardiomyopathy cases a stressful event could not be determined.

The condition is most common among elderly women, who frequently report antecedent physical or emotional triggers. While these patients may first present afraid and/or petrified, many will survive, with a rate of death of 5.6% per patient-year. Compared to patients with ACS, the reduction of left ventricular ejection fraction (LVEF) was both more common in patients with takotsubo cardiomyopathy (86.5% vs 54.2%) and more severe (mean value 40.7% vs. 51.5%, P<0.001).4 This reduction is not permanent, as follow up studies have demonstrated the ability of patients to unbreak their heart and return to normal LVEF.

Prevalence of Underlying Neurological and Psychiatric Disorders

The prevalence of underlying neurological or psychiatric disease is significantly higher in takotsubo cardiomyopathy than in acute coronary syndrome patients.

Proposed mechanisms for takotsubo cardiomyopathy favor a neurohormonal model, in which increased catecholamines shot through the heart are the likely source of blame. This surge may trigger a transient coronary vasospasm, resulting in the EKG changes and troponin elevations which mimic ACS.

Take Home Point

The diagnosis of takotsubo cardiomyopathy cannot be made in the emergency department, and patients presenting with new EKG changes or signs of heart failure must be treated per standard algorithms. Prompt recognition and aggressive management may allow for these once broken hearts to go on and on.

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References

1. Von Tress, Don. (1992). Achy Breaky Heart. [Recorded by Billy Ray Cyrus]. On Some Gave it All. Mercury Records. January 1992.
2. Sato HTH, Uchida T, Dote K, Ishihara M. Tako-tsubo-like left ventricular dysfunction due to multivessel coronary spasm. In: Kodama K, Haze K, Hori M, eds. Clinical aspect of myocardial injury: from ischemia to heart failure. Tokyo: Kagakuhyoronsha Publishing, 1990:56-64. (In Japanese.)
3. Akashi YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo cardiomyopathy: a new form of acute, reversible heart failure. Circulation 2008;118(25):2754-62.
4. Templin C, et al. Clinical features and outcomes of takotsubo (stress) cardiomyopathy. New England Journal of Medicine 2015;373:929-38.
5. Mandeep S, et al. Temporal changes in left ventricular strain vis-à-vis ejection fraction in patients with takotsubo cardiomyopathy. Journal of the American College of Cardiology 2014;63.
6. Wittstein IS, et al. Neurohormal features of myocardial stunning due to sudden emotional stress. New England Journal of Medicine 2005;352(6):539-48.