Yes, You Can Die From a Broken Heart
Welcome to Impact Factor , your weekly dose of commentary on a new medical study. I'm Dr F. Perry Wilson from the Yale School of Medicine.
A patient comes crashing into the emergency room with severe chest pain. The EKG looks like this:
As a doctor, if you see this, you're calling the cardiac cath lab. This is an ST-elevation myocardial infarction — the big one — indicative of a blood clot blocking blood flow to a large section of the heart. The sooner you get that blood clot out, the better chance the patient has to survive.
So the patient is rushed to the cath lab, and they find… nothing. Clear coronaries. No blood clot. Further questioning reveals that the patient, an older woman, lost her husband recently. This is stress-induced cardiomyopathy, medically known as Takotsubo cardiomyopathy (TC). It's the pathophysiologic manifestation of a broken heart.
First described in 1991, Takotsubo syndrome occurs in the setting of deep psychological, emotional, or physical stress.
Despite being aware of it for decades, we still don't really understand what the underlying processes are, though they probably have something to do with an excess of catecholamines. But a new study cobbles together data from across the United States to give us new insight into the epidemiology and outcomes of the syndrome.
Interestingly, women are much more likely to get a broken heart. But men are more likely to die from it.
We got a nice Takotsubo analysis this week, thanks to this article in the Journal of the American Heart Association , from Mohammad Movahed of the University of Arizona and colleagues.
They used a database called the National Inpatient Sample. It is what it sounds like: a sample of data from patients hospitalized around the nation. It's a weighted dataset; it doesn't have data from every hospitalization, but individual patients in the dataset can stand in for those who aren't there. This allows you to estimate stuff like the total number of admissions for a certain diagnosis across the whole country.
The researchers flagged admissions with a diagnosis code for TC. All told, they identified 39,984 individuals with the syndrome, which scales up to an estimated 199,890 US admissions in total from 2016-2020 — about 40,000 admissions per year in this country. It's not a huge number; there are around 600,000 admissions per year for acute myocardial infarction, but it's not exactly rare.
Women were much more likely to have TC; 83% of all the cases were female. You can see here a slight increase in prevalence over time, but nothing dramatic, especially considering that the last year of data would encompass the start of the COVID pandemic.
If we break down the incidence by age group, you can see an interesting increase in risk as people got older, with a near doubling of risk after age 45.
People have hypothesized that estrogen may play a protective role in this condition, so we might be seeing an increased risk associated with menopause here, but I would have liked to see this stratified by sex to be certain.
The authors compare outcomes among those hospitalized with TC to outcomes of hospitalized patients without TC. That feels like an overly broad control group, to be honest, so it isn't surprising that there is, for example, a 12-fold risk for cardiogenic shock compared with the general inpatient population. Individuals admitted to the hospital with other types of heart disease, or a heart attack, would have told us a bit more about the unique risks of TC. Maybe next time.
Of course, the worst possible outcome is death, and 6.58% of the patients with TC died during their admission. That's against a background rate of 2.4% of all other patients in the hospital — about a threefold increase in mortality risk.
But men with TC were much more likely to die than women, with an 11.2% mortality rate compared with 5.5% among women. This has also been increasing over time. There's no clear explanation for the discrepancy. Men were more likely to develop the condition from physical, as opposed to emotional, stress, and that might change the risk profile. Alternatively, it's possible that this is a 'stubborn man' phenomenon; men might be less likely to go to the hospital when symptoms are mild, so if they do make it to the hospital, they are in worse shape. Take care of yourselves, guys.
This paper may have raised more questions than answers, but I appreciate the opportunity to highlight something we often forget — that there is a profound connection between our minds, our emotions, and our bodies, and that connection is not purely subjective. Takotsubo cardiomyopathy is a potentially fatal disease, with all the risks of a major heart attack and without a convenient treatment like cardiac catheterization. And though I hope most of us never experience the levels of stress — emotional or otherwise — that would precipitate this disease, the very existence of a syndrome like this shows us that stress can be toxic. None of us can live stress-free lives, of course, and I'm not sure what the dose-response effect is, but in the end, perhaps knowing that how we feel affects how we feel can help us better manage how we feel.
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