THE “HEARTBREAK” SYNDROME: IS IT TO BE UNDERESTIMATED?

In the common lexicon, the “heartbreak” is what happens to the heart after a big trauma, a strong grief, a great emotional or physical stress. However, it is not a simple way of speaking, but rather it is a real disease: the heartbreak syndrome (also called Takotsubo syndrome or stress cardiomyopathy) has a mortality rate similar to that of infarction (4-5% in its acute phase) and it is equally dangerous. In this article we talked about it with Paolo Camici, Full Professor of Cardiology at the Vita-Salute San Raffaele University, Director of the Postgraduate School in Diseases of the Cardiovascular Apparatus and Head of the Center for Myocardial Diseases at the San Raffaele Hospital.

Professor Camici, what is Takotsubo syndrome?

Usually, infarction (acute coronary syndrome) is caused by a thrombus in a coronary artery. In Takotsubo syndrome it’s not like that. Although the symptomatology is the same (chest pain, sudden breathlessness) and the electrocardiogram presents some alterations similar to those of the infarction, to a coronarography the arteries appear strangely normal in most cases. Furthermore, the heart has a particular appearance in the apical part of the left ventricle, a phenomenon called apical balooning. The tip of the left ventricle does not contract, it even extroverts during systole, making the heart assume a shape that recalls the vase (tsubo) that the Japanese fishermen use as a trap to collect octopus (tako).

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Is it true that it mainly affects women?

Yes, it’s true. Female prevalence is very high: over 80% of people affected by Takotsubo syndrome are women. Indeed, according to an important international study involving 1750 patients (published in 2015 by the New England Journal of Medicine), the woman-to-man ratio is 9 to 1. As for classical coronary disease, the risk increases after menopause. In fact, it seems that Takotsubo syndrome is somehow linked to estrogen deficiency, that have a protective effect on the vessels and the coronary circulation.

What could the triggering causes be?

Patients with Takotsubo syndrome have often been subjected to strong emotional, but also physical, stress. For example, again talking about Japan (where the disease was first highlighted), it was observed that the incidence of this disease increased particularly after earthquakes. Stress – that is an alarm situation that the individual can not manage or can not react to – involves an activation of the cerebral cortex and of our autonomic nervous system, in particular of the sympathetic branch.

Photo credit: ShutterStock
Photo credit: ShutterStock

Cortisol and other particular hormones called catecholamines are released. It is precisely the catecholamines which, released in amounts 100 times higher than normal, have a toxic effect on the heart muscle and give the left ventricle this typical balloon appearance that is evident in Takotsubo syndrome. Moreover, catecholamines are doubly harmful because, in addition to being toxic to the heart, they can also produce vasoconstriction of the coronary and microcirculation (small vessels that flow into the wall of the ventricle) with consequent ischemia. Basically, the effect is similar to the heart attack even if the causes are not the same.

Compared to heart attack, is this a benign pathology?

At first it was thought that it was, but unfortunately it is not. Takotsubo syndrome is not less dangerous than infarction. The acute (and even chronic) mortality of these patients, at one year, are not very different from the traditional heart attack. I underline it in my article “Pathophysiology of Takotsubo Syndrome”, published in 2017 on “Circulation”: as for the infarction, Takotsubo syndrome involves a negative prognosis with a mortality of 4-5% in the acute phase. At present there is no specific treatment for this syndrome, whose benignity is to be debunked.

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