What is broken heart syndrome?

It’s rare, but you really can die of a broken heart.

A sudden emotional shock such as the death of a loved one can shock the heart into an unusual oval shape, rendering it unable to do its job.

“When a person first arrives, the heart may feel terribly weak. It may be barely pressed. In a severe case, you would be in shock in the intensive care unit, and without medical care you would not you wouldn’t survive,” said Dr. Ilan Wittstein, assistant professor of medicine at Johns Hopkins Medicine, who published one of the first papers on broken heart syndrome, also called stress cardiomyopathy.

Yet when Mary Brittingham’s heart first broke at the age of 53, then again at 56 and 69, it had nothing to do with losing someone special to her. Dear.

“I didn’t have my heart tragically broken over a love affair. My first was a surprise, a shock, actually,” said Brittingham, a former law professor at Georgetown Law School. “My second was anger, and my third was fear.”

It was 2006. Brittingham had been told to prepare a quick toast for his fellow honorees at a staff party in Georgetown. Suddenly she heard the host say, “We’re going to hear three speakers tonight, for about 15 minutes each. And our first speaker is Mary Brittingham.”

“It was a total WHAT moment?” she recalls. “I was completely blown away. I was supposed to get up and prepare a speech about my beloved colleagues? All I had was two lines prepared! And I suddenly felt this sort of crushing pressure on chest. It was very painful, but I wrote let’s go for the anxiety.”

Dazed and hurt, Brittingham managed to get to the stage and talk for a few minutes: ‘I must have said some meaningful things because I had a few laughs,’ she said with a chuckle .

But when the pain didn’t ease as the evening progressed, she went to the hospital, fearing she had suffered a heart attack.

“My heart enzymes were elevated, so they pictured, and I had heart failure,” she said. “My dad died of heart failure at the age of 36. So I thought ‘Oh man, this is it.’ But it turned out that I didn’t have a heart attack or heart failure, I had broken heart syndrome.”

A broken heart has an unusual shape

Wittstein first encountered stress cardiomyopathy as a young attending physician in a coronary cardiology unit in 1998, when he had three consecutive unusual cases.

“I saw three patients in a row who had all experienced emotionally stressful events. The first was the death of her mother, the second was in a scary car accident and the third was a surprise reunion. Yet they each are came to the hospital with very similar echocardiogram results,” Wittstein said.

The images showed that the left ventricle of each of their hearts – which is the main pumping chamber – had swelled into an odd shape eerily reminiscent of a takotsubo, a pot used by Japanese fishermen to trap octopuses.

An illustration of takotsubo cardiomyopathy, also known as broken heart syndrome.

Dubbed “takotsubo” cardiomyopathy when first identified in Japan in 1990, the syndrome was not well known in the United States and may have often been misdiagnosed, Wittstein said.

Symptoms such as sweating, chest pain and shortness of breath can be the same as a heart attack, he said. But unlike a heart attack, which is usually caused by blocked arteries, these early patients had “normal, pristine coronary arteries,” with little or no signs of cholesterol and plaque.

Stranger still: Despite blood tests showing significant injuries, the women’s heart muscles did not remain permanently altered or damaged as in a heart attack, Wittstein said. For many patients, function returned to normal within days or weeks.

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“In the early years, we were just amazed at how quickly we saw hearts straightening out. It’s almost like they’re waking up,” he said. “I remember people being sent to our center because they thought they would need a heart transplant. And a week later they’re home.

“At the time it was completely new, but once you recognized the clinical features of the syndrome, it started popping up everywhere,” he said.

Wittstein and his team began to study the phenomenon, publishing one of two seminal papers in 2005.

“We gave it the nickname ‘broken heart syndrome’ because at the time no one in medicine believed that emotions could have such a dramatic impact on the human heart. We wanted to raise awareness,” Wittstein said.

What triggers a broken heart

Today, science still doesn’t know precisely why broken heart syndrome occurs or why some people have repeated episodes, Wittstein said.

“We think it has to do with a malfunction in the body’s fight or flight response, the release of chemicals such as adrenaline, noradrenaline and dopamine that the body uses to prepare us to either flee or beat,” Wittstein said.

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It is estimated that around 2% of people seen in the emergency room for a heart attack may have the syndrome, and a 2020 study found that cases are on the rise, particularly among women. The increase in diagnosis may simply be due to doctors’ greater awareness of the syndrome, Wittstein said.

Almost all people who have episodes of broken heart syndrome are women, he said, especially postmenopausal women who are now low on estrogen.

“When you actually inject estrogen into a blood vessel, the blood vessel expands, gets bigger. So estrogen is a very important mediator of blood vessel function in women,” Wittstein said. “In fact, studies have shown that your risk of broken heart syndrome increases fivefold after age 55 if you’re female.”

Today, doctors know that only a third of all cases are related to emotional shock, Wittstein said. Two-thirds are caused by physical triggers, such as severe pain, asthma attacks, seizures, strokes, high fever, low blood sugar, surgery, and pneumonia.

“We know that of all the physical triggers that can cause this disease, pneumonia is one of the strongest,” he said.

That’s a concern during the pandemic, Wittstein added, because Covid-19 damages the lungs and also causes microvascular function, where the body’s small blood vessels don’t work properly. Damage to these small blood vessels around the heart is another theory of disease.

“When we’re stressed, we want more blood to reach our heart and help the body respond, right?” Wittstein said. “But with broken heart syndrome, we think the rush of adrenaline causes tiny blood vessels in the heart to constrict instead of widen and temporarily reduce the amount of blood getting to the heart.”

Surviving Broken Heart Syndrome

When Mary Brittingham felt a familiar pain in 2009, she knew she was having another attack. It was three years after her first episode, and this time she was in the middle of a heated argument with another lawyer.

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“That’s my telltale sign, that overwhelming sensation just below my sternum that radiates from my chest all the way to my neck,” she said. “And then I know, ‘Oh my god, it’s not anxiety or indigestion.’ That’s really it.”

The third episode happened a decade later when his beloved doodle Alfie was threatened while out for a walk.

“For five minutes I took care of it, then I walked into the house, closed the door and my chest started collapsing,” she said. “Now I had retired and done all sorts of things to reduce the stress in my life. And I thought to myself, I’m almost 70 – is the next one going to kill me?”

By then Brittingham had sought out Wittstein as a doctor, and she went to him with her concerns.

“I asked him, ‘How can I explain this to people who are going to think I’m fragile? I really am not. I feel pretty tough.’ He told me that being frail had nothing to do with it and that a woman had had eight episodes without dying,” she said.

“My favorite story he told me to make me feel better was about a woman who was camping with her husband and decided to dye her hair while he was out fishing,” she added. “A tent started flying away and she had to deal with it before she could wash off the dye. All she could think about was the color of her hair.”

Wittstein echoed the story: “And she had an episode of broken heart syndrome,” he said.

“It’s strange, when we started describing this, we thought it had to be triggered by a massive tragedy, like the death of a loved one or a near-fatal car accident,” he said.

“What we’ve seen over the years is that’s actually not true. Some of the triggers may seem quite mild.”

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