We can all agree that a breakup is one of the most stressful moments that we have all surely experienced. Some may go to extremes such as calling their ex 14 times in the early morning hours and then leaving them a 10-minute voice note in which, between sobs and cries, they are unable to formulate more than a couple of coherent sentences (not that it has ever happened to me cough cough), while others are able to overcome it relatively quickly and get on with their life as if nothing had happened. Still, even the latter have to admit that a broken heart can be worse than many diseases.

But what if I told you that the emotional pain of a broken heart, or the loss of a loved one, can cause a physical condition so real as to literally cause death? We often comfort people by saying that "no one has died of a broken heart," but as you are about to discover, dear reader, we have been lying to them. It turns out that these situations are perfectly capable of causing real harm to our body, although it is probably a good idea to hide this fact from those currently having a bad time emotionally; the last thing they need to know is that they can die at any moment. But for those of us who are not going through such a situation (I hope), it can’t hurt to learn a bit about this pathology, and how we can prevent it when he or she finally confesses that they do not love you (and that they cheated on you with your best friend. Bummer, I know). I’m talking about the Takotsubo Cardiomyopathy, or as it is also known, Broken Heart Syndrome.

Rare Diseases: Broken Heart Syndrome

I have previously talked about how things considered abstract, such as beliefs or feelings, can have quite real and measurable effects on our body. Knowing this, it is not a big surprise that a strong negative feeling can adversely affect our health, but Takotsubo syndrome has some characteristics that make it stand out. For example, and as you can perhaps guess by the name "cardiomyopathy", it affects the heart. It may seem appropriate, but it ceases to make as much sense if we remember that what we perceive as emotions actually have do not have that much to do with the circulatory system; everything we feel is caused by a variety of chemicals known as neurotransmitters, triggered by various experiences, and which our brain receives and interprets as happiness, sadness, anger, love, or other feelings. This explanation may seem somewhat cold and insensitive, but hey, things as they are. But then, how is it that these sensations, mainly mediated by the brain, neurotransmitters, glands and neurons, can damage the cardiac muscle? Well, to answer this, we have to know a few things about how the heart works.


Although ever since we have kept written records, humanity has associated the heart with feelings, even considering it as the center of all emotions, the truth is that if we leave behind all romanticism, the heart is not much more than a glorified pump, no a lot more complex than those used to supply water to our homes. After all, what is the circulatory system but a network of pipes that distribute blood throughout our body? Of course, it has a notable difference with most common pumps, and that is that blood is not just any liquid; its job is to transport everything that the muscles and organs need for its proper functioning, and one of these components is oxygen, so it has to pass through the lungs. Let's see, then, the role of the heart in this blood transport system.


Let's start by talking a bit about cardiac anatomy; we know that the heart bears little resemblance to the artistic representation that we know so well and that surely we have all drawn (poorly) for our mothers at some point in our childhood. In reality, the heart is basically a hollow organ, made of a tough and resistant muscle tissue called the myocardium, and divided into 4 compartments: two ventricles, a right one that pumps blood, first to the lungs for oxygenation, exiting through an artery called the pulmonary artery, and a left one, which sends it to the rest of the body through the aorta artery, the largest-caliber artery in the body. Likewise, it has two atria, the right one that receives deoxygenated blood, collected by the entire venous system that empties into the vena cava which, in turn connects to the heart, and the left one, where the recently oxygenated blood from the lungs arrives, through the pulmonary vein. In short, oxygen-free blood enters the right atrium, from there it goes down to the right ventricle through a valve called tricuspid, which allows blood flow only in one direction and prevents it from returning to the atrium. From the ventricle it goes to the lungs, passing through the pulmonary artery and its pulmonary valve, and returns full of oxygen to the left atrium, to then go to the left ventricle passing through the mitral or bicuspid valve, and finally exits through the aortic artery, passing through its aortic valve and is distributed throughout the body.





Having made clear the composition of the heart, we can study in depth the so-called broken heart syndrome. Although for several decades it had been noted that the death of a loved one increased the incidence of heart disease by up to a factor of 7, it was not until the 1990s that a study was conducted in Japan in a number of patients, mostly female and of middle-to-advanced age, they presented symptoms extremely similar to those of acute heart attack, such as severe oppressive chest pain along with dyspnea (respiratory distress), increased sweating, and changes in the electrocardiogram consistent with a cardiac infarction, but without any alteration in the coronary arteries, which supply blood to the heart muscle tissue (all this recalling that a heart attack is the death of part of the myocardium due to lack of blood supply, commonly due to coronary obstructions), and in most cases, after situations with intense emotional stress, such as the death of a family member or a breakup.


The specific cause of this syndrome is not entirely known yet, but it is known that it is more frequent in women, especially in those post-menopausal, so it is possible that estrogen, the main female sex hormone, has some protective effect. Despite its alternate name of "broken heart syndrome," cases have been documented following other strong feelings such as a diagnosis of some other disease with a poor prognosis, loss of money or valuables, or the occurrence of a natural disaster. There have even been cases after positive events, such as winning the lottery or a surprise party. And to explain why situations like these can produce the symptoms described above, we refer to the pathophysiology: although the mechanisms of this disease are not entirely clear, we know that in all cases there have been high levels of catecholamines (hormones and neurotransmitters that basically prepare the body for physical activity), such as dopamine and especially adrenaline.


These catecholamines have a variety of effects; First, they act as vasoconstrictors, making the arteries compress, hindering blood circulation and even preventing it, through the capillaries (terminal part of the arteries) of smaller caliber. Furthermore, epinephrine and norepinephrine increase cardiac activity, also increasing its blood and oxygen requirements, and, due to vasoconstriction, the entirety if the heart cannot be properly irrigated, thus causing temporary ischemia (lack of oxygen) which manifests as the classic oppressive pain so similar to that of a heart attack, and causing the amount of blood pumped to be decreased. Along with all this, there is an increase in the contractility of the left ventricle and a bulging of the tip, the pathophysiology of which is not fully understood, but it is believed to be related to a compensatory mechanism in which the myocardium seeks to become less susceptible to the excess catecholamines flooding the blood. It should be noted, by the way, that this ventricular bulge is what gives the name to this condition: "Takotsubo" is the Japanese name for a type of octopus trap, whose shape resembles that taken by the ventricle in those affected by this disease.





Detecting this syndrome based solely on the clinical manifestations is difficult due to its similarity to a heart attack, so for the diagnosis the differences between this and other coronary events should be explored. As I mentioned above, one of the differences is that this heart disease is temporary and rarely leaves serious sequelae (though in some severe cases it can provoke death), unlike an acute infarction, however, this is not very useful for diagnosis since waiting and seeing if the patient dies or survives is not a very practical idea. It is better to find out about the situation in which the condition occurred, asking the patient if he has a previous history of heart disease (common in heart attacks, not so much in this syndrome), and if he recently experienced any exaggerated emotional stress. Although an electrocardiogram can be imprecise, imaging studies such as the echocardiogram, MRI or a coronary angiography can be of great help, allowing one to see the heart and notice if the characteristic ventricular bulge is present, and it helps in ruling out obstructions in the coronary arteries that would make us think of a typical heart attack.


Regarding treatment, although there is no specific one for Takotsubo syndrome, at first it is treated as if it were a common heart attack (vasodilators, anticoagulants, oxygen and morphine) since it is almost impossible to differentiate one thing from the other without conducting several studies. Once the differential diagnosis is achieved, supportive treatment is indicated with drugs such as beta-blockers (mainly used for arrhythmias and hypertension, although some studies have produced contradictory evidence regarding their usefulness against this heart disease), or ACE inhibitors (angiotensin-converting enzyme inhibitors; they basically cut the chain of mechanisms responsible for the increase in blood pressure), along with aspirin to prevent the formation of blood clots that could lead to a real heart attack. However, being a merely temporary condition, the only really effective treatment is time; the symptoms usually disappear in a maximum time of 1 or 2 months, rarely leaving sequelae.


It is quite clear to us that a breakup can “break our hearts” in a much more literal way than we thought, although it is true that a strong positive emotion can also leave us suffering from this syndrome (although personally I would not mind suffering from it if it is because of, let's say, winning the lottery). It would be easy to recommend that we do not allow situations to affect us so, but the truth is that it is often difficult to control what we feel (and impossible to prevent many negative experiences), so a better tip would be to try to enjoy everything good that happen to us, because we never know when the universe concludes that we are having too much fun, and decides to send us some random catastrophe to remind us that we are its bitch there must always be some bad to make us appreciate the good.

References:

• Medscape – Takotsubo cardiomyopathy
• Harvard Health Publishing – Takotsubo cardiomyopathy
• Heart matters – What is Takotsubo syndrome?
• Livescience – “Broken Heart” syndrome is real
• Wikipedia – Catecholamine