Division of Cardiology
Johns Hopkins University School of Medicine
The broken heart syndrome
hroughout history, mankind has had an intu- itive understanding of the connection between emotional stress and the heart. Descriptions of “heartache” and “dying from a broken heart”
have appeared in the literary works of diversecultures for centuries. Similarly, the medical literature is replete with descriptions of sudden death and myocar- dial infarction (MI) in the setting of fear, anxiety, and bereavement.1,2 In the modern era, reports of sudden death and MI have been well documented in popula- tions subjected to emotionally traumatic events such as natural disasters3 and acts ofwar,4 but the direct effect of acute emotional stress on cardiac contractile function has remained obscure.
Recently, a novel syndrome of transient left ven- tricular (LV) systolic dysfunction precipitated by acute emotional or physical stress has appeared in the medical literature.5–7 For years this syndrome has been underrecognized and misdiagnosed, andonly now are physicians beginning to appreciate the constellation of clinical features that characterize it.
This brief review will highlight those distin- guishing features, provide some historical back- ground of this relatively new syndrome, and review what is known about its possible pathophysiologic mechanisms.
■ A SYNDROME WITH SEVERALNAMES
In 1980, Cebelin and Hirsch reported a series of mur- der victims who had been emotionally and physically traumatized prior to their deaths. At autopsy, no internal injuries were identified, but most of the vic- tims had extensive myocardial contraction band necrosis.8 This histologic finding, frequently observed in high catecholamine states, suggestedto the authors that these victims may have died from the deleterious effects of catecholamines on their hearts, and they referred to the condition as “human stress cardiomy- opathy.” This term reappeared in the medical litera- ture in 1997 when Pavin et al reported two cases of
* Dr. Wittstein reported that he has no financial relationships that pose apotential conflict of interest with this article.
reversible LV dysfunction precipitated by acute emo- tional stress.9 Stress cardiomyopathy was an obscure and almost unheard of condition in Western medical literature at the time of Pavin’s publication. In the Japanese literature, however, reversible LV dysfunc- tion precipitated by acute emotional or physicalstress had already been well described. In 1990, Satoh et al were the first to refer to this syndrome as takotsubo cardiomyopathy,10 named after the octopus trapping pot with a wide base and narrow neck that they believed resembled the unusual shape of the left ven- tricle in patients with this syndrome.
Throughout the 1990s, takotsubocardiomyopathy appeared in Japanese journals in the form of case reports and small case series. Ironically, when Japanese authors finally introduced this syndrome to a Western audience in 2001,5 they referred to it as transient LV apical ballooning, a name they perhaps felt would be more descriptive to and more easily remembered by Westernphysicians.
In February 2005, the clinical and neurohumoral features of myocardial stunning due to emotional stress were presented in the New England Journal of Medicine.6 This study referred to the syndrome as stress cardiomyopathy, but because several of the patients had presented following the death of a loved one, the name “broken...