Broken Heart Syndrome: Q&A With D. Douglas Miller, MD

Cardiology Advisor recently interviewed D. Douglas Miller, MD, CM, MBA, about the risks, treatments, and clinical outcomes for Takotsubo cardiomyopathy.

Dr Miller is dean of the School of Medicine at New York Medical College in Valhalla, New York. Previously, he served as an internist, cardiologist, and medical imager at the University of Texas Health Sciences Center at San Antonio, Saint Louis University, and the Veterans Administration.

As Dr Miller explains, Takotsubo cardiomyopathy, otherwise known as “broken heart syndrome” (BHS), was first described in Japan in the 1990s.¹ The condition was named “Takotsubo” because the affected heart assumes the shape of a Japanese octopus fishing pot (see image below).

The Cardiology Advisor: What are some prevention/screening mechanisms in place for stress-induced cardiomyopathy?

Dr Miller: No primary prevention or screening exists. A second attack might be prevented or reduced in severity by chronic treatment with a beta-blocker drug like propranolol or metoprolol.²

The Cardiology Advisor: Who is at greatest risk for BHS? 

Dr Miller: Women between the age of 58 and 75 (median age, 63) comprise 90% of all reported cases.² Clinical reports and animal (rat) studies indicate that postmenopausal subjects are much more susceptible to a sudden surge of adrenaline that “stuns” the heart muscle.² Other cases have been reported after general anesthesia, transplantation surgery, general surgery, etc.²

The Cardiology Advisor: What kinds of collaborative efforts can be made by cardiologists and mental health professionals to reduce the morbidity associated with BHS? 

Dr Miller: Because the patient and the heart usually recover within 1 to 2 months, there have been no reported clinical trials of drugs and/or psychotherapy. It is important to alleviate any physical or emotional stress that may have contributed to triggering the condition.² Case reports have described typical and atypical Takotsubo cardiomyopathy in patients with posttraumatic stress disorder (PTSD).³

The Cardiology Advisor: What are the current treatments/management techniques for BHS? 

Dr Miller: Most cardiologists empirically treat the condition with standard medications for heart failure to “unload” blood pressure stress on the heart muscle.⁴ Some add aspirin and statins.² There are no new therapies in the pipeline.

The Cardiology Advisor: Has the prevalence of BHS changed over time, or are incidence rates being influenced by increasing awareness of the diagnosis?

Dr Miller: The condition has only been recognized since the 1990s. Cardiologists are now more aware of it; approximately 5% of women being evaluated for a possible heart attack² are found to have this condition, so emergency departments and coronary care units are more attuned to it and take proper diagnostic measures to evaluate for it. Associated heart rhythm disturbances (arrhythmias) may require the placement of cardiac electrophysiology devices in rare cases.

 

Imaging of Takotsubo cardiomyopathy (left), and 
a Japanese octopus fishing pot after which the condition is named (right)¹ 

References

1. Sato HTH, Uchida T, Dote K, Ishihara M. Tako-tsubo-like left ventricular dysfunction due to multivessel coronary spasm. In: Kodama K, Haze K, Hori M, eds. Clinical aspect of myocardial injury: from ischemia to heart failure. Tokyo: Kagakuhyoronsha Publishing, 1990:56-64. (In Japanese.)
2. Takotsubo cardiomyopathy (broken-heart syndrome). Harvard Women’s Health Watch. Harvard Medical School. Published November 1, 2010. www.health.harvard.edu/heart-health/takotsubo-cardiomyopathy-broken-heart-syndrome. Updated April 9, 2016. Accessed February 15, 2016.
3. Bartoli C, Nadar MM, Loyd GE, Kasdan ML.  An atypical case of reverse Takotsubo cardiomyopathy during general anesthesia in a 30-year-old male with post-traumatic stress disorder. J Cardiothorac Vasc Anesth. 2011;25(6):1116-1118. doi:10.1053/j.jvca.2010.09.025
4. Templin C, Ghadri JR, Diekmann J, et al. Clinical features and outcomes of Takotsubo (stress) cardiomyopathy. N Engl J Med. 2015;373(10):929-938. doi:10.1056/NEJMoa1406761