This past December, actress Debbie Reynolds passed away two days after the death of her daughter, actress and author Carrie Fisher, who suffered a catastrophic heart attack. Headlines were quick to blame “broken heart syndrome.” Though the cause of Reynolds' death was subsequently reported to be a stroke (she had suffered two other strokes in 2015), these events left many people wondering: Can you really die of a broken heart?
Takotsubo cardiomyopathy is the medical term for broken heart syndrome, which may occur after suffering deep, unrelenting sadness over the loss or end of a relationship. (The medical profession also refers to it as apical ballooning syndrome or stress cardiomyopathy.) The term was coined in Japan more than 25 years ago, but it wasn’t until a paper was published in the New England Journal of Medicine in 2005 that the condition began to gain international recognition.
A broken heart or a heart attack?
Broken heart syndrome is often misdiagnosed because its symptoms resemble those of a heart attack, with shortness of breath and chest pain. There may even be similar changes on an electrocardiogram (which measures the electrical activity of the heart), as well as on a blood test done when patients present in the emergency room with a possible heart attack. However, unlike a heart attack, with broken heart syndrome there is nothing obstructing blood flow in the coronary arteries (that is, there is no blood clot). Instead, usually a portion of the wall of the heart’s major chamber—the left ventricle, which is responsible for pumping blood throughout the body—thins and expands like a balloon. (The shape of the ballooning resembles a pot that Japanese fishermen use to catch octopuses, called a tako-tsubo, hence the medical name.)
Diagnosis is not straightforward but rather involves ruling out a heart attack caused by coronary artery disease, which is done with a coronary angiogram (a test that visualizes the coronary arteries). A normal coronary angiogram in someone who has acute heart injury (as shown on other tests) and has experienced recent “stress” most likely has stress cardiomyopathy.
The symptoms of broken heart syndrome can start a few minutes after experiencing an extreme emotion. But it’s not just the loss of a relationship that may precipitate it. There may be other intense psychological as well as physical factors responsible, such as receiving bad news or a big shock, experiencing a natural disaster, being in a car accident or physical fight, or having surgery. In a paper presented in 2014 at the annual meeting of the American College of Cardiology, researchers reported a dramatic increase in the condition in Vermont and Missouri after massive storms hit both states.
And it’s the intensity of the stressor—not whether it’s a happy or sad one—that triggers the condition. A 2016 study in the European Heart Journal, which looked at data from 25 medical centers in the U.S. and Europe, found that 4 percent of the events associated with takotsubo cardiomyopathy were happy ones, such as a wedding, a birthday party, or the birth of a grandchild (thus, the coining of the term “happy heart syndrome”).
Postmenopausal women account for most cases of broken heart syndrome—near 90 percent, according to a 2015 study in the New England Journal of Medicine (NEJM), which included 1,750 patients. In women, it’s often related to psychological stress, or there’s no apparent cause, whereas in men it’s more likely triggered by physical stress.
The cause of broken heart syndrome (apart from the trigger) isn’t entirely clear, but the prevailing thought is that it’s related to the rapid secretion of stress hormones, including adrenalin, which may cause the very small coronary vessels—those too small to be seen on angiogram—to temporarily narrow, thereby reducing blood flow to the heart muscle. In postmenopausal women, it’s been hypothesized that reduced levels of estrogen may affect how these small blood vessels react, or how the heart muscle itself reacts to stressors. There may also be a genetic link.
How serious is it?
It was once thought that patients with broken heart syndrome fully recover within days or weeks. But it’s now known that the condition can be life threatening because of potentially lethal heart rhythm abnormalities (arrhythmias), along with a drop in blood pressure and congestive heart failure (where the heart’s pumping action is compromised). And in men, the condition is more likely to be associated with cardiac arrest.
In the NEJM study cited above, people with broken heart syndrome had significantly worse pumping action in their left ventricle and similar rates of cardiogenic shock and death, compared to patients presenting with heart attacks or unstable angina. The most common adverse events in those with broken heart syndrome were stroke, transient ischemic attacks (TIAs, or mini-strokes), and death, particularly in men. That means that it’s still possible that broken heart syndrome, though not the direct cause of Debbie Reynolds’ death, may have contributed.
Though there are no formal recommendations, broken heart syndrome is often treated with some of the same medications that are typically used for heart failure, including diuretics, beta blockers, and ACE inhibitors.
What's known and not known
Takotsubo cardiomyopathy is diagnosed in about 1 to 2 percent of people presenting with symptoms of a heart attack along with electrocardiogram and blood-test abnormalities. Unfortunately, much is still unknown about the condition, including how often it occurs after an emotional or physical stressor and its long-term prognosis. In the meantime, the best advice is to care for your heart and recognize the signs of a heart attack, which can be different in women than in men.
Also see Screening Tests for Heart Disease.