Broken Hearts on Valentine's Day, Seriously? Yes, seriously!

Valentine’s day is not a day for celebrating for some of us – especially when you feel your heart is broken! Hold on... This reminds me of Broken Heart Syndrome, also known as Takotsubo cardiomyopathy. Let’s write a little poem to highlight some of the features of this condition!

Takotsubo – such a rare name,

For loving hearts in stress and pain.

No arterial blockage, nor clots, nor scar,

but by the burden of emotions gone too far

Most hearts can bear all this weight,

but what to do if they really break? 

Takotsubo - such a rare name,
for loving hearts in stress and pain.

Many of you might already have heard of the “broken heart” syndrome (Takotsubo myocardiopathy or stress myocardiopathy). The term Takotsubo describes a Japanese octopus trap, and it has been referred to to describe the shape of the dilated apical regin on echo. 

 Do you know how to spot the problem on echo? Participate in this interactive video and answer the questions!

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Explanation: 

Female, age 58, Chest pain and dyspnea after emotional stress - This patient developed pulmonary edema after a dramatic breakup. The four-chamber view shows the typical fears of Takotsubo syndrome: a symmetrically dilated and akinetic apex and midventricular segments (apical / mid-ventricular ballooning), while the basal segments are hypercontractile. 

Emotional stress is a trigger: 

The analogy is quite striking when we compare this to how we metaphorically express the result of intense emotional pain by saying someone has a “broken heart.” Interestingly, this condition can actually be caused by significant emotional distress!

No arterial blockage, nor clots, nor scar…?

Takotsubo cardiomyopathy closely mimics myocardial infarction (MI) due to its acute presentation with chest pain, dyspnea, and diaphoresis, often triggered by stress. ECG changes (ST-segment elevation, T-wave inversions) and elevated cardiac biomarkers (troponin, CK-MB) further resemble acute coronary syndrome (ACS).

An angiography and ventriculography were obtained. What are the main results?

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You have surely noticed that the coronary angiograms of the patients show normal coronary arteries, i.e. an absence of obstructive CAD. The apical ballooning we noticed already on echocardiography is also demonstrated in the ventriculography. 

The absence of arterial obstruction sets Takotsubo syndrome apart from a myocardial infarction. In particular, the left anterior descending artery (LAD) shows no obstruction. A Takotsubo should not be classified as a MINOCA (Myocardial Infarction with Normal Coronary Arteries) as it is generally a self-limiting reversible condition that does not lead to myocardial scarring.

Most hearts can bear all this weight, but what do you do if they really break? 

Unlike MI, myocardial dysfunction in Takotsubo is transient and reversible and does not leave scars. It typically resolves within weeks. The pathophysiology is driven by catecholamine surge and myocardial stunning rather than ischemic necrosis, which causes scarring and often persistent wall motion abnormalities.

While most cases are self-limiting, some severe complications can occur, the most serious being cardiac rupture; so the heart can actually “break”. So some patients actually die of ventricular rupture secondary to Takotsubo cardiomyopathy. 

When the Heart Truly Breaks

While most cases of Takotsubo cardiomyopathy resolve without long-term damage, the condition is not always as benign as once believed. Among the most devastating complications is ventricular rupture, a rare but frequently fatal consequence. Cardiac rupture (CR) is more commonly associated with acute myocardial infarction (AMI); however, it has been reported in stress-induced cardiomyopathy as well (Romeo, 2024). The mortality rate associated with CR in Takotsubo syndrome is alarmingly high, reaching 64% in documented cases, with the left ventricular free wall being the most commonly affected site (Denicolai et al., 2024).

Several risk factors have been associated with CR in Takotsubo cardiomyopathy, including female gender, emotional triggers, and the classic apical ballooning pattern seen on imaging (Denicolai et al., 2024; Romeo, 2024). The timeline of rupture is typically within the first 48 hours of symptom onset. Importantly, electrocardiographic changes, such as a prominent R-wave in lead aVR (termed the "Goldberger sign"), have been suggested as potential predictors of this catastrophic event (Denicolai et al., 2024). Despite these insights, ventricular rupture remains difficult to anticipate, making early diagnosis and intervention critical.

The need for further research into the pathophysiology and risk stratification of Takotsubo cardiomyopathy cannot be overstated. While stress-induced cardiomyopathy often carries a favourable prognosis, the possibility of cardiac rupture should not be underestimated. 

We've shared enough tales of broken hearts and grim diagnoses! Now, are you looking to solve such cases and "heal your patients' hearts"? Then benefit from our Valentine's Day offer now! -40% for our 6 months access available only today, on Valentine's Day! 

And afterwards, turn off your computer or phone and enjoy a lovely Valentine’s Day with someone special!

References

ACHD Bachelorclass, 123 Sonography, with Elena Surkova, MD, MSc, PhD, Matthias Schneider, MD, MSc, and Prof. Thomas Binder, MD, FESC

Denicolai, M., Morello, M., Del Buono, M. G., Sanna, T., Agatiello, C. R., & Abbate, A. (2024). Cardiac rupture as a life-threatening outcome of Takotsubo syndrome: A systematic review. International Journal of Cardiology, 412, 132336. https://doi.org/10.1016/j.ijcard.2024.132336

Romeo, F. J. (2024). When the heart truly breaks: Cardiac rupture in broken heart syndrome. International Journal of Cardiology, 414, 132432. https://doi.org/10.1016/j.ijcard.2024.132432