Stress-induced cardiomyopathy is a condition that is poorly understood, but mimics symptoms of a heart attack such as chest pain, shortness of breath, fainting, and palpitations.
What is stress-induced cardiomyopathy?
Stress-induced cardiomyopathy is one of those strange conditions that the general public seemed to recognize long before the medical community accepted it. If you've ever heard of someone who "died of a broken heart" that person may have had stress cardiomyopathy. Despite rapidly increasing interest in the disease, it remains poorly understood and has only recently begun to be recognized worldwide.
Symptoms include chest pain, shortness of breath, fainting, and palpitations.
After other diagnoses have been ruled out and imaging hasn't identified any arterial blockages, treatments for this condition are largely supportive. Medication to regulate blood pressure may be prescribed.
You should visit your primary care physician within the next 24 hours. Your doctor will likely prescribe heart medications to reduce the workload on the heart while you recover.
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Stress-induced cardiomyopathy symptoms
- Chest pain: This is the most common symptom. This is classically felt in the area surrounding the heart (from the breastbone to the left chest), though pain radiating to the neck or arm is also commonly reported.
- Shortness of breath: This is reported about half of the time.
- Fainting: This occurs less frequently but can result from decreased blood flow out of the heart.
- Palpitations: This describes the feeling of your heart racing or beating irregularly which can occur due to abnormal heart rhythms triggered by stress cardiomyopathy.
Causes of stress-induced cardiomyopathy
Stress-induced cardiomyopathy is a rare disease and it is more likely the individual describing "death by a broken a heart," was just being poetic, but it turns out that severe emotional distress can actually trigger a potentially fatal cardiac event.
In 1990, a Japanese team first described a series of patients who had symptoms resembling a heart attack but with no blockages in their coronary arteries. Furthermore, they shared a unique pattern of cardiac dysfunction in which the tip (or apex) of the heart moved poorly but other areas remained functional. This pattern led to the nickname "apical ballooning syndrome" along with the condition's most famous name "Takotsubo Cardiomyopathy" after the Japanese octopus trap (takotsubo) with a similar distinctive shape. Eventually, the recognition that many people afflicted with this disease had recently been through a traumatic life event led to the more approachable name of stress cardiomyopathy.
The exact cause remains unknown
As one would expect for such a mysterious and recently recognized disease, the exact causes of stress cardiomyopathy remain elusive. Stress cardiomyopathy has been identified most frequently in women over 50 years old. Even in that group, it remains a rare condition, with the most generous estimates suggesting that stress cardiomyopathy accounts for around one percent of hospital admissions for a presumed acute coronary syndrome.
To date, many theories have been proposed to explain the causes of stress cardiomyopathy. One study found evidence of unrecognized plaque rupture, the cause of many true heart attacks, to be present in multiple people diagnosed with stress cardiomyopathy. However, other studies have found no evidence of hidden blockages.
The most prevalent theories explaining stress cardiomyopathy focus on the role of catecholamines, a group of hormones and neurotransmitters released in response to stress or overstimulation.
- Details: The most well-known catecholamine is epinephrine, better known as adrenaline. Adrenaline surges during times of stress, and it is believed that the majority of stress cardiomyopathy is triggered by a physically or emotionally stressful life event.
- Examples of triggers: Generally, these events are far more severe than everyday life difficulties; classic examples include the loss of a spouse or a major car accident.
- Catecholamines in other conditions: Supporting this theory, studies have found that most people diagnosed with stress cardiomyopathy show elevated catecholamine levels. The levels were significantly higher than those found in similar patients having heart attacks. Furthermore, syndromes similar to stress cardiomyopathy have been seen in those with extremely high catecholamine levels due to accidental overdose or an adrenaline-producing tumor (known as a pheochromocytoma).
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Treatment options and prevention
The most important step in managing a possible case of stress cardiomyopathy is verifying that there is no blockage within the coronary arteries, which is to say making sure the person is not having a heart attack (or other forms of "acute coronary syndrome").
Currently there is little that can be reliably recommended to reduce the risk of stress cardiomyopathy. One would assume that reducing stress and avoiding extremely stressful events would decrease the likelihood of developing stress cardiomyopathy, but this is impractical and has not been proven effective. If nothing else, one could theoretically reduce the risk by avoiding stimulant drugs (such as amphetamines) that are known to trigger catecholamine release.
The diagnosis of stress cardiomyopathy requires verification of clear coronary arteries by cardiac catheterization and a coronary angiogram. During this procedure, a wire (or catheter) is guided into the outflow tract of the heart where the coronary arteries take blood to supply the heart muscle. A contrast dye is then injected into the coronary arteries and visualized using X-rays to prove that they are still open and carrying blood effectively.
Ruling out a heart attack
In a true heart attack, blood flow needs to be restored as fast as possible. Given their similar presentations, a possible instance of stress cardiomyopathy is generally treated like a heart attack until proven otherwise.
- Catheterization: Described above, this will be done to check the coronary arteries as soon as possible.
- Echocardiogram: This is the other vital part of imaging, where sound waves are used to visualize the heart similar to ultrasound used in pregnancy. In stress cardiomyopathy, this will likely show the classic "apical ballooning" shape which gave the condition its unique Japanese name.
- Other initial testing: This will include an electrocardiogram (also known as EKG or ECG) and cardiac enzymes which are used as markers of damage to heart tissues.
Once a heart attack has been ruled out and the diagnosis of stress cardiomyopathy is verified, treatment is mainly supportive. The condition is almost always transient, with complete resolution usually seen within a few weeks. However, the short-term dangers are significant and mortality can be as high as would be seen in a true heart attack. For the most part, supportive treatment is targeted at managing symptoms of acute heart failure. These medications are usually not needed once heart function has recovered.
- Fluids or medications to help maintain blood pressure
- Devices or medications to regulate heart pumping: These may be needed to support the heart's pumping function while it recovers.
- Anticoagulants: Also known as blood thinners, these are often given to prevent blood clots, which have a tendency to form within a heart that is not beating effectively.
When to seek further consultation
Given the danger of untreated heart disease, it is vital that anyone who has symptoms indicating these conditions seek medical assistance immediately. While stress cardiomyopathy is still considered rare, the symptoms mimic those of a heart attack and need to be addressed as soon as possible. If you or someone you know is experiencing the following or other symptoms related to a heart attack, call an ambulance immediately:
- Chest pain
- Sudden difficulty breathing
For anyone who has been diagnosed with stress cardiomyopathy, or any serious heart condition, it is important to follow-up regularly with your physician. Most people with stress cardiomyopathy achieve significant recovery within a month of the original incident, and most people never suffer a recurrent episode.
Questions your doctor may ask to diagnose
- Have you been feeling more tired than usual, lethargic or fatigued despite sleeping a normal amount?
- How severe is your chest pain?
- Is your chest pain constant or come-and-go?
- Is your chest pain getting better or worse?
- How long has your chest pain been going on?
Self-diagnose with our free Buoy Assistant if you answer yes on any of these questions.
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- Brieler J, Breeden MA, Tucker J. Cardiomyopathy: An overview. Am Fam Physician. 2017 Nov 15;96(10):640-6. AAFP Link
- Komamura K, Fukui M, Iwasaku T, Hirotani S, Masuyama T. Takotsubo cardiomyopathy: Pathophysiology, diagnosis and treatment. World J Cardiol. 2014;6(7):602-9. NCBI Link
- Redfors B, Vedad R, Angerås O, et al. Mortality in takotsubo syndrome is similar to mortality in myocardial infarction - a report from the SWEDEHEART registry. Int J Cardiol. 2015;185:282-9. NCBI Link