They Call it Takotsubo

The 77 year old man found his way into the emergency room, it seemed, almost by accident. He appeared dazed, shaken, dyspneic (short of breath), was feeling nauseas, had recently vomited, and was now clutching at his chest in apparent distress. Several of the nurses knew him only as Mr. Zims. He occasioned this small town ED frequently after the death of his wife several weeks earlier. 

By all measures and algorithms, it appeared that Mr. Zims was having an acute myocardial infarction, or MI (heart attack). But that's not what was happening. In fact Mr. Zims had very few of the traditional cardiac risk factors for a heart attack. He didn't have hypertension, hyperlipidemia (high cholesterol) or diabetes. He wasn't a smoker and he didn't have a family history for cardiovascular disease. But what he did have was something far more ominous. And something that we have all experienced more than once in our lives. What Mr. Zims had, and what the diagnostic and imaging tests would confirm, was that for all intents and purposes, he was suffering from...a broken heart. 

"Broken Heart Syndrome" or Takotsubo cardiomyopathy, was first described in Japan in 1990. Takotsubo mimics acute coronary syndrome. Just like Mr. Zims, patients often present with chest pain. Their EKG's show abnormalities suggestive of MI including ST-segment elevation. These patients also have elevated cardiac enzymes. All of these findings are consistent with an MI. But, the thing is, they are not having a heart attack. 

The Japanese word Takotsubo translates to "octopus pot", because this is the shape the heart takes on when it is in this stressed state. The apex (or bottom of the heart) balloons out when the ventricles contract. But, surprisingly, there is NO significant coronary artery stenosis. Although the exact etiology is still unknown, the syndrome appears to be triggered by a significant emotional or physical stressor. For Mr. Zims, this stressor undoubtedly was the recent loss of his wife. The prognosis in Takotsubo cardiomyopathy is excellent, nearly 95% of patients experience complete recovery within 4-8 weeks. 

Octopus Pot 

I write about this "Broken Heart Syndrome" mostly because I am completely mesmerized by the fact that such a thing exists; that we can, in fact, die of a broken heart. How poetic. How horrifying. How sad. How, in some mystical way, touchingly beautiful. Mr. Zims will be okay, I am sure of that. Figuring out what was wrong with him was the first step towards his recovery. At least his physical recovery. His grief may last the rest of his days. 

In medicine, and especially in training, we all have our "bucket lists" of medical conundrums we wish to see. Learning about Takotsubo was a good fortune, mostly because I will now have it on my differential diagnosis in the future. Mr. Zims will help me help others. But there are other things, other medical phenomena that one may only read about. These are the "zebras" that we learn about. Phenomena so rare one doesn't usually think of them first when a patient arrives with a unique clinical presentation. In my PA program, witnessing a "pheochromocytoma" would be nothing short of an act of god. And not that I wish misfortune or ill will on another human being, but there are other things I hope to see. And I'm sure even more that I hope not to. 

Either way, take care of your hearts, all. They really can break. I know that now.