Broken heart syndrome explained

One physician has dedicated his time to understanding the connection between the heart and the emotions.

For many centuries, people have talked about a connection between emotions and the heart.

The popular concept is very simple: Feelings such as sadness, anguish and stress, among others, can have a detrimental effect on our cardiovascular health.

I clearly remember a story that my great grandmother used to tell everyone about a man who suddenly died from a broken heart three weeks after the death of his spouse. At the time, I thought it was silly. In retrospect, I find it ironic that it took scientists this long to begin understanding the association between the brain and the heart, and between emotional stress and cardiac function.

Ilan Wittstein, MD, a heart failure specialist and assistant professor at Johns Hopkins University, has devoted much of his career to the study of stress cardiomyopathy, or broken heart syndrome. His interest in the field dates back to when he was a medical student. He remembers reading several case reports about women who had developed acute decompensated HF in the setting of intense emotional stress. Later on during his fellowship years, he encountered several patients who had experienced some type of brain injury who then presented to the CCU with significant cardiovascular findings, including deep T wave inversions and transient left ventricular dysfunction.

Wittstein finished his cardiology fellowship at Hopkins and stayed on as faculty. During his first attending year, he took care of three consecutive patients in the ICU, all of whom presented with decompensated HF after having been through an unexpected stressful event. Their echocardiograms showed systolic dysfunction with apical ballooning and basal sparring. They had impressive T wave inversions in the precordial leads, QT prolongation, and a mild serum troponin elevation. Their coronaries were free of obstructive disease. Wittstein suspected that these were cases of transient heart injury, perhaps stunning, so he performed daily echocardiograms on the patients. He knew he was on to something when the patients’ heart function returned back to normal in a remarkably short period of time.

Juan Rivera

Over the next several years, this same clinical scenario repeated itself in dozens of individuals admitted to the Johns Hopkins CCU with signs and symptoms of HF. A relatively new clinical entity was taking shape, and in 2005, Wittstein and colleagues reported the clinical and neurohormonal features of stress cardiomyopathy in The New England Journal of Medicine, bringing international attention to a then obscure syndrome.

Dealing with the skeptics

New ideas and concepts are usually not instant sellers and stress cardiomyopathy was no exception. It takes time for people to challenge and get rid of their preconceived notions and embrace new scientific and clinical data. Someone doing research on a relatively unexplored and perhaps controversial topic may feel overwhelmed by a significant amount of skepticism or criticism towards his/her work. That may be enough, particularly for fellows, to abandon that line of research. When I asked Wittstein about the early skepticism surrounding the stress cardiomyopathy diagnosis, he said, “I was convinced that it was a real medical entity. The criticism back then was due to the fact that there wasn’t a lot of data and information about this condition. I have to admit that it was frustrating at times, but for the most part my colleagues at Hopkins were extremely supportive and have been instrumental over the years in helping me to pursue my research further.”

Syndrome with many names

While stress cardiomyopathy now goes by many names, including Takotsubo cardiomyopathy, left ventricular apical ballooning syndrome and broken heart syndrome, a significant number of people at Hopkins affectionately refer to stress cardiomyopathy as Wittstein’s Syndrome. He has spent innumerable hours teaching students, residents, fellows, nurses and other attendings about the clinical manifestations and the science behind the broken heart syndrome. His enthusiasm and love for his work is extremely contagious. That is probably why almost everyone in the hospital will call him at the sight of a stress cardiomyopathy patient. Due to this wonderful hospital staff collaboration, Wittstein has created a database that includes approximately 130 affected individuals. His next goal is to study individual susceptibility factors, including personality traits, genetic predisposition, and sex hormone associations.

We can all learn from Wittstein’s quest to understand the broken heart. His research career started at the patient’s bedside, trying to piece together the individual’s histories to a repetitive clinical presentation that did not fit traditional criteria. His open mentality and scientific inquiry have helped him contribute to the understanding of this relatively new medical entity.

His enthusiasm and eagerness to teach others have turned his research into a collective effort.

Juan Rivera, MD, is a Fellow at the Johns Hopkins Ciccarone Center for Prevention of Heart Disease and a member of the Today in Cardiology Fellows Advisory Board. He also writes a cardiovascular prevention blog for Hispanics called Corazon Hispano. The blog can be viewed at: www.corazonhispano.blogspot.com.