Throughout history, there have been stories that have linked emotional stress or an emotional event with abnormalities in the way the heart functions. These abnormalities range from the heart beating faster, a sensation of the heart pounding, chest pain, abnormal heart rhythm and sudden death. Takotsubo syndrome (TTS) has likely always existed, but we have only recently recognised it. We have heard stories of “dying of a broken heart” or being “scared to death” but these stories have been considered more of a myth than truth. Stories, and even publications describing the signs and symptoms that we see in TTS have been available for many years,1,2 but TTS was not properly recognised until 1990 by Japanese researchers.3 Even then, it took another 10 years for TTS to be recognised and accepted in Western countries.
Everyone experiences some degree of stress during their lifetime, but not everyone has an episode of TTS. People respond differently to stress, and it would appear that our bodies also respond differently to the physiological changes that occur in response to stress. Researchers have for a long time suspected that there is a brain and heart interaction that has a role in the development of TTS. A recent small but promising study by Swiss researchers showed that compared with people with no history of TTS, people with TTS have altered function in areas of the brain that control emotions and the autonomic nervous system (responsible for heart rate and the ‘fight or flight’ response).4,5 Although this does not provide a complete answer, and it is not certain whether these altered functions are a cause or effect of TTS, it is an important piece of the puzzle and provides a direction for further research.
Many people report extreme fatigue that may last for a few days to months after the acute episode of TTS. Often, the cardiologist will tell them that their heart has returned to normal shape and function. In most cases the test that is used to judge whether the heart has returned to normal is the echocardiogram. The heart is deemed to have returned to normal if it appears to be a normal shape and the ejection fraction (EF) is greater than 50-55%. EF is only an approximate measure of heart function. When the left ventricle (the main chamber of the heart) contracts, the motions of contraction cannot be completely captured by conventional echocardiography. Not only does the heart contract, it has a twisting motion like ‘wringing out’ to efficiently empty. In TTS this motion is impaired and this may persist for some months following the acute episode of TTS.6.7
Magnetic resonance imaging (MRI) studies have shown that there is oedema (fluid and swelling) in the heart muscle affected by TTS at 3 months after the event. This was also correlated with blood tests that detected inflammation. Some people with have elevated NTproBNP (a blood test that is a marker of heart failure) for many months after TTS.8
Health professionals need to understand that a ‘normal’ ejection fraction does not mean that the heart function has recovered completely.
Recovery time is different for everyone. Some people recover very quickly whilst some report feeling unwell for many months after the acute episode of TTS. For people with other underlying medical conditions, this may also result in delayed recovery and this can impact on quality of life.9
You should keep in mind the following:
Join the Takotsubo Support Group (TSG). Hearing about the experiences of others and getting their advice and encouragement can help.
See the page on this website about stress and relaxation.
People with TTS are less likely to be offered CR compared with people who have an acute coronary syndrome (heart attack/angina).11 CR is most commonly offered to patients after a heart attack, although this has now been extended to other cardiac conditions in some institutions. CR is best defined as
“the coordinated sum of activities required to influence favourably the
underlying cause of cardiovascular disease, as well as to provide the best
possible physical, mental and social conditions, so that the patients may,
by their own efforts,preserve or resume optimal functioning in their
community and through improved health behaviour, slow or reverse
progression of disease.”10
The main components of CR are secondary prevention strategies (reducing the risk of a further cardiac event by minimising the impact of cardiac risk factors) and an exercise program. CR has been shown to decrease morbidity and mortality, and improves QoL for patients with cardiovascular disease (CVD),12 but currently there is no evidence about benefits of CR for people with TTS. There are some reasons why CR may be of help for people with TTS, and reasons why some aspects of CR would not be of direct benefit.
The secondary prevention role of CR is to help people reduce risk of CVD recurrence by addressing CVD risk factors. CVD occurs due to atherosclerosis (which causes blockages in the arteries of the heart that can lead to a heart attack). Risk factors associated with the development of atherosclerosis are advanced age, family history of CVD under 65 years of age, smoking, high blood pressure, high cholesterol, diabetes, obesity, and stress (including anxiety and depression). With the exception of psychological stress, there is currently no evidence of an association between these traditional risk factors for cardiovascular disease and TTS.
With regard to the exercise component of CR, anecdotal evidence from the Takotsubo Support Group (TSG) shows that some people find it is of benefit and some find that it makes their symptoms worse. This likely depends upon how advanced they are in their recovery from TTS and timing of the CR program post the acute TTS event.
CR could be tailored to meet the needs of people with TTS, providing that the health professionals involved have a good understanding of TTS. CR could help people with TTS receive up-to-date and accurate information about their condition. Currently this is not offered and increases stress and anxiety for people with TTS.11
Research is needed to ascertain the benefit (or otherwise) of the exercise-based component of CR for people with TTS.
1Cebelin, M.S. and Hirsch, C.S., 1980. Human stress cardiomyopathy: myocardial lesions in victims of homicidal
assaults without internal injuries. Human pathology, 11(2), pp.123-132.
2Doshi, R. and Neil-Dwyer, G., 1980. A clinicopathological study of patients following a subarachnoid hemorrhage. Journal of neurosurgery, 52(3), pp.295-301.
3Sato H, Tateishi H, Uchida T, et al. Kodama K, Haze K, Hon M, eds. Clinical Aspect of Myocardial Injury: From Ischaemia to Heart Failure. Tokyo: Kagakuhyouronsya; 1990. 56-64.
4Templin, C., Hänggi, J., Klein, C., Topka, M.S., Hiestand, T., Levinson, R.A., Jurisic, S., Lüscher, T.F., Ghadri, J.R. and Jäncke, L., 2019. Altered limbic and autonomic processing supports brain-heart axis in Takotsubo syndrome. European Heart Journal. FREE https://doi.org/10.1093/eurheartj/ehz068
5Klein, C., Hiestand, T., Ghadri, J.R., Templin, C., Jäncke, L. and Hänggi, J., 2017. Takotsubo syndrome–predictable from brain imaging data. Scientific reports, 7(1), p.5434.
6 Nowak, R., Fijalkowska, M., Gilis-Malinowska, N., Jaguszewski, M., Galaska, R., Rojek, A., Narkiewicz, K., Gruchala, M. and Fijalkowski, M., 2017. Left ventricular function after takotsubo is not fully recovered in long-term follow-up: A speckle tracking echocardiography study. Cardiology journal, 24(1), pp.57-64. https://doi-org.access.library.unisa.edu.au/10.1007/s00330-018-5475-2
7Dawson, D.K., 2018. Takotsubo: the myth of rapid and complete recovery. European Heart Journal, 39(42), pp, 3762–3763, https://doi.org/10.1093/eurheartj/ehy660
8Neil, C., Nguyen, T.H., Kucia, A., Crouch, B., Sverdlov, A., Chirkov, Y., Mahadavan, G., Selvanayagam, J., Dawson, D., Beltrame, J. and Zeitz, C., 2012. Slowly resolving global myocardial inflammation/oedema in Tako-Tsubo cardiomyopathy: evidence from T2-weighted cardiac MRI. Heart, 98(17), pp.1278-1284.
9Neil, C.J., Nguyen, T.H., Singh, K., Raman, B., Stansborough, J., Dawson, D., Frenneaux, M.P. and Horowitz, J.D., 2015. Relation of delayed recovery of myocardial function after takotsubo cardiomyopathy to subsequent quality of life. The American Journal of Cardiology, 115(8), pp.1085-1089.
10World Health Organization, 1993. Needs and action priorities in cardiac rehabilitation and secondary prevention in patients with CHD. Geneva World Health Organization. Available from http://whqlibdoc.who.int/euro/-1993/EUR_ICP_CVD_125.pdf
11Schubert, S.C., Kucia, A. and Hofmeyer, A., 2018. The Gap in Meeting the Educational and Support Needs of Women with Takotsubo Syndrome Compared to Women with an Acute Coronary Syndrome. Contemporary Issues in Education Research, 11(4), pp.133-144.
12Dalal, H.M., Doherty, P. and Taylor, R.S., 2015. Cardiac rehabilitation. BMJ351, p.h5000.