Heart Attack or Broken Heart Syndrome?

"If I could give other women advice, I'd say don't self-diagnose if you're having chest pain."--Patricia Pyle
ONE AFTERNOON IN FEBRUARY 2015, Patricia Carlyle Pyle was sitting on her couch, talking with some friends, when she noticed a slight burning sensation in her chest. “The pain increased after they left, so I lay down for about an hour, then called my primary care physician,” she recalls. “My doctor said to go immediately to the emergency department at Eisenhower and get it checked out. “When I got there and said I’d been having chest pain for close to two hours, boom — I was rushed in, hooked up to an IV and having tests within ten minutes,” Pyle continues. “Dr. Fitts walked in and said because the blood tests showed something was going on with my heart, he was sending me upstairs for a cardiac catheterization.” “My initial concern was that Mrs. Pyle was having a heart attack related to a blocked artery, which is what we typically see in situations where we have positive cardiac markers in the setting of chest pain,” explains Cardiologist James Fitts, MD, Board Certified in Nuclear Cardiology, Echocardiography and Cardiovascular Disease, referring to troponin, a protein that’s released into the bloodstream during a heart attack.

Medical term: Takotsubo cardiomyopathy

“We performed an echocardiogram right away to help determine what was going on, and she had the appearance of takotsubo cardiomyopathy,” he continues. “But we couldn’t prove that was the problem until we did a diagnostic catheterization, since a severe blockage in the left anterior descending coronary artery could also make the heart look the way it did.”

Takotsubo cardiomyopathy — also referred to as broken heart syndrome, apical ballooning, or stress cardiomyopathy — is a condition in which the heart muscle becomes suddenly weakened or stunned and the left ventricle, one of the heart’s chambers, temporarily changes shape.

It can produce the same symptoms as a heart attack — including chest pain, shortness of breath, irregular heartbeat, nausea, sweating, anxiety, and loss of consciousness or fainting — but isn’t caused by coronary artery disease. Without testing, however, there’s no way of knowing if these symptoms are the result of a heart attack or takotsubo cardiomyopathy, so they should be treated as an emergency.

Women aged 50-plus are most at risk

"Don't ignore symptoms. Any symptom that can't be readily explained should be evaluated."--James Fitts, MD
Takotsubo cardiomyopathy most often affects women aged 50 and older, commonly occurring immediately after experiencing extreme emotional or physical stress — such as the sudden death of a loved one, a natural disaster or car accident. It was first identified in Japan in 1990, and named “takotsubo” because during the acute phase of the syndrome, the left ventricle balloons out, taking on a shape that’s similar to a Japanese fisherman’s octopus trap (tako-tsubo).

Although the exact cause of the syndrome isn’t known, research suggests that the sudden release of stress hormones (norepinephrine, epinephrine and dopamine) “stuns” the heart. This triggers changes in heart muscle cells which weaken the left ventricle and prevent it from pumping oxygen-rich blood throughout the body.

Although takotsubo cardiomyopathy is typically triggered by an unexpected stressful event, over one-quarter of individuals have no clear triggers — which was the case in Pyle’s situation. “We kept her in the hospital for two days and gave her medications, including a beta blocker and ACE inhibitor, to protect and help improve her cardiac function,” Dr. Fitts relates. Under his care, she eventually was weaned off the medications after her heart returned to normal.

“As in the majority of cases, Mrs. Pyle’s heart sustained no permanent damage and the left ventricle’s ballooning subsided within a few weeks,” Dr. Fitts says. “In most patients, complete recovery usually occurs within three months, and this condition is rarely fatal,” he notes.“I continue to see her and perform periodic echocardiograms, and everything remains normal,” he adds.

“If I could give other women advice, I’d say don’t self-diagnose if you’re having chest pain,” Pyle says. “If I’d stayed on my couch, it could have created major problems. Thankfully, I didn’t have a heart attack, but my husband died of one. We have to realize we’re as vulnerable as men are.”

“Heart disease is the number-one cause of death in women,” Dr. Fitts affirms. “Symptoms shouldn’t be ignored. Chest pain that’s brought on by exertion and relieved with rest is a hallmark for cardiovascular disease in both women and men. That’s unlikely heartburn, and you should seek medical attention right away.”

SCAD and MVD also more common in women

Dr. Fitts also notes that there are types of heart disease — in addition to takotsubo syndrome — that are more common in women than men.

“And recent literature suggests that we need to do more to educate women on these conditions,” he says.

One of these is spontaneous coronary artery dissection (SCAD), an emergency condition that occurs when a tear forms in a blood vessel in the heart. As blood flow slows or is blocked entirely, it can result in a heart attack, heart rhythm disturbances, or sudden death. It most commonly affects women in their 40s and 50s who have no prior history of or risk factors for heart disease.

“Although it is a rare condition, about 90 percent of SCAD cases occur in women,” Dr. Fitts notes, “and there is growing research related to SCAD in female heart patients, including a registry of patients and clinical trials at the Mayo Clinic.” Another form of heart disease — and one that affects four times as many women as men — is what’s called microvascular disease (MVD). It’s also more common in people with diabetes or high blood pressure.

This is a condition in which the walls of the small arteries in the heart are damaged, causing signs and symptoms of heart disease, such as chest pain. It’s often diagnosed after a doctor finds little or no narrowing in the main arteries of the heart, despite a patient having symptoms that suggest coronary artery disease.

More research needed

“There needs to be more research in this area so we understand the mechanisms in play,” Dr. Fitts says, noting that estrogen, or the lack thereof, may be a factor.

“Endogenous estrogen, which refers to the natural form of estrogen in the body, is considered to have a protective effect on the heart, which is why coronary disease often presents in women after menopause,” he adds.

He also acknowledges that the symptoms of heart disease — particularly a heart attack — can present differently in women than men, underscoring the single-most important piece of advice he gives women:

“Don’t ignore symptoms,” he stresses. “Any symptom that can’t be readily explained should be evaluated. Shortness of breath, for example, could be a chest pain equivalent when it comes to coronary disease. Granted, chest discomfort could be acid reflux or a pulled muscle, but we want to always make sure there’s no cardiac source.”

To contact Eisenhower Desert Cardiology Center, call 760.346.0642.