Is It a Heart Attack or a Broken Heart?

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Many people have felt the pain of the metaphoric broken heart. But the broken hearts of songs and poetry also have a physical counterpart. Known medically as stress cardiomyopathy, the condition is also referred to by the less-clinical term “broken heart syndrome.”

Stress cardiomyopathy is a sudden and severe weakness in the heart muscle caused by intense emotional or physical distress. On the emotional side, one of the most common triggers is the unexpected death of a loved one. Sometimes, though, the emotional stress is intense but related to a far less severe situation. Researchers have reported cases in which people suffered stress cardiomyopathy in reaction to a public speaking engagement and even a surprise party. Physical triggers can include a car accident, an asthma attack, or a seizure.

The diagnosis

The symptoms of stress cardiomyopathy are similar to those of a heart attack: chest pain, dizziness, trouble breathing, and weakness. Similar changes may even be seen on an electrocardiogram, as well as in the results of a blood test performed when patients present in the emergency room with a possible heart attack.

However, unlike a heart attack, broken heart syndrome doesn’t involve an obstruction of blood flow in the coronary arteries-there is no blood clot. Instead, a portion of the wall of the heart’s major chamber-the left ventricle, which is responsible for pumping blood throughout the body-usually thins and expands like a balloon.

Diagnosis involves ruling out a heart attack caused by coronary artery disease, which is done with a standard invasive coronary angiogram or a coronary CT angiogram. A person with a normal coronary angiogram who has acute heart injury (as shown on other tests) and has experienced recent extreme stress most likely has stress cardiomyopathy.

The symptoms of broken heart syndrome can start a few minutes after experiencing an extreme emotion. And it’s the intensity of the stressor-not whether it’s a happy or sad one-that triggers the condition. A study in the European Heart Journal in 2016 examined data from 25 medical centers in the United States and Europe and found that 4 percent of the events associated with stress cardiomyopathy were happy ones, such as a wedding or the birth of a grandchild (thus, the coining of the term “happy heart syndrome”).

The risk factors

Stress cardiomyopathy appears to be more common than once thought. The condition accounts for about 1 to 2 percent of patients seeking medical care for symptoms of what they believe is a heart attack. Researchers are also learning more about who is at risk: Postmenopausal women account for most cases of broken heart syndrome-near 90 percent, according to a study published in 2015 in The New England Journal of Medicine (NEJM), which included 1,750 patients.

In women, stress cardiomyopathy is often related to psychological stress, or there’s no apparent cause, whereas in men, it’s more likely triggered by physical stress. Experts can only speculate as to why. Men’s heart muscle cells have more receptors for stress hormones; it may take longer for this larger number of receptors to become saturated by stress hormones, thus protecting men’s hearts from being overwhelmed.

Also, certain factors-including depression, anxiety disorders, smoking, and other health conditions-may raise a person’s risk. Beyond that, scientists are still trying to understand what makes certain people susceptible, and it’s likely that both genetics and environment are responsible.

The NEJM study, for instance, found that a history of neurological or psychiatric disorders was more than twice as common in patients with stress cardiomyopathy compared with those who experienced a heart attack.

Another smaller study found that a majority of women with a history of stress cardiomyopathy had low levels of vitamin D, although it’s not clear if that was responsible for the condition. Vitamin D does help regulate body cells’ calcium levels, and there’s evidence that calcium activity within cells plays a role in stress cardiomyopathy. Estrogen also helps regulate calcium, and still another theory is that estrogen deficiency in some older women may make them more vulnerable.

Yet another study found that of 25 women with broken heart syndrome, 44 percent had a history of migraines, while only 16 percent of women who suffered a heart attack did.

The prognosis

Though there are no formal recommendations, broken heart syndrome is often treated with some of the same medications that are typically used for heart failure, including diuretics, beta-blockers, and ACE inhibitors.

It was once thought that patients with broken heart syndrome fully recovered within days or weeks. But now it’s known that the condition can be life-threatening because of potentially lethal heart rhythm abnormalities (arrhythmias), along with a drop in blood pressure and congestive heart failure. In men, the condition is more likely to be associated with cardiac arrest.

In the NEJM study, people with broken heart syndrome had significantly worse pumping action in their left ventricle and similar rates of cardiogenic shock and death, compared with patients presenting with heart attacks or unstable angina. The most common adverse events in those with broken heart syndrome were stroke, transient ischemic attacks (TIAs, or ministrokes), and death, particularly in men.

Unfortunately, much is still unknown about the condition, including how often it occurs after an emotional or physical stressor, as well as the long-term prognosis. In the meantime, the best advice to follow is to take care of your heart and recognize the signs of a heart attack, which can be different in women than in men.