A Broken Heart

By Peter Galvin, MD

This case comes from the University of Michigan Medical School in Ann Arbor. A 76-year-old retired cardiovascular nurse presented to the ER with a two-hour history of chest pain that had been triggered by severe emotional distress and was associated with changes in the EKG on her smart watch. Physical examination was normal. The single-channel (one lead) smartwatch EKG showed new T-wave inversions and lower QRS amplitude than had been observed at baseline (one month before the ER visit). An EKG records the electrical activity associated with a heartbeat. Normally, the electrical cycle of each heartbeat begins with a P-wave, which is a small upward bump caused by contraction of the atria, or upper chambers (someone with atrial fibrillation has no P-waves because the atria quiver and do not contract). Next, there is an upward or downward spike known as the QRS complex, which corresponds to the contraction of the ventricles, or lower chambers. Lastly, there is a larger upward bump, called the T-wave, caused by the electrical repolarization of the ventricles.

Looking at Panel A, “At Baseline” shows an upward QRS spike, followed by an upward T-wave bump. Next, “At Onset of Chest Pain” shows a smaller QRS spike and the T-wave bump is now downward. Finally, note that at “24 Hours after Onset” the QRS spike is gone, and the T-wave bump is further downward. The patient had an elevated troponin level (a protein, when elevated, that is specific for heart muscle damage). A coronary angiogram showed clear coronary arteries, and an echocardiogram (heart ultrasound) showed left ventricular apical (bottom of the heart) ballooning and a decreased ejection fraction (heart output). A diagnosis of takotsubo syndrome, also called broken heart syndrome, was made.

Takotsubo syndrome (TS) consists of ballooning of the apex, or bottom, of the heart associated with decreased cardiac output (less effective pumping of blood) in the absence of heart disease. It is most commonly seen in postmenopausal women following severe physical or emotional stress. Physical stressors include sepsis, shock, brain hemorrhage, an endocrine tumor called pheochromocytoma, or chemotherapy. Emotional stressors include bereavement, divorce, job loss, or betrayal, and rarely, happy events such as a wedding or winning a jackpot. The syndrome is not fully understood, but it is thought that the stress causes a massive catecholamine (adrenalin, noradrenalin) release that has a toxic effect on the heart, essentially “stunning” it. This leads to congestive heart failure and decreased cardiac output. The term takotsubo comes from the heart assuming the shape of a Japanese octopus trap. In most cases, TS is self-limited and the patient, if she survives the initial shock, will recover fully with supportive care in about two months, as the patient in this case did.

Although this medically trained patient used her smartwatch to identify cardiac injury, smartwatch EKGs are not FDA approved for this use.

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