Diagnosis: Broken Heart

NYTimes

June 18, 2006
Diagnosis
Heart Ache
By LISA SANDERS, M.D.

1. Symptoms

"I'm not going to lose my mom," the young man's voice cracked with feeling. Beside him a half-dozen men and women in scrubs swarmed around the gurney rolling the woman into a cubicle in the I.C.U. The patient's face had a deathly pallor, her light brown hair was dark with sweat, her mouth was open and her chest heaved as she struggled to breathe. "We'll do our best," the doctor assured him, as he observed the woman and the monitors that showed just how sick she was. The young man, who was in his mid-20's, grabbed the doctor's arm as he turned to follow the patient. "No — you have to save her," he answered fiercely. "You have to."

His mother had been fine that morning, the young man told the doctor. She went to work just as she did every day. But then the phone rang, and she learned that her husband of more than two decades had been killed in a crash. She rushed to the site, found his body and collapsed next to him, sobbing and shouting his name as if she were trying to wake him. She lay next to her husband, cradling him in her arms until his body was taken away. Two hours later, she collapsed again, and this time she couldn't get up.

The son paused and roughly rubbed the tears from his face with his sleeve. When she got home, his mother told his sister that her chest hurt and that she felt as if she couldn't breathe. The ambulance rushed her to the nearest hospital. "The doctors there told us she'd had a heart attack," the young man continued, "and that she was fixing to have another one." He and his two sisters were terrified. They had already lost their dad — they just couldn't lose them both. They decided to have her transferred here, to the regional hospital with a specialized cardiac-care unit.

The doctor in the I.C.U. glanced through her chart and turned his attention to the patient. She was 45 years old and a smoker. She had recently been told she had narrowing of the arteries that carried blood to her legs and feet — called peripheral vascular disease — but otherwise she was healthy. She took no medicines and worked full time now that her children were grown up.

2. Investigation

On examination, she appeared younger than her 45 years. But her tanned, unlined face was shiny with sweat, and her pale blue eyes were open and unfocused. Her heart was beating rapidly, and a blood-pressure cuff that inflated automatically beeped its warning that her pressure was dangerously low. An oxygen meter on her finger showed that although she was breathing rapidly, she wasn't getting enough air. Her skin was clammy to the touch and pierced by thick intravenous needles delivering saline and medicines to raise her blood pressure.

It was clear that the patient's heart was failing. She was young to be having a heart attack, but she was a smoker and had a history of clogged arteries in her legs, which put her at risk of having the same problem in her heart. A heart attack occurs when one of the arteries supplying blood to the heart gets blocked. Without blood, that part of the heart dies rapidly. Her EKG was abnormal, and blood tests revealed damage to the heart cells — all consistent with a heart attack.

Dr. Conard Failinger, the cardiologist on call, was worried by the grainy images of the sonogram that showed the patient's heart in motion. Her heart was pumping with only a fraction of the expected strength. In fact, most of the heart muscle wasn't pumping at all; the patient was dying. The only way to treat her would be to quickly find and clear the blockage so that blood could flow once more. There are chemical clot busters that can do this, but a more effective way is to thread a tiny catheter into the affected artery, locate the blockage and then use the tiny tube to blast the vessel open. Done quickly enough, this process, known as cardiac angioplasty, can save the heart muscle and save the life. The patient was quickly transported from the I.C.U. to the "cath" lab.

Once there, Failinger watched another doctor rapidly thread the tiny catheter through a large artery in the patient's leg into her heart. He carefully placed the catheter into one of the major vessels of the heart and pressed the plunger of the attached syringe, which shot a tiny amount of contrast dye into the artery to determine the site of the blockage. On a monitor, the cardiologists stared in wonder as the arteries brightened, lighted by the dye flowing through them. There was no obstruction. The doctor manipulated the catheter again, moving it to another vessel. Again, the dye flowed through the artery, completely unimpeded. Several more tries produced the same result. There were no blocked arteries. The patient was not having a heart attack.

What else could cause such profound heart muscle weakness? Alcohol can do this, but the patient had no history of heavy alcohol use. A number of drugs — most commonly those used to treat certain cancers — can cause this type of damage, but this patient had never been exposed to any of those medications. Infection could do this, but the patient reported no symptoms other than those caused by the failing heart itself.

3. Resolution

Failinger immediately realized that it was none of these. He recognized what it was, though he had never seen it. He had read about it a short time before in The New England Journal of Medicine. This was stress cardiomyopathy, also called "broken-heart syndrome." First described by the Japanese 15 years ago, this disease occurs when an emotional trauma causes the brain to release high doses of stress hormones. This hormonal blast paralyzes the muscle cells of the heart, preventing them from working to pump the blood. Typically only one section of the heart is spared this devastating paralysis — the part closest to the aorta so that with each heart beat only the upper portion contracts and the heart looks like a narrowed-necked vase. The Japanese called it takotsubo after a type of trap that is used to capture octopus and has the same vaselike shape. For reasons that no one understands, this mostly affects post-menopausal women.

There is no cure. There is no clot to bust, no bugs to kill. Like its metaphorical counterpart, the only treatment is support and the passage of time. The initial burst of hormones subsides and the patient must be kept alive until the heart recovers. For those who survive long enough to reach the hospital, the prognosis is good. Once she made it to the hospital, this patient needed additional oxygen and medicine to keep her blood pressure up. On arrival at the hospital, her heart was able to pump out only 5 to 10 percent of the blood it contained (normal is 50 to 60 percent). After several days, it was pumping well enough for the doctors to stop the medications that increased her blood pressure. By the end of the week, her heart's capacity had doubled. Just days later, it was nearly normal.

"If anyone had told me that you could die of a broken heart," the patient told me recently, "I'd never have believed it. But I almost did." Reflecting on those couples you hear about, when one dies and the other one follows a few days later, she said, "I bet their hearts were broken, just like mine was."

It's an interesting idea: perhaps the metaphors we use to speak of devastating loss grew out of physiological truth. But if love lost almost took this patient's life, she says she believes that it was also love that brought her back. "I remember when I was in the hospital, I was in the most peaceful rest," she told me. "I didn't see any light or anything, but it was just as beautiful and peaceful a rest as I could ever imagine. I just wanted to stay there forever. But then, way off in the distance, I heard my kids calling to me, and I knew I couldn't stay. They're the ones who really saved my life.