Broken Heart Syndrome

The stress cardiomyopathy ( also Broken Heart Syndrome, Tako- tsubo cardiomyopathy, Tako- Tsubo syndrome, transient left ventricular apical ballooning or Broken -Heart Syndrome ) is a rare, acute onset and often serious disorder of the heart muscle, which predominantly occurs in older women. The symptoms are similar to those of a heart attack and usually occur immediately after an extraordinary emotional or physical stress on. The cause of described as a distinct disease until the 1990s disorder is unclear; the most significant increase in blood levels of stress hormones, particularly the body's catecholamines such as adrenaline and noradrenaline seems zuzukommen a crucial importance. The prognosis is favorable in most patients, after a few weeks, the cardiac function in the majority of them are normalized. In the acute stage, however, serious and even life-threatening complications are common.

• 5.1 ECG
• 5.2 Imaging Methods
• 5.3 Laboratory tests

History

The disease was first described in 1991, was named after a Japanese octopus trap in the form of a pitcher with a short neck ( Tako- Tsubo, see figure). Reminiscent it peculiar shape of the left ventricle (left ventricle ) at end systole was considered by the first author as a result of circulatory disturbance of the heart muscle, caused by the spasmodic contraction of several coronary arteries ( coronary spasm ).

The updated in March 2006 definition and classification of cardiomyopathies of the U.S. American Heart Association ( AHA) is the "Stress ( Tako - Tsubo ') cardiomyopathy " classified alongside of myocarditis as primary acquired cardiomyopathy.

Epidemiology

Reliable epidemiological data are lacking, the knowledge of stress cardiomyopathy is based on individual case descriptions and the description of " mini-series " with a few patients. By mid-2006 only about 700 patients have been described with a tako tsubo cardiomyopathy, including about 400 in Japan and each about 150 in Europe and North America around the world. Since 2004, patients have also been reported in Australia and South America, so that starting from a global and previously underestimated dissemination.

Based on each small numbers of patients has been previously found that in Japan 1.2 to 2.2 %, in the U.S. about 2.2 % and Germany 2.3 to 2.6 % of all patients with an acute coronary syndrome in a stress - cardiomyopathy, suffered the female patients, this proportion was at least about 7.5 %. More than 90 % of the reported patients were women, the mean age was 62-75 years.

Pathophysiology

Origin and development of disease ( pathogenesis ) are not fully understood. In many patients with stress cardiomyopathy significantly increased blood levels of endogenous catecholamines have been detected. Epinephrine, norepinephrine, metanephrines ( metanephrine and normetanephrine ) and vanillylmandelic acid have been found in higher concentrations than in severe heart attacks. The high concentration of these substances, also known as stress hormones is discussed as a cause of stress cardiomyopathy, which is supported by several observations of individual cases Tako tsubo -like events in patients with pheochromocytoma, a tumor of the adrenal gland katecholaminproduzierenden, supported. First time in 2004 by two sisters have been reported with apical ballooning, suggesting a genetic predisposition. On the occasion of the detection of infection with cytomegalovirus in a patient with Tako- Tsubo syndrome in 2006 was also discussed about a possible causation by viruses.

Regarding the pathophysiology is believed that the greatly increased catecholamine alters the activity of the cardiac muscle in such a way that there is a tension in the coronary vessel wall, or to an overload of calcium. Cause of increased catecholamine levels could be an over-activity of the autonomic nervous system after previous findings that produces too many stress hormones by the sudden stressful situation. A relative lack of estrogen after menopause may contribute to the increased activation of the sympathetic nervous system. The unusual for other circulatory disorders of the heart affected especially near the tip of the muscle regions could be due to a different density of beta- adrenoceptors, which is proved at least in dogs.

Disease

Acute phase

The symptoms of stress cardiomyopathy similar to those of a heart attack. Characteristic incipient violent chest pain ( angina ) and shortness of breath are suddenly (dyspnea ). In the acute stage, a distinction to heart attacks without cardiac catheterization is not possible, so that the event is first referred to and treated as an acute coronary syndrome.

Almost all patients have in common that the symptoms of shortly after an emotionally stressful event such as the death of a close person, the separation from a partner, an accident, an assault, a natural disaster, a violent quarrel, the loss of material existence or diagnosis Insert serious illness, but also by quite pleasant surprises like the news of a major lottery win. Contrary to initial and still widespread today expressed suspicions is the Tako- Tsubo cardiomyopathy dangerous. Within the first few hours, the risk of serious complications is high. Information on the frequency range between 18.9 % and up to 46%. Cardiogenic shock occurs in about 15% of a serious cardiac arrhythmia (ventricular tachycardia or ventricular fibrillation ) of the patient at about 9%.

Course and prognosis

The changes in the heart muscle form usually within weeks all the way back, and the ECG returned to normal usually. In a 2005 survey published to date all published cases, a mortality of 3.2 % is specified. After surviving the acute phase, the risk of recurrence (relapse ) of the syndrome appears to be low.

Diagnostics

As diagnostic criteria for stress cardiomyopathy apply:

• A temporary movement disturbance of the left ventricle, which does not correspond to the coverage area of a coronary vessel,
• The exclusion of higher-grade stenoses of the coronary arteries,
• Newly occurring ECG changes similar to those of a heart attack and
• The temporal context of a previous stress situation.

The physical examination may result in normal findings or reveal signs of heart failure such as a third heart sound or rales over the lung.

ECG

The ECG shows in the acute phase of ST-segment elevations (see ECG nomenclature) or diffuse changes of the T wave, within the first 48 hours often an extension of the QT interval. ECG changes are similar to those in a heart attack, however, often occur in a plurality of ECG leads to that not only represent the coverage area of a coronary vessel.

Imaging methods

The radiograph of the thorax is unremarkable or show a so-called pulmonary congestion ( " water in the lungs " ) as a result of heart failure. When echocardiography is typical of the Tako- Tsubo syndrome movement disorder ( disorder contraction ) of the left ventricle is often detectable, the apical ballooning. This also detectable in the Laevokardiografie during a cardiac catheterization of the left ventricle contraction disorder makes often than impressive immobility ( akinesia ) or even paradoxical movement ( dyskinesia ) of the apex of the heart felt, may have the similarity with an aneurysm.

In contrast to the heart attack, however, no blockage of the coronary arteries can be detected with coronary angiography. It is this finding of cardiac catheterization allows the reliable differentiation from heart attack.

Significant findings also supplies the magnetic resonance imaging ( MRI) that can both detect the movement disorder of the heart muscle in good quality and after gadolinium the lack of scarring.

Laboratory tests

The specific cases of stroke suspected in the blood serum so-called cardiac markers troponin and creatine kinase ( CK) are in stress cardiomyopathy such as during a heart attack usually elevated, but suggest a lesser extent than the ECG changes and the movement disorder of the heart muscle. In 80-90 % of patients in the acute stage, a slight increase of troponin is to provide evidence which, however, is two to three times the upper limit of normal rarely exceeds. A slight increase in CK also usually observed in 50-70 % of patients. The brain natriuretic peptide (BNP ) is increased significantly in many patients.

Blood levels of stress hormones selected from the group of catecholamines ( adrenaline, noradrenaline, dopamine, and derivatives) are increased in the majority of patients, they are an average of two to four times higher than that of patients with myocardial infarction. This corresponds to an increase of the 7 - to 34 - times the usual symptom-free concentrations of people. The above high hormone levels can usually still prove a few days after the triggering event in the blood. Since Tako- tsubo -like events and elevated catecholamine concentrations occur with a pheochromocytoma in patients, this tumor should be excluded, particularly in patients without a triggering stress event.

Therapy

In the absence of appropriate therapy studies, there is no secured data by objective standard treatment of stress cardiomyopathy. Due to the high rate of complications in the acute stage a monitor monitoring in the ICU is made. Since the high catecholamine levels are a known cause, it is advisable to greatest extent possible restraint in the supply of other catecholamines. For patients in shock a cautious fluid replacement is recommended, where appropriate, the early use of intra-aortic balloon pump (IABP ). Analogous to the treatment of pheochromocytoma crisis can be useful alpha blockers and for hemodynamically stable patients beta-blockers.