Chest pain, nausea and difficulty in breathing: in the case of one elderly emergency patient this essentially pointed to a myocardial infarction. Medical colleagues were all the more surprised when they found neither thrombi nor stenosis. Emotional strains – a few months earlier her husband had died – had led to short-term, reversible contraction disorders of the left ventricle. After a few hours the symptoms subsided.
Wicked octopus trap
This is no isolated case: In the medical literature reports accumulate about so-called Takotsubo cardiomyopathy occurring after extreme stress situations. Meanwhile, this stress-cardiomyopathy, also called broken-heart syndrome, is accepted as a clearly defined clinical entity. Frequently it is women from 62-75 years of age who are affected. Depending on the country, figures given are 1.0 to 2.6 per cent of all patients with acute coronary syndrome. Takotsubo means: an octopus trap with a narrow neck and bulbous body. The form is reminiscent of sonographic recordings of patients’ hearts. Typical is its balloon-shaped apex.
First a few details: with Takotsubo-type there is apical akinesia and basal hyperkinesia, with the reverse form doctors observe a basal akinesia and an apical hyperkinesia, while with the midventricular-type both a basal and apical hyperkinesia are described. In a haemogram markers such as creatine kinase or troponin are only slightly increased. Cardiologists advise intensive care monitoring, including symptom control whereby many patients recover quickly after recovering from crisis and have an excellent long-term prognosis.
Stress in the blood
Researchers have not yet fully interpreted how Takotsubo cardiomyopathy comes to take place, but plausible hypotheses exist. Doctors have found significantly increased levels of stress hormones in blood taken from patients, first and foremost adrenalin and noradrenalin. An older case description offers a possible indication which has been confirmed several times: patients with a pheochromocytoma indeed show “Takotsubo-like” symptoms. This Tumor produces, among other substances, adrenalin and noradrenalin. Grief, anxiety, stress, rage but also joyful events like winning the lottery have similar effects on the heart. Thus after natural disasters or terrorist attacks cardiologists observe a significant increase of Takotsubo cardiomyopathy. In the heart itself the density of β-adrenoceptors is very high, which is something that can explain an inadequate response to strong catecholamines.
The receptors are coupled to G-proteins (Gs and Gi). Once Gi is inactivated with toxins, in an animal model the symptoms disappeared, but these mice died as a result of the receptor blockage. The calcium sensitiser levosimendan shows similar effects without influence on the death rate.
Heart in a vice
Whereas Takotsubo cardiomyopathy in many cases remain without consequences for patients, emotional strain can also lead to much more serious disease. Coronary heart disease (CHD) or myocardial infarctions occur with depressive people far more frequently than with comparison groups with similar cardiovascular disease but without emotional impairment conditions. Meta-analyses involving more than 100,000 people from population-based studies showed a relative risk of 1.60 to 1.90. Anxiety and depression increase the risk of dying from CHD for patients with pre-existing conditions. From a medical perspective, psychiatric pre-existing conditions are on a par with type 2 diabetes, smoking, hypercholesterolemia and hypertension.
Overweight, depressed patients (BMI > 30) have a three-fold higher risk of CHD compared to the control group not suffering emotional strain. Doctors advise therefore, in addition to obtaining a cardiac history, initiating targeted searching for specific psychiatric disorders and introducing the appropriate therapies. However the reverse also applies: patients with CHD often have emotional impairment conditions. As one study of 135 coronary artery bypass patients has shown, these often suffer postoperatively from depression and anxiety regardless of the success of the OP.
Biochemical sustained fire
Researchers are now trying to establish a link between the medical pictures of the conditions. Depressed patients pay less attention to their health. They smoke on average more frequently, nourish themselves more unhealthily, consume more alcohol and do less sport. Also biochemical pathomechanisms play an important role, with negative consequences for the heart and blood vessels. Stress activates the hypothalamo-pituitary-adrenal axis, which is done via corticotropin releasing factor and adreneocorticotrope hormone leading to increased release of cortisol. In addition, immunologically active molecules are detectable in the blood of patients with CHD: acute-phase proteins and proinflammatory cytokines activate platelets and the tendency toward coagulation rises.
Cardiologists have also found evidence that endothelial dysfunctions occur as precursors to subsequent atherosclerosis. At the same time stress influences the autonomic nervous system, which has fatal effects on the regulation of heart rate. The heart muscle adapts to external stress poorly, pulse and heart rate rise.
Recommendations for practice
Given these situations and data, the advice remains as such: with CHD patients find out whether depressive symptomatology is present. In order to obtain early indications, simple questions about possible depression, sadness or feelings of hopelessness are enough, as well as about – possibly absent – interest in activities and social contacts. The German Society of Cardiology, Heart and Circulatory Research has now updated the respective positional paper. In the instance of level A evidence and the highest recommendation level I, the authors recommend considering psychosocial factors in the assessment of CHD risk.
Also, heart-surgery patients should be cared for by interdisciplinary teams who deal with psychological stress disorders. The professional society makes an I-B recommendation calling for treatment of related conditions such as depression as a primary prevention of CHD. Patients with such comorbidity should be treated after suffering acute coronary events with antidepressants, preferably SSRIs.