The Smidt Heart Institute published a study in the Journal of the American Heart Association1 that found that cases of broken heart syndrome were increasing in middle-aged and older women, even before the pandemic.
Psychological, Economic and Social Stress
Broken heart syndrome is more than a myth or an old wives’ tale. The medical term for this condition is Takotsubo cardiomyopathy (TCM) or Takotsubo syndrome (TTS).
The disease is named after a vessel used by Japanese fishermen to catch squid. The diagnosis was first made by a Japanese scientist in 1991. After the 1991 paper was published, doctors found several more cases over the next decade, but the disease remained largely unrecognized outside the Eastern culture. In 2004, after the earthquake in Japan, 16 people were diagnosed with TTS.
This attracted the attention of scientists in the West, who later named the disease Broken Heart Syndrome in reference to those who suffer from it after the death of a loved one. After the dissemination of COVID-19, the prevalence of depression, anxiety, and stress increased significantly in the general population.
A systematic review and meta-analysis of five studies involving 9074 individuals found that the number of mental health-impacting disorders increased during COVID-19. In the December 2020 U.S. Census Bureau survey, more than 42% of Americans reported having symptoms of anxiety or depression; on the other side of the world, in New Zealand, depression and anxiety exceeded population norms.
Rising stress levels during the pandemic also led to a surge in opioid and stimulant use. According to the CDC,9 the number of drug overdose deaths in the 12 months ending January 2018 was 70,122. After dropping slightly for a few months, the numbers began to rise again in November 2019, and the CDC reports that there were 96,779 drug overdose deaths in the 12 months ending March 2021.
This represents about a 37% increase in drug overdose deaths in 2020 and 2021, and the scare in 2020 resulted in a significant mental, economic, and social toll on people. The data showed that in addition to mental health problems and drug overdoses in 2020, the number of cases of TTS, also known as stress cardiomyopathy, also increased.
Rising Number of Broken Heart Syndrome Prior to COVID
The rising number of broken heart syndrome diagnoses during the COVID 19 pandemic was perhaps to be expected. However, recent data show that the numbers were increasing among middle-aged and older women even before the global spread of COVID-19.
The researchers examined trends in the diagnosis of TTS and found that incidence changed in different age groups and genders. They analyzed trends in diagnosis from 2006 to 2017 in patients 18 years and older.
The data came from the National Inpatient Sample Database and included 135,463 documented cases. The researchers found that annual incidence increased steadily in both sexes. However, 88.3% of cases were diagnosed in women, particularly those over age 50.
The increase in incidence among middle-aged men was also significant but did not extend to older men. Interestingly, the ratio of men to women at risk in the U.S. population remained stable throughout the study period.
The researchers acknowledged that the analysis was limited by reliance on correct ICD-9 or ICD-10 diagnosis coding in hospital records. However, they believe that the number of cases documented over nearly two decades shows not only an increasing incidence, but also:
… a steep increase, particularly among middle-aged and older women. This overall trend was disproportionate to that observed in other subgroups and apparently cannot be fully explained by improvements in clinical detection.
Before the data from this study, researchers knew that TTS affected women more often than men. This was the first time age- and sex-specific differences were found.Dr. Susan Cheng is the director of research at the Smidt Heart Institute and lead investigator of the study. In a press release, she commented:
Although the global COVID-19 pandemic has presented many challenges and stressors for women, our research findings suggest that the increase in takotsubo diagnoses occurred long before the disease outbreak. This study reaffirms the important role that the heart-brain connection plays in overall health, especially for women.
What is Broken Heart Syndrome?
People who suffer from broken heart syndrome describe sudden heart attack-like symptoms, such as chest pain and difficulty breathing. However, while a heart attack is caused by blocked arteries cutting off oxygen to the heart muscle, TTS is something completely different.
In some cases, it can be misdiagnosed as a heart attack because test results show rhythm changes and rising troponin levels that are indicative of a heart attack. However, unlike a heart attack, other tests do not indicate blocked arteries. In TTS, the left ventricle temporarily enlarges and does not pump enough blood. The rest of the heart functions normally and may even contract more to compensate for the left ventricle’s poor function.
According to the American Heart Association, the syndrome can lead to severe, short-term heart failure. Most recover completely within a few weeks. However, there is no standard treatment. Instead, doctors must rely on other symptoms, such as low blood pressure or pulmonary edema, to determine treatment options. Although death is rare, persistent heart failure can occur in about 20% of those affected.
Link between Brain and Heart Could Be Cause of Broken Heart Syndrome
Scientists have long suspected that TTS is related to a connection between the brain and the heart. One hypothesis suggests that the connection between the sympathetic nervous system and the way heart cells respond to stress hormones affects the left ventricle’s distension. Cheng explains the way the brain and nervous system respond to changes as women age. This may partly explain why TTS is more common in middle-aged and older women.
The emotional and physical triggers may be associated with psychiatric or neurological disorders. Typical neurologic changes associated with high risk of TTS include subarachnoid hemorrhage and seizure disorders. Brain changes in the limbic system and decreased connectivity with the autonomic nervous system may also increase risk.
The data also suggest that regions of the brain associated with emotional processing and control of heartbeat, breathing and digestion may not communicate in the same way in people without broken heart syndrome. Study author Christian Templin, professor of cardiology at University Hospital Zurich, said in a news release:
We found for the first time a correlation between changes in the functional activity of specific brain regions and TTS [Takotsubo cardiomyopathy], supporting the idea that the brain is involved in the underlying mechanism of TTS.
Emotional and physical stress are strongly associated with TTS, and it has been hypothesized that overstimulation of the autonomic nervous system may lead to TTS events.
The following events are known to trigger broken heart syndrome:
- Car or other accident
- Asthma attack
- Serious illness, surgery or medical procedure
- Death or serious illness or injury of a loved one, including a pet
- Domestic violence
- Financial loss
- Severe anxiety
- Speaking in public
- Sudden surprise
- Job loss
Consider these Strategies for coping with Stress
- Scientists believe the link between broken heart syndrome and middle-aged and older women is the release of stress hormones that affect heart cells during difficult events. Sometimes extreme stress is unavoidable, but managing daily stress is one way to protect your overall health from its negative effects.
- If you experience chest pain after a stressful event, be sure to see a doctor right away to rule out heart attack or broken heart syndrome.
- One way to reduce your risk for TTS and other stress-related conditions is to control your stress levels, and therefore your stress hormones. Below are some strategies that can help you take control of your health and reduce stress.
Emotional Freedom Techniques (EFT) – The procedure is also called tapping and is a tool that can help you free your mind to approach challenges without fear. This is one of my favorite techniques to reduce stress and encourage creative problem solving.
- Stop watching excessively bad news – COVID-19 is not the only bad news that is spread in the mainstream media every day. While this strategy targets your chronic stress levels, it can also impact your resilience to acute stressful events. The ability to adapt to situations, including adversity, trauma and tragedy, is part of resilience.
- Some research-based practices that help promote resilience include changing the narrative in your mind, practicing compassion for yourself, meditation, and cultivating forgiveness for your own mental and physical health.
- Meditation – There is growing evidence that meditation can reduce age-related brain atrophy and improve productivity. There are two common types of meditation. Mindfulness involves keeping attention in the present moment in all activities.
- Self-induced transcendence is an undirected form of meditation in which one achieves a fourth state of consciousness, distinct from waking, sleeping and dreaming.
- Spend more time in nature – A study published in Scientific Reports found that spending 120 minutes a week in nature was associated with better health and well-being. It didn’t seem to matter how those 120 minutes were divided up during the week.
- Nor did the researchers in this study find that more is necessarily better. In other words, the positive association with spending time outdoors peaked between 200 and 300 minutes per week. After that, there was no further increase.
- Gardening – A meta-analysis of the literature that included case studies published after 2001 compared data from the United States, Europe, Asia, and the Middle East. The researchers found that gardening produced a range of health benefits, including reductions in body mass index, depression and anxiety. Participants also reported higher life satisfaction, quality of life and a better sense of community.
- Combining magnesium and vitamin B6 – A study published in PLOS One found that taking magnesium and vitamin B6 at the same time had a complementary effect that reduced stress. Previous studies had shown this effect in animals. In this human study, researchers found that the treated group experienced a 44.9% reduction in perceived stress.
- Living near the sea – Many people dream of living near the sea, and according to a study from the University of Exeter in England, this can be good for mental health. Using data from the Health Survey for England of 25,963 adults from 2008 to 2012, researchers compared respondents’ health status with their proximity to the sea.
- They found that even those who lived between 1 and 5 km from the coast had a 25% lower risk of poor mental health than those who lived further away.
- Breathing through the nose – Nasal breathing slows down breathing and makes it more regular. This improves the oxygen supply. It also activates the parasympathetic nervous system, which has a calming effect and lowers blood pressure. Mouth breathing causes you to breathe too much and not exhale completely.
- Although most people breathe between 12 and 14 breaths per minute, research published in the medical journal Breathe found that an optimal breathing rate is in the range of six to 10 breaths per minute. This has been shown to have a positive effect on the respiratory, cardiovascular, cardiorespiratory and autonomic nervous systems.
- Sleep – Matthew Walker, Ph.D., is a professor at UC Berkeley and author of “Why We Sleep.” He says insomnia may be the result of a heightened fight-or-flight nervous system. Cortisol may play a role, so people who have trouble falling asleep typically have an increase in the stress hormone cortisol at bedtime and an overactive sympathetic nervous system.
- Wakefulness is also associated with mitochondrial stress. Without adequate sleep, neuron degeneration sets in, which can lead to dementia.
12. JAHA, 2021