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"We do not know what happens locally at the heart"

Broken Heart Syndrome: "We do not know what happens locally at the heart"


Photo: Doctor Christof Burgdorf

Doctor Christof Burgdorf;
© private

When the heart literally breaks and a relationship is ending, it’s usually a painful experience for the people involved. Similar experiences, though they are less attributed to lovesickness, but rather to a traumatic shock, the death of a beloved person or extreme stress are the ingredients for a life-threatening cocktail.

The afflicted person experiences chest pain attacks and complains about shortness of breath. Behind the symptoms of a classic heart attack however, there often hides the lesser known broken heart syndrome. asked Doctor Christof Burgdorf, senior physician at the University hospital Schleswig-Holstein in Lübeck, Germany, and Specialist in Internal Medicine and Cardiology, about scientific explanations for this syndrome, what questions are still unanswered in research and what the medical care of these patients looks like.
: The broken heart syndrome plays with the idea of a broken heart. What is actually “breaking” in a figurative sense?

Christof Burgdorf: The original belief was that many patients had mentally a deeply disturbing experience, before they get these heart complaints. Needless to say, there is no organ that’s actually breaking, but it’s rather the soul that is broken. This for instance expresses itself in the shape of physical ailments like chest pain. The term “broken heart“ thus refers to the connection between the psyche and the heart. Which events can trigger something like this?

Burgdorf: A multitude of different events have been described as triggers. Generally, it is deeply stressful and traumatizing events in the immediate prior medical history of the patient. Exemplary in these cases are patients who mourn the recent death of a family member or they are patients who got assaulted and robbed. People who nearly drowned in the ocean or a lake also belong to this patient group. In addition there are situational events like for instance during the Soccer World Cup. During Germany’s game against Sweden, one female patient got so upset, that she suffered from broken heart syndrome. If you ask the patients whether they had experienced a stressful incident in recent times and this is affirmed, it then gives physicians in the anamnesis (medical history) already clues that this could possibly be broken heart syndrome. On the other hand, in some patients you don’t find psychological stress, but rather a strong physical strain like for instance a longer illness in the past. Pneumonia could be named as an example here. Which patient group is especially affected by this disease?

Burgdorf: Approximately 90 percent of all patients are women past menopause. We know from available records and studies that patients on average are between 65 – 75 years of age. Why are women in particular being affected?

Burgdorf: This is a central, still unanswered question. There are some scientists who suspect that possibly the female sex hormones, the estrogen, play a role. Unfortunately, we are still in the beginning stages so that we don’t know anything definite. What changes in the bodies of these patients due to this illness? Are there for instance specific cardiac markers?

Burgdorf: The patients that come to the emergency room present with the typical chest pains. At first this suggests heart disease. We then do an ECG, which either shows decreased blood flow of the myocardial muscle or precisely nothing of the sort. Then we conduct a blood examination and the blood test results, the cardiac markers, for instance the troponin or also the CK, the creatine kinase, are generally elevated. Through the overall picture, the chest pain and elevated cardiac markers – though not specifically, since the cardiac markers are also elevated in other diseases – we determine that a patient has an acute coronary syndrome and that we have to conduct a cardiac catheter examination as quickly as possible. Not until the cardiac catheter procedure do we see, whether this is a classic myocardial infarction or indeed broken heart syndrome. The catheter can very clearly differentiate between a classic myocardial infarction and the broken heart syndrome. Before doing all this, the syndrome can merely be suspected. During a cardiac ultrasound we also see typical cardiac wall motion abnormalities which are suggestive of this, but it can only safely be determined with the catheter. In addition we need to rule out that the coronary blood vessels show a change. In patients with broken heart syndrome, the coronary blood vessels generally are completely in order.

Photo: Heart

In patients with broken heart syndrome coronary blood vessels are not blocked; © Kaulitzki As you describe it, the symptoms resemble those of a “normal“ myocardial infarction. How does broken heart syndrome distinguish itself from a myocardial infarction?

Burgdorf: That’s difficult. The classic myocardial infarction is characterized by coronary blood vessels either being completely or almost entirely blocked. In patients with broken heart syndrome this is not the case. The coronary arteries normally look inconspicuous. Yet it can happen that patients that have broken heart syndrome, exhibit deposits in the coronary arteries. It is also possible that the patient had a vessel blockage which for now has opened up again. That’s why it makes sense to conduct an additional examination and subsequently do a magnetic resonance tomography (MRT). There are specific criteria for this, which in turn differentiate between broken heart syndrome and classic myocardial infarction. As the trigger for this disease, often hormones and particularly stress hormones are held responsible. Are there any new findings on this?

Burgdorf: It is suspected that there is an excessive dump of adrenalin or other stress hormones, which has a damaging, toxic effect directly on the myocardial muscle. This is assumed, but it is not really known yet. So we don’t know what happens locally at the heart. This has two reasons. On the one hand this is due to the fact that we can only perform research on patients and not on animal models. The syndrome can simply not be reliably reenacted on an animal model. A second point is: There are only a few patients and the prevalence, the frequency of this disease pattern is very low. There are also only limited examination options to depict the nerves or hormones in the heart. The scintigraphic methods of evidence are often not exact. What happens on a pathophysiological level in the myocardial muscle cell or in the area of nerve fibers in the heart is presently not well known. What does research look like if there are so few patients?

Burgdorf: At first we ask ourselves some pivotal questions: Where does the disease come from, which mechanism is being set in motion here, why are only women affected by it and what prognosis do patients with broken heart syndrome have? The prognosis can be issued by for instance us creating registries and gathering the data of the patients there . This way we monitor and record the course of the disease for patients over five to six years and inquire whether new diseases occurred additionally. In a second step we develop the pathophysiological connections. For example we can examine the patient’s myocardial tissue. But this is not without risk and an ethics proposal to the University Hospital always needs to be made in advance.

In Lübeck we have established the largest monocentric registry and treated 108 patients with this syndrome in the past nine years. At the same time we collaborated with other centers and hospitals. In addition there is a registry of the ALKK, the working group of leading cardiology hospital physicians, which comprises over 250 patients from different hospital associations. Has the relatively late discovery of the syndrome have any effects on the epidemiological data and thus on the treatment?

Burgdorf: The first detection of the syndrome can be dated back to the early 90s in Japan. However, there is nothing stating that the disease wasn’t already around before that time. You just weren’t able to definitely diagnose it, since not until the early to the mid 80s was the technology of the cardiac catheterization procedure routinely being used. After all, only the cardiac catheter provides definite information on whether a patient has broken heart syndrome or has suffered from a classic myocardial infarction. In 2001 the first English publication was published. As time went by more and more cases were described and the broken heart syndrome awareness continued to rise. Today it needs to be a regarded as a true differential diagnosis to the classic myocardial infarction.

Generally we treat patients with broken heart syndrome exactly like we treat patients with a myocardial infarction. They receive blood thinning agents and are watched via a monitor. They are in the intensive care unit and are being administered drugs that support circulation like Adrenaline or Noradrenaline as needed. Several physicians however criticize the additional administering of these agents, since these hormones are after all suspected to trigger the broken heart syndrome. As an alternative, circulation assistance systems lend themselves as treatment. Do patients have to count on long term health consequences similar to those with a myocardial infarction?

Burgdorf: This is a question on which I am currently scientifically concentrating on. In science the popular belief is that generally there is a good prognosis for patients with broken heart syndrome. This is due to the fact that the cardiac output of the patients normalizes within a relatively short amount of time. The heart beats strongly again and the prognosis is correspondingly good. But this is probably just the cardiac prognosis, because patients with broken heart syndrome increasingly have accessory symptoms. Some studies by now are dealing with this subject.

In Lübeck we noticed and published repeatedly that patients increasingly get cancer. This means: Either in the patient’s previous medical history cancer had once occurred or they will develop a new cancer in the next few months or years. In collaboration with the Kerckhoff Clinic in Bad Nauheim and the University Hospital, I examined 191 patients. On average, 24 percent had a malignant underlying disease. If you compare these numbers with those of the general population, that’s twice as many cases. If you compare the data with patients with classic myocardial infarctions, then the cases are increased three times as much. Based on this, we hypothesized the following: The cardiac prognosis is very likely good, but the overall prognosis or the overall mortality rate of patients is higher than that of the general population.

We are currently creating an international registry for this, in which data is being recorded and analyzed. The registry will be complete in the next few weeks and we can collect the first patient data. At first this happens across Germany and later in international collaboration.

The Interview was conducted by Diana Posth

(Translated by Elena O'Meara)


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