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Dead of a Broken Heart
Maddie & Tae, an American country music duo, is currently enjoying a popular song on country radio that asks an intriguing question: “Mama, can you die from a broken heart?” As we discuss with the following scenario, that answer is yes.
Imagine a normal day in your EMS system as units are dispatched to the cardiac arrest of a 75-year-old male at a local residence. The call gets a full complement of resources, prepared to perform CPR for the duration of the event. The first unit arrives, and the crew finds the patient supine on the living room floor. Thanks to the work of emergency medical dispatch, early CPR is being performed by an elderly female. She is pressing on his chest while she pleads for the situation to be different.
The crews perform their tasks flawlessly, working the arrest in place and by protocol. Other units arrive and assist, but there is little response from the patient. Ultimately the district supervisor arrives; she confirms clinical procedures are being performed correctly and protocols are being followed. She then turns to her checklist for this situation, and it directs her to perform family care.
She locates the distraught female who was performing chest compressions and learns she is the patient’s wife. They have been married for nearly 56 years. She learns of the day’s events, which started as an ordinary day of yardwork and playing with grandchildren. After eating lunch the patient complained of a pressure in his chest and went to rest in the living room.
As resuscitation efforts continue, they’re explained to the wife, and she’s provided an opportunity to witness the responders working. She walks briefly into the room but quickly returns to safety in the kitchen.
As the providers reach the end of their protocol, all responders agree discontinuation is the most appropriate action. The district supervisor delivers the news to the wife in the kitchen of the home she shared with her longtime mate: “The paramedics have tried very hard to save your husband, but I am sorry to inform you that your husband has died.” The response is one of grief but understanding. The wife is grateful for the responders yet obviously in disbelief that the love of her life, her partner for over five decades, is no longer there.
The scene is cleared, and the responders go about their shift but keep the wife’s grief in their minds. As they prepare for shift change the next morning, they receive a cardiac arrest dispatch for a familiar address. “We just responded to a cardiac arrest there yesterday,” one paramedic says. Dispatch says it’s a 74-year-old female in cardiac arrest—the wife of the patient who died just the day before.
Takotsubo Cardiomyopathy
Broken heart syndrome may also be referred to as stress-induced cardiomyopathy or takotsubo cardiomyopathy. The common term for the cardiomyopathy, takotsubo, is the Japanese name of an octopus pot, which resembles the appearance of the left ventricle when affected by this syndrome, preventing the normal flow of blood.1 Although unknowns remain about this condition, there are some relevant findings from years of research that can help provide awareness to EMS providers.
This type of cardiomyopathy was first observed in Japan and is much more prevalent in women than men, usually affecting older patients.2 The cause and pathophysiology are not well understood; neither is why it affects postmenopausal women more than any other group.3 First described in 1990, it was mostly unrecognized for the first 10 years and is still thought to be underdiagnosed.4 Some research suggests a sudden release of stress hormones, including adrenaline, contributes to the condition.5
Stress-induced cardiomyopathy is usually triggered by an acute exposure to emotional or physical stress such as a death of a loved one, catastrophic medical diagnosis, or even natural disaster.6 If you consider how emotionally charged death situations and conversations can be, this is vital information for responders who deliver death notifications. Pay attention in scenarios like the one above and anticipate a stress reaction to bad news. These messages are emotionally traumatic and extremely damaging for the recipient.
The clinical presentation for a patient experiencing broken heart syndrome is similar to that of myocardial infarction and may or may not include chest pain. There is also the possibility of electrocardiogram abnormalities such as ST-segment elevation, but that may not be present. This condition, just like myocardial infarction, can lead to cardiac arrest in the most extreme cases.7
Although we have no way to screen for this condition, awareness of the risk and performing a thorough history on the patient provides a piece to our assessment puzzle. We are more likely to encounter a patient experiencing this condition after an emotionally traumatic event, and we should recognize the potential for this syndrome.
Prehospital Concerns
Treat patients experiencing chest pain per your normal protocol, using caution with inotropic agents due to involvement of the left ventricle. Monitor for hypotension and be prepared to treat it with a fluid challenge. Other treatment modalities remain the same and include aspirin, pain management, and transport to the appropriate facility for percutaneous coronary intervention (PCI).8 We can also add a dose of emotional support to our conversations with the patient, which may go a long way to treating the broken heart.
This is a condition that should be on the mind of responders and anyone delivering traumatic and emotionally charged messages to someone. Because of our current practice of discontinuing cardiac arrest efforts in the field, we are charged with delivering an increasing number of death notifications, making awareness of this syndrome critically important. Remember the deep personal connection the recipient may have had with the patient and let them know it is OK to show their emotions. We also can provide emotional support and offer to contact friends, neighbors, and clergy to assist with their time of grief.
As these crews witnessed firsthand, you certainly can die of a broken heart. Keep this scenario in mind when providing family care during cardiac arrests and other significant events. The families of our patients, or those receiving bad news, can easily become additional patients.
References
1. Virani SS, Khan AN, Mendoza CE, Ferreira AC, de Marchena E. Takotsubo cardiomyopathy, or broken-heart syndrome. Tex Heart Inst J, 2007; 34(1):76–9.
2. Kawai S, Susuki H, Yamaguchi H, et al. Ampulla cardiomyopathy Takotsubo cardiomyopathy: reversible left ventricular dysfunction with ST elevation. Jap Circ J, 2000; 64: 156–9.
3. Nykamp D, Titak JA. Takotsubo cardiomyopathy, or broken-heart syndrome. Ann Pharmacother, 2010 Mar; 44(3): 590–3.
4. Napp LC, Bauersachs J. Takotsubo syndrome: between evidence, myths, and misunderstandings. Herz, 2020 May; 45(3): 252–66.
5. Harvard Health Publishing. Takotsubo cardiomyopathy (broken-heart syndrome), www.health.harvard.edu/heart-health/takotsubo-cardiomyopathy-broken-heart-syndrome.
6. Chlus N, Cavayero C, Kar P, Kar S. Takotsubo Cardiomyopathy: Case Series and Literature Review. Cureus, 2016 Jun 20; 8(6): e649.
7. Mohan J, Parekh A, DeYoung M. Sumatriptan Induced Takotsubo Cardiomyopathy; the Headache of the Heart: A Case Report. Front Cardiovasc Med, 2019 Sep 18; 6: 134.
8. Aura V, Vlad P, Radu-Gabriel V. The Great Myocardial Mimic—Takotsubo Syndrome. Maedica (Buchar), 2020 Mar; 15(1): 111–21.
Joshua Holloman, MHS, NRP, CEMSO, is deputy director for Johnston County (N.C.) Emergency Services.
