The Broken Heart Syndrome

llan Wittstein has published and given lectures and states there are clinical criteria, diagnostic criteria and treatment and prognosis information that can be readily identified. Synonyms include neurogenic stunned myocardium, acute coronary syndrome, stress myocarditis, and Takotsubo syndrome (named after the japanese pot used to capture octopus).  The syndrome is a REVERSIBLE disorder with very abnormal EKG, U waves, ST elevations, Q waves, elevated troponins, normal coronaries on cath, and return of EF to normal within days to weeks.  The pathology includes contraction band necrosis in myocardium, and is linked to hypersympathetic state.  It is a huge problem involving 2 percent of patients undergoing cath and 5-7 % of women.  Most patients are postmenopausal Caucasian women with risk factors who present with chest pain and shortness of breath.  Many have mood disorders


Diagnostic criteria are divided into "helpful" and "required"
HELPFUL-
1.  Acute trigger-- could be emotional (anxiety, joy, grief, fear, anger) or physical (procedure, respiratory drugs) even surprise party. 
2.  Characteristic EKG-- presenting EKG has steep ST elevation without reciprocal changes, T wave inversions everywhere, QT prolongation,  that becomes milder within 2-4 days
3.  Troponin elevation is mild-- less than 5, never more than 20

REQUIRED
1.  Absent coronary thrombosis
2.  Wall motion abnormalities extend beyond a single coronary artery territory  ( 3 patterns:  apical, basal, and midventricular)
3.  Rapid recovery of systolic function within 2 weeks at most

Diagnostic tests that are helpful (but possibly hard/unlikely to obtain esp. acutely)
1.  MRI heart unlike ECHO differentiates dead and stunned tissue.  Dead cardiac tissue lights up with Gadolinium but stunned heart will not

Therapy:
1.  supportive-- possibly not in ICU- arbs, ACEi's, diuretics.  Anticoag if apex not moving to prevent clot kicking, avoid pressors (catechols are a problem)
2.  Balloon pump better than pressors
3.  HHH  good for brain, bad for heart

Prognosis
1.  recurrence 3-10 percent with 2 % mortality
2.  Death is due to etiology not to cardiac dysfunction per se.

Pathophysiology
contraction band necrosis- direct myocyte injury related to calcium overload.