Broken Heart Syndrome - Dubai Cardiology Clinic

It is called also  Apical Ballooning Syndrome (ABS) and Tako tsubo cardiomyopathy. It is first described by Dote in Japan 1991.

What is Apical Ballooning Syndrome (ABS)?

It is an acute onset reversible dilated cardiomyopathy. It occurs mainly in women after menopause, 6.3 fold more in women than men, with incidence rate of 1-3 % of patient admitted with heart attack (STEMI).

What are the main symptoms?

The patient usually presents with:

• Severe chest pain with shortness of breath after stressful event (emotional or physical) in two third of cases.
• ECG changes: ST elevation – Q wave abnormality .
• Mild increase in cardiac enzyme ( Troponin I – Troponin T – CK MB)
• Echocardiography: the hallmark of ABS is the presence of wall motion abnormality especially middle segment and apex of left ventricle look like balloon, but these changes are transient and disappear in few days or weeks.
• Coronary angiogram shows non significant stenosis in epicardial coronary arteries.

Diagnostic points are four:

• Suspected AMI chest pain, dyspnea, ECG changes (ST elevation – abnormal Q) , positive cardiac enzyme like troponin I.
• Transient LV apical ballooning by echo or LV cine in Catheter and decline in ejection fraction ( the performance of the heart)
• No significant angiographic stenosis within (less than 50% narrowing) 48 hours.
• No known cardiomyopathy.

 Triggering factors

• Stressful emotional or physical event: sudden accident, death/funeral of family member—vigorous excitation- inexperience with exercise like dancing , blowing, lifting work during house moving.
• Excessive alcohol consumption.
• Aggravation of underlining disorders: CVA – epilepsy – exacerbation of bronchial asthma, acute abdomen , non cardiac surgery or general anaesthesia for orthopaedic surgery, cholecystectomy , subtotal gastrectomy and procedure like intubation or dialysis therapy.

Mechanism

There is no clear cut pathophysiology but the most favourable explanation is catecholamine mediated myocardial stunning(stressful event), we have to think about microvascular spasm which is one type of ischemia without significant stenosis in an epicardial artery. This novel heart syndrome might be one of the clinical Models of stress-related sudden death.

Regional apical ballooning.. Why apex??

Some anatomic and physiologic factors may contribute to left ventricular apical wall motion abnormality:

            1 – LV apex does not have a three layer myocardial structure.

            2 – Easy loss of elasticity of LV apex after excessive expansion.

            3 – Apex is the border zone of the perfusion area of major coronary arteries

            4 – The delay of functional recovery from global dysfunction.

 Main Complications: 

• Arrythmia: AV block – sinus bradycardia – paroxysmal AF – VT – VF
• Hypotension
• Pulmonary edema
• Cardiogenic shock

Rare   Ventricular free wall rupture – VSD – thromboembolic events related to LV hypokinesia or dyskinesia may also occur.

Overall in hospital mortality rate is 1-3 % mainly from cardiogenic shock or systemic embolization but generally are much lower than from other acute cardiac illness.

Management

The cardiologist will manage the situation depending on the clinical situation, the blood pressure, the pulse, the accumulation of fluid in the chest, and so on. However supportive treatment leads to spontaneous rapid recovery in nearly all patients.

Recovery and outcome

Recovery starts usually after 3 days and it takes a few weeks to a few months but, anyway, the end result is excellent. The in-hospital death is 1-3 % and the recurrent rate is 1-2 % during one year.

Dubai Cardiology Clinic - Treatment of various cardiovascular diseases such as Hypertension, Ischemic heart disease, Holter monitoring, Heart failure, Stress test, chest pain and echocardiography  are now available in DRHC.