27 May 2019
Article from In Practice
When 61-year-old Judith Hemsworth collapsed on her living room floor with chest pain one night, she thought she was having a heart attack.
“As well as the chest pain, my legs went weak, one of my arms went numb, and I was sweaty and shaky,” Judith says. “I was quite lucky my daughter was still up, and she called an ambulance.” Hospital staff did an echocardiogram (ECG) and blood tests, which confirmed it appeared to be a heart attack. “The angiogram that followed found there were no blockages in my heart, but the left ventricle was ballooned out and not functioning properly.” Judith soon learned she had suffered an episode of Takotsubo Syndrome—a condition much less known than a heart attack and often mistakenly considered less serious.
WHAT IS TAKOTSUBO CARDIOMYOPATHY?
Reversible left ventricular dysfunction usually associated with an acute physical or emotional stressor that leaves residual inflammation that may result in ongoing debilitating symptoms for some people.
1. THERE IS A LACK OF AWARENESS AROUND THE CONDITION
“I was fortunate to have been taken to a hospital where the cardiology department were aware of Takotsubo and knew what to do,” Judith says. “Others I know have been told they’re just anxious and to ‘take a chill pill.’” “What I didn’t get was information about what was going to happen to me next. I think the condition is so poorly understood,” she says. On a mission to change that is Lyell McEwin Hospital cardiac nurse and university researcher Dr Angela Kucia, who has developed a world-first website dedicated to the condition. “The website has been developed in consultation with an international panel of experts and people with Takotsubo Syndrome to equip health professionals with the information they need to support people with this condition, and their families,” Dr Kucia says. The impetus for the website—funded by a research grant from the Rosemary Bryant Research Centre and the Australian Nursing and Midwifery Federation (SA Branch)—came from the reported experiences of people with Takotsubo syndrome and the lack of information and support they received both in hospital and after discharge.“Takotsubo was identified by the Japanese people in the early 1990s but has been largely ignored by Western medicine for many years.” “When working on the coronary care unit at The Queen Elizabeth Hospital prior to Takotsubo Syndrome being recognised, we would sometimes see women presenting with ECG changes and abnormal blood tests, yet angiograms didn’t show any blockages in the arteries. I found that odd,” Dr Kucia says. Also piquing her interest was that many of these cases were linked to a stressful event. “When an Italian lady presented with chest pains after arriving home to find her husband dead on the kitchen floor, it appeared that she was having a very large heart attack. At the time, thrombolytic therapy was used to treat myocardial infarction. “While an angiogram done soon after showed a very poorly functioning left ventricle, an ECG done three months later showed the ventricle had recovered completely—that was unheard of.” Following a decade of research, Dr Kucia says, it is most likely this lady had what we now know to be Takotsubo syndrome.
2. KNOWN CAUSES AND TRIGGERS
“Bereavement can of course be a trigger, but so can happy events like a lottery win or a surprise party—anything that prompts an extreme release of stress hormones or catecholamines.” “It can also actually happen from emotional stressors that you’d generally consider quite trivial. One lady’s dog started chewing her glasses, another came home to find her freezer had defrosted.” Because of the many cases tied to emotional event and largely only in women, Takutsubo became more colloquially known as Broken Heart Syndrome—a description Judith finds somewhat bothersome. “I’m classified as having secondary Takotsubo, as it was triggered by the stress on my body caused by other acute medical conditions,” Judith says. “I have Grave’s disease and had a relapse, so I was acutely thyrotoxic. I also have severe episodes of pain due to longstanding osteoarthritis. Together, this triggered Takotsubo.” Dr Kucia says stressors, as in Judith’s case, are more common than psychological (emotional) stressors. “Research tells us that 30 per cent of cases are caused by emotional stressors, 40 per cent by physical stressors, and the cause of the other 30 per cent we don’t actually know,” Dr Kucia says. “It may occur in the setting of a chronic illness, a fall or fracture and sometimes it may just be the flu or a flu injection,” she says. Further research is being done to find other links to Takotsubo. “Heat is also considered to be factor. There are several reports of an increase in cases of Takotsubo during heat waves.” The relationship between Takotsubo and cancer/cancer treatment is also being explored.
3. DIAGNOSIS IS DIFFICULT
“Takotsubo is difficult to diagnose as it presents the same as unstable angina or acute myocardial infarction,” Dr Kucia says. “People present with chest pain, shortness of breath and sometimes cardiac arrest, although the earlier two symptoms are the most common,” she says. “If a person appears to have a STelevation myocardial infarction, they’ll go to the cardiac catheterization lab and it will be identified pretty quickly that they won’t have a blockage, but with Takotsubo they’ll have ventricular wall abnormalities that are characteristic of the condition. That is, she says, as long as clinicians are aware of the condition. “Most cardiac clinicians would be aware of Takotsubo now, but when the condition occurs in other areas—such as obstetrics, anaesthetics, surgery, ICU—it may not get recognised in a timely way.” Dr. Kucia says that although most people do recover completely from Takotsubo, there are recognised complications that can be catastrophic, such as heart failure, stroke, and ventricular arrhythmias. “In-hospital mortality is similar to that of myocardial infarction.” Latest statistics show around 20 percent of patients in the acute phase of Takotsubo Syndrome will experience a serious adverse event (including death).
4. ONE IN FIVE PATIENTS WILL HAVE RECURRENT EPISODES
Dr Kucia says there is a misconception that episodes of Takotsubo are one-off and people will recover quickly. “Up to 20 per cent of patients will have a recurrent event and a few will have multiple recurrent events. Furthermore recovery is certainly not as simple as once believed.
“For the first few months after my episode, I spent most of every day sleeping and couldn’t walk five minutes down the road,” Judith says. “It’s been 14 months now and the fatigue still sometimes hits you like a wall.” Judith has since been rushed to hospital twice for chest pain and shortness of breath, as part of Takotsubo’s trademark heart inflammation that can take many months to recover, if at all. Dr Kucia says some people continue to have debilitating symptoms of chest pain, breathlessness and extreme fatigue long after the initial event. “Recent research has shown that, in some people, recovery of heart function is incomplete,” she says.
5. PREVALENCE AND AT-RISK GROUPS
Dr Kucia says as the syndrome is being increasingly recognised, the number of identified presentations is rising. “You’d generally see between 50 and 100 presentations per year, depending on the size of the hospital and their ability to recognise it,” Dr Kucia says. “Around 80 per cent of those affected are post-menopausal women, although it can affect anyone across their lifespan, from neonates to the elderly.”