“The 401 highway running through the centre of Toronto is said to be the busiest road in the world,” said my wife reading from our Canadian travel guide that we bought to prepare us for our time in Canada for my interventional fellowship. Not long off the plane, and driving ‘on the wrong side of the road’, I certainly felt stressed and was relieved to have a short drive to our new home. But after only a couple of months in my new job, it became clear that many people become more stressed than I did and faced a bigger challenge coming off the 401.
Before 2007, mainly looking after patients from Scotland’s third city and its surrounding rural area, I’d certainly seen patients with Takotsubo cardiomyopathy (TTC), but not that many. So-called “Broken heart syndrome” or “stress-related cardiomyopathy”, was more clearly in my mind in patients with very sudden and deep emotional stressors, such as: sudden and unexpected bereavements, assaults and robberies, or earthquakes…not common in Scotland I know, but big in Japan, where TTC got its name.
I came to realise that the external perceived degree of stress on our TTC patients could be much more subtle than I first thought. Public speaking, the return home of a long departed relative and being unable to get off the 401, all brought patients through the STEMI pathway and into the cath lab, and slightly disappointingly for the interventional fellow, they were found to have normal coronaries.
Unobstructed coronaries shouldn’t be your only assessment in the cath lab, a pump LV angiogram is indicated for a suspected TTC, especially as the findings are often pathognomic in the acute phase; although, I do find the recovering LV angiogram days away from presentation a bit less clear. We probably all now recognise the “classical form” with apical ballooning, but also be aware of the pattern of the rarer basal, mid-cavity and focal types.
Intriguingly, the list of potential stressors for a TTC continues to grow, with physical stressors also clearly implicated, including: any type of surgery (elective or urgent); respiratory and urinary infections; in fact, any important illness. Is it the emotional impact of having the physical condition in these settings that causes TTC? A middle-aged woman who had TTC following an urgent lap chole convinced me “she wasn’t a worrier”, and she’d been quite relaxed before her operation; could her physical stress alone have been sufficient stimulus to give her the TTC?
After a STEMI presentation, the fuller history and subsequent ECG progression most often make the diagnosis clear but, it is helpful to get the confirmatory data from an early MRI as well, if possible. Characteristically all of the myocardium is oedematous in TTC, even those portions not showing systolic dysfunction, showing clearly the cause is a pan-myocardial insult; how this differential effect on function occurs continues to be discussed.
So is the incidence of TTC really increasing, and if so, is it a reflection of a more stressed society? It has been estimated that 2% of patients presenting as an ACS have TTC, in women alone it may be up to 7.5%. It is clear that post-menopausal women are the vast majority of TTC patients, the reason for this is still uncertain.
Reassuringly for our patients who overcome the acute phase, the medium-term prognosis has been shown to be very good, with complete recovery of the LV in most within 4–8 weeks; and most often there appears to be no residual consequences of TTC after recovery of the LV to normal. But, the recurrence rate of TTC may be from 2 to 12%, and most often the preceding stressor is not the same as the index event, so the predictability of a certain type of stressful event or occurrence causing TTC again appears impossible.
It seems clear TTC is not just a first world problem, but a human one. If there is an increasing diagnosis of TTC, it probably reflects healthcare systems better awareness and improved diagnostic accuracy, which is clearly a good thing.
As a Cardiologist we feel our job is largely done when with our patient’s cardiac recovery, but a TTC patient recently shared with me that the they felt specific psychological support in addition would have been optimal for their recovery. It is probably fair to assume that TTC patients psychological needs are different to the more usual cardiac rehabilitation patient, leading to me consider if I should refer all TTC patients to a clinical psychologist?
Will we ever be able to define those at highest risk of TTC and protect them from the stresses we can all face in the world that would cause it? Hopefully, but that is a challenge. Just now we all must do what we can, and stay off the 401!