Broken Heart Syndrome on Rise in Women

J.Adderton, BSN, MSN

Researchers from Cedars Sinai have found the incident of Takotsubo syndrome (TTS), or broken heart syndrome, is on the rise, especially in middle-aged and older women. The findings¹come on the heels of a 2020 Cleveland Clinic study that found a link between TTS and increased levels of stress during the COVID-19 pandemic. You can read about the Cleveland Clinic study here².

The Study

Researchers analyzed data pulled from the National Inpatient Sample Database (NIS)³ provided by the Healthcare Cost and Utilization Project⁴ to find trends in TTS incidence from the years 2006 to 2017.

Patient Sample Criteria

Age 18 or older
Primary or secondary diagnosis of
- ICD-9-CM code 429.83 Takotsubo Syndrome, or
- ICD-10-CM code 51.81Takotsubo Syndrome

The following patients were excluded from the study:

Patients without coronary angiography, or
With coronary angiography, or
With coronary angiography and later percutaneous coronary intervention

Over the study period, researchers found 135,463 documented cases of TTS.

Findings

According to findings, the incidence of TTS was growing even prior to the COVID-19 pandemic, especially in women. In fact, most of the study's cases (88.3%) were represented by women, particularly women age 50 and older. Below is a breakdown of women ages and case incidence per year.

Middle-aged: 128 cases per million/year
Older women: 96 cases per million/year
Younger women: 15 cases per million/year

Overall, researchers found TTS diagnoses have steadily increased in both sexes and across all ages.

What is Broken Heart Syndrome

First described by a Japanese cardiovascular specialist in 1990, Takotsubo syndrome is a temporary type of acute heart failure. Symptoms, such as chest pain and trouble breathing, often mimic a heart attack. The condition is considered rare, however, collected data suggests 6-7% of all heart attacks treated by a cardiology department are actually attributed to broken heart syndrome.

TTS and Triggers

TTS, also called stress cardiomyopathy, is the heart's over-reaction to emotional or physical stress or something traumatic. Here are a few examples:

The loss of a loved one
An acute medical illness, such as a stroke, exacerbation or major operation
Experiencing an economic hardship
Being physically or emotionally abused

Some people can have triggers that are milder and in 30% of cases⁵, no obvious trigger can be identified.

Regardless of the underlying cause, the human body releases a surge of hormones as part of the "fight or flight" response.

Different From a Heart Attack

Although the symptoms of TTS mimic a heart attack, there are several differences in the diagnostic work-up.

Much lower troponin levels
Often an absence of blocked coronary arteries
Usually no permanent heart damage
Recovery within few days to weeks

There are factors that may reduce the chances for a full recovery from TTS. These include:

Having a physical trigger, such as a stroke
Being male (men make up 20% of cases with long-term damage)
Having chronic or serious conditions such as renal disease, lung disease, cancer, or anemia

Who's At Risk

Women biologically respond differently to stress and are at a higher risk for TTS. Menopause also increases risk because lower estrogen levels prevent arteries from dilating during the fight or flight response. Therefore, females over 60 may not be getting as much blood flow to the heart when experiencing acute stress. Other risk factors include:

History of anxiety or depression
Alcohol abuse
High cholesterol
Hypertension
Smoking
Obesity
Chronic stress

Study Limitations

The research data analysis was dependent on correct ICD-9 or ICD-10 coding of patient diagnosis and procedures. Additionally, NIS data doesn't include biomarkers, electrocardiogram and angiogram measures that are usually used to evaluate TTS cases.

Discussion

In conclusion, researchers found that TTS cases steadily increased from 2006 to 2017, especially among women 50 and older. The study authors found other contributing factors to the rise in cases in the rise. These include:

Advancements n diagnostic testing
Improved documentation of TTS diagnosis
Increased size of the at-risk population- aging adults, especially aging women 50 and older
Secular changes in socioeconomic and environmental changes