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Takotsubo, what is “broken heart” syndrome

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Like a heart attack. Severe chest pains, possibly with changes in the electrocardiogram trace. But the coronary arteries have no significant obstructions. Three clues make a test and precisely these characteristics, in addition to the shape that the left ventricle takes which becomes like a pot-bellied vessel with a narrow neck, characterize the classic “heartbreak” or if you prefer, according to science, the sindrome di Takotsubo. The damage focuses on the apical region of the heart because that is where the dysfunction is located, so much so that the heart takes on the characteristic shape of a basket to collect the polyps, which the Japanese call Takotsubo. Women are especially at risk, after menopause: even if the damage is usually temporary, in fact, the disease can be potentially lethal and, according to a study conducted at theMonash University in Melbourne, the risk of mortality would be nine times higher in women. Science says that in just under ten out of a hundred cases of myocardial infarctions, no coronary artery involvement is detected. Some patients are diagnosed with broken heart syndrome, while others remain undiagnosed. In this sense, to facilitate an early diagnosis, an MRI of the heart could be useful, at least according to a research by theKarolinska Institute of Stockholm published in the magazine JACC Cardiovascular Imaging.

What happens to the heart?

In short: science is trying to steal the secrets of this condition that mainly affects women. But there are still no certainties. In fact, it has long been known that in general terms, strong emotional tension leads to an increase in blood pressure and heart rate, two mechanisms that tend to make the atherosclerotic plaque present in one or more coronary arteries less stable. But in Takotsubo cardiomyopathy or broken heart syndrome, the arteries are not blocked. The condition is characterized by reduced heart function which is likely related to stress and which exhibits the same symptoms as a regular heart attack. So, how does the picture arise and what happens in the brain of those who develop the syndrome? The answer comes from research showing that, while involving the heart muscle, this reaction is a daughter of a recent severe stress such as mugging, home burglary, or sudden death, would be the result of a cascade mechanism that originates in the nervous system and which can be affected by differences from person to person in the reaction to stressful events. To say it is a study on cellular metabolism that appeared on European Heart Journal, who examined brain imaging scans in 41 people who then developed a Takotsubo picture, comparing them to those obtained in 63 subjects without specific problems. The rationale for this investigation is simple: generally the brain areas with greater metabolic activity are those that are used the most and if more “action” is detected in the areas involved in the stress response, a more significant emotional involvement can be thought of. some predisposed people. The study, coordinated by Ahmed Tawakol, of Massachusetts General Hospital, has shown that a “key” of the pathological process would lie in the activity of the amygdala: when this intensifies in response to a stress it would increase the risk of developing a Takotsubo more quickly. If, on the other hand, there are slower reactions, the picture can develop in the following years. In short: the syndrome would not only be the result of a rare and terrible event such as the death of a spouse or child, as the classic examples say, but according to American experts there would be predisposed subjects, in which even exposure to factors of more common stresses, such as a troubling diagnostic test or a fracture, can trigger the picture.

[[ge:rep-locali:content-hub:293462085]]In Takotsubo syndrome, therefore, stress can be the driving force behind heart problems. And the heart is subjected to a real storm of catecholamines which is maintained over time and leads to a prolonged increase in oxygen demand by the myocardial cells. The result is that eventually the heart no longer has strength to contract and symptoms appear. Adrenaline and noradrenaline produced by the adrenal glands in response to stress in fact cause damage to the myocardium not due to the formation of occlusions along the coronary arteries, which in this form remain patent, but for a abnormal demand for energy by the myocardial cells themselves. This mechanism, in addition to economic, social and emotional stress, can be linked to a bereavement and manifests itself in the days immediately following the loss. In this sense, the Covid-19 pandemic also adds an additional risk. According to research recently published in Jama Network Open, coordinated by Ahmad Jabri of the Cleveland Clinic, during the pandemic period in two hospitals in the US state there were a significantly higher number of cases (we are in the order of four times) of Takotsubo compared to the pre-Covid periods: mortality did not change, but the hospital stays were longer during the pandemic period.


Treatment? Tailored on a case by case basis

In terms of therapies, according to experts, it is necessary to initially behave as is done with a classic heart attack, then act quickly and well. “The first thing to do in patients with Takotsubo syndrome is to perform a coronary angiography because this syndrome is present in 1-3% of all patients falsely hospitalized for Stemi heart attack (an electrocardiographic condition typical of some forms of ischemia that differs from non-Stemi heart attack) – he explains Ciro Indolfi, president of the Italian Society of Cardiology – since Takotsubo syndrome does not imply a coronary obstruction, the demonstration of a coronary tree free from acute thrombosis is necessary for its diagnosis. Regarding the therapy it must be emphasized that there are no guidelines on the treatment of Takotsubo syndrome. Acute phase therapy is highly dependent on the state of left ventricular function and empirically relies on supportive drugs such as ACE inhibitors, diuretics and beta-blockers. Although the causes of Takotsubo syndrome are not completely clear, an activation of the sympathetic nervous system has been consistently documented. On this basis, even in the absence of specific recommendations, it might be reasonable to administer beta-blocking drugs in the absence of contraindications at least until left ventricular dysfunction normalizes. In case of severe acute decompensation, it may also be necessary to use mechanical systems to support arterial circulation (such as an intra-aortic balloon or a turbine). Takotsubo syndrome still remains in some ways a mystery. In the acute phase of the disease, the only certainty for these patients is the need for hospitalization in a cardiological therapy unit, the classic Utic, to prevent possible serious consequences in the form of cardiac arrhythmias “.


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