Women’s Hearts (And Brains) Break Differently

SOME OF THE MOST DRAMATIC MOMENTS in the emergency department happen when cardiac patients come in.
Often, it’s just what you would expect to see on a TV show: a middle-aged or older man lying limp on a stretcher, an emergency medical technician (EMT) astride him doing chest compressions while the nurses wheel him through the doors. But for women, the situation often looks far different.
One day a few years ago, a woman came in on a stretcher in the late evening. She was pale, sweating, and gasping for breath—all signs of flash pulmonary edema or sudden heart failure. She was younger than I would have expected for someone with these symptoms—in her mid-fifties—and while slightly overweight, not obese. The friend who’d followed the ambulance to the ED told the intake staff that my patient had suddenly collapsed over dinner in one of Providence’s trendy restaurants.
Once the patient, whose name was Sharin, was admitted and stabilized, she was sent to the cath lab for testing. I had a moment to speak with her friend, who was huddled in her chair in the waiting area.
“I don’t know what happened,” the friend sobbed. “One minute, she was fine. The next, she was keeling over!”

“Did Sharin have any heart troubles before this?” I asked. There was nothing on her chart except an anxiety diagnosis, but given how commonly women’s heart disease is misdiagnosed, I always like to get the other side of the story.
“Not that I know of,” the friend replied. “She’s healthy! She works out every day.”
“How about stressful events in her life recently?”
“Well, her husband died a few weeks ago. It was unexpected. She’s got two kids in college and one still at home. She’s kind of in shock.” The friend dissolved into tears again. “I was just taking her out to dinner to cheer her up!”
My heart went out to her—and to Sharin, who was suddenly facing a future full of uncertainty.
After asking an aide to help settle the friend, I called our cath lab. “Have you done the angiogram yet?” I asked. “I think we may have a case of Takotsubo’s here.”
Takotsubo cardiomyopathy, also known as “stress cardiomyopathy” or “broken heart syndrome,” primarily affects women. After a stressful or traumatic event, the body experiences a massive rise of catecholamines (aka, the “fight or flight” hormones). All of a sudden, the left ventricle of the heart is stunned and balloons outward, and the heart can no longer beat very well. Often, the patient will experience intense, angina-like pain in the chest area; other times, she will collapse completely.
The name Takotsubo comes from the Japanese tako-tsubo, which means “fishing pot for trapping octopus”; when this condition is present, the swelling of the left ventricles causes the heart to take on that distinctive fishing-pot shape.

In Sharin’s case, the shock and stress of losing her husband had caused her stress hormones to skyrocket. Thankfully, Takotsubo’s is transient and, with proper supportive care and medication, will often resolve in a few days or weeks. However, if the underlying cause of the stress is not addressed, women who experience Takotsubo’s are at risk for other incidences of cardiac failure in the future.
Sharin didn’t come back to the ED but was instead sent up to a room in the main hospital for supportive care and observation. I hoped that she would not only recover from her sudden heart failure but also receive what she needed to process what had happened and grieve for her husband. I hoped she would heal and be there for her kids.
This is the hard part, for me, of working in the ED. My job is to tackle the acute issues of the moment and then send my patients to the specialists who can care for them in the longer term. I get the story of the illness but not always the full story of the healing.
Sharin’s case stuck with me in large part because of her anxiety diagnosis. There is a huge overlap between heart disease and anxiety diagnoses in women. Takotsubo cardiomyopathy, in particular,seems to strike women with anxiety more heavily. One small study found that “in comparison to background controls, TTC [Takotsubo] patients reported significantly less well-being, more neuroticism, more depression, and more anxiety.”1
This made sense to me. Of course women with previous anxiety would be more prone to a condition triggered by extreme levels of stress hormones. But what about other heart conditions? Was anxiety an underlying cause—or just the default diagnosis for a pattern of chronic and subtle female heart disease that our male-centric model doesn’t understand?

References:

Thomas Emil Christensen et al., “Neuroticism, Depression and Anxiety in Takotsubo Cardiomyopathy,” BMC Cardiovascular Disorders 16 (2016): 118. doi: 10.1186/s12872-016-0277-4.

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