By Michael H. Crawford, MD, Editor

SYNOPSIS: Analysis of a multicenter, multicountry database of patients with stress cardiomyopathy revealed that 1% experienced a preceding positive emotional event rather than the usual negative one. These patients more likely had mid-wall left ventricular wall motion abnormalities rather than the usual apical ballooning.

SOURCE: Ghadri JR, Sarcon A, Diekmann J, et al. Happy heart syndrome: Role of positive emotional stress in takotsubo syndrome. Eur Heart J 2016;37:2823-2829.

Although usually associated with strong negative emotions, stress cardiomyopathy has been reported after positive emotional experiences. Investigators from the International Takotsubo Registry analyzed the prevalence and characteristics of stress cardiomyopathy after pleasant events. Data from 26 centers in nine countries included 1,750 patients, of whom 485 presented after an emotional event. The rest experienced a physical stress, a combination, or no identifiable trigger. Wall motion patterns from imaging were classified as apical ballooning, mid-ventricular, basal, or focal. Among the 485 participants who presented with an emotional event, only 20 (4%) were classified as pleasant and almost all were women (n = 19). In comparing happy heart and broken heart patients, happy hearts were older (71 vs. 65 years; P = 0.026) and less likely to be hypertensive (35% vs. 62%; P = 0.014). Otherwise, they were largely similar in other characteristics, including presenting symptoms, ECG findings, vital signs on admission, left ventricular function, and lab tests. Overall, the distribution of wall motion abnormalities was not significantly different between the two types, but in a post-hoc comparison, happy hearts demonstrated a higher prevalence of mid-ventricular pattern compared to the broken hearts (35% vs. 16%; P = 0.03). Clinical outcomes were not different between the two groups. The authors concluded that stress cardiomyopathy can be triggered by positive as well as negative emotions and that the midventricular pattern of wall motion abnormality was more prevalent among happy hearts.

COMMENTARY

We’ve seen the holiday heart, the broken heart, and now the happy heart, which seems to be much less common than the broken heart. We have received sporadic reports of patients with stress cardiomyopathy (SCM) who have demonstrated mid-wall rather than apical dyskinesis, and this report finds that this pattern is more common in the happy heart variant. Also, around the year 2000, there were several reports of basal wall motion abnormalities associated with subarachnoid hemorrhage (SAH). Thus, different types of stress can cause severe dysfunction of selective parts of the left ventricle. In contrast to stress cardiomyopathy (broken and happy) in SAH-associated dysfunction (SAD), ST elevation is rare, whereas in SCM it occurs in about two-thirds. In SAD, deep T-wave inversions occur more often. Clinicians usually discover SAD patients because of heart failure, which leads to an echocardiogram. In SCM, the presentation is more similar to acute coronary syndrome. Studies in animals have suggested that SCM is due to a large amount of epinephrine in the blood stream, whereas the SAD heart is associated with norepinephrine release from sympathetic fibers in the heart. Since these fibers are more concentrated at the base of the heart, this may explain the basal predominance of wall motion abnormalities in SAD heart. Why circulating epinephrine predominately affects the apical to mid wall is unclear, but has been reproduced in rodent models.

A Japanese cardiologist first described SCM in 1990, calling it the takotsubo syndrome because the left ventricle on angiography resembled an octopus jar. It was noted to be much more common in postmenopausal women and usually associated with a strong negative emotional or physical experience. These study authors noted that although unusual, it also can be associated with strong positive emotions. In fact, the authors pointed out that one is 27% more likely to suffer a myocardial infarction on one’s birthday as compared to any other day. A brief article that accompanied this paper suggested clinicians call the happy heart Diagoras syndrome after the ancient Greek story of Diagoras of Rhodes.1 He was an Olympic athlete whose two sons competed in the 83rd Olympiad. Both of his sons won their events, lifted their father from the stands, and carried him in a triumphant ovation to the cheers of the crowd. Diagoras died on the spot, presumably of happiness. There is a statue in Rhodes commemorating this event.

Fortunately, the happy heart seems rare. In this paper, it was 4% of those with a clear emotional event, but only 1% of the whole SCM database. Another paper accompanying this report opined that SCM is a form of acute coronary syndrome (ACS), along with STEMI, non-STEMI, and variant angina, and hypothesized that is due to catecholamine-induced small vessel vasospasm.2 We know that the central nervous system plays a role in ACS, especially as a trigger for some of these events. Unfortunately, at this time a specific treatment for SCM doesn’t exist. Thought to be relatively benign, if supported through the acute phase, the in-hospital mortality for SCM is similar to STEMI at 4%.

REFERENCES

  1. Katsanos S, Filippatou A, Ruschitzka F, Filippatos G. Positive emotions and Takotsubo syndrome: ‘Happy heart’ or ‘Diagoras’ syndrome? Eur Heart J 2016;37:2821-2822.
  2. Luscher TF, Teplin C. Is takotsubo syndrome a microvascular acute coronary syndrome? Towards a new definition. Eur Heart J 2016;37:2816-2820.