She was admitted to the hospital, where an ultrasound confirmed what we already suspected: her heart had weakened to less than half its normal capacity and had ballooned into the distinctive shape of a takotsubo. But no other tests were amiss, no sign of clogged arteries anywhere.
Two weeks later, her emotional state had returned to normal and so, an ultrasound confirmed, had her heart. Takotsubo cardiomyopathy has been linked to many stressful situations, including public speaking, domestic disputes, gambling losses, even a surprise birthday party.
It’s even been associated with widespread social upheaval, such as after a natural disaster. For example, in 2004, a massive earthquake devastated a district on the largest island in Japan. More than 60 people were killed, and thousands were injured.
On the heels of this catastrophe, researchers found that the incidents of takotsubo cardiomyopathy increased 24-fold in the district one month after the earthquake, compared to a similar period the year before.
The residences of these cases closely correlated with the intensity of the tremor. In almost every case, patients lived near the epicenter.
Interestingly, takotsubo cardiomyopathy has been seen after a happy event, too, but the heart appears to react differently, ballooning in the midportion, for example, and not at the apex.
Why different emotional precipitants would result in different cardiac changes remains a mystery. But today, perhaps as an ode to our ancient philosophers, we can say that even if emotions are not contained inside our hearts, the emotional heart overlaps its biological counterpart, in surprising and mysterious ways.
Heart syndromes, including sudden death, have long been reported in individuals experiencing intense emotional disturbance or turmoil in their metaphorical hearts.
In 1942, the Harvard physiologist Walter Cannon published a paper called “‘Voodoo’ Death,” in which he described cases of death from fright in people who believed they had been cursed, such as by a witch doctor or as a consequence of eating taboo fruit. In many cases, the victim, all hope lost, dropped dead on the spot.
What these cases had in common was the victim’s absolute belief that there was an external force that could cause their demise, and against which they were powerless to fight.
This perceived lack of control, Cannon postulated, resulted in an unmitigated physiological response, in which blood vessels constricted to such a degree that blood volume acutely dropped, blood pressure plummeted, the heart acutely weakened, and massive organ damage resulted from a lack of transported oxygen.
Cannon believed that voodoo deaths were limited to indigenous or “primitive” people. But over the years, these types of deaths have been shown to occur in all manner of modern people, too.
Today, death by grief has been seen in spouses and in siblings. Broken hearts are literally and figuratively deadly. These associations hold true even for animals.
In a fascinating study in 1980 published in the journal “Science,” researchers fed caged rabbits a high-cholesterol diet to study its effect on cardiovascular disease. Surprisingly, they found that some rabbits developed a lot more disease than others, but they couldn’t explain why.
The rabbits had very similar diet, environment and genetic makeup. They thought it might have something to do with how frequently the technician interacted with the rabbits.
So they repeated the study, dividing the rabbits into two groups. Both groups were fed a high-cholesterol diet. But in one group, the rabbits were removed from their cages, held, petted, talked to, played with, and in the other group, the rabbits remained in their cages and were left alone.
At one year, on autopsy, the researchers found that the rabbits in the first group, that received human interaction, had 60% less aortic disease than rabbits in the other group, despite having similar cholesterol levels, blood pressure and heart rate.
Today, the care of the heart has become less the province of philosophers, who dwell upon the heart’s metaphorical meanings, and more the domain of doctors like me, wielding technologies that even a century ago, because of the heart’s exalted status in human culture, were considered taboo.
In the process, the heart has been transformed from an almost supernatural object imbued with metaphor and meaning into a machine that can be manipulated and controlled.
But this is the key point: these manipulations, we now understand, must be complemented by attention to the emotional life that the heart, for thousands of years, was believed to contain.
Consider, for example, the Lifestyle Heart Trial, published in the British journal “The Lancet” in 1990. Forty-eight patients with moderate or severe coronary disease were randomly assigned to usual care or an intensive lifestyle that included a low-fat vegetarian diet, moderate aerobic exercise, group psychosocial support and stress management advice.
The researchers found that the lifestyle patients had a nearly 5% reduction in coronary plaque.
Controlled patients, on the other hand, had 5% more coronary plaque at one year and 28% more at five years. They also had nearly double the rate of cardiac events, like heart attacks, coronary bypass surgery and cardiac-related deaths.
Now, here’s an interesting fact: some patients in the controlled group adopted diet and exercise plans that were nearly as intense as those in the intensive lifestyle group. Their heart disease still progressed.
Diet and exercise alone were not enough to facilitate coronary disease regression. At both one- and five-year follow-ups, stress management was more strongly correlated with reversal of coronary disease than exercise was.
No doubt, this and similar studies are small, and, of course, correlation does not prove causation. It’s certainly possible that stress leads to unhealthy habits, and that’s the real reason for the increased cardiovascular risk.
But as with the association of smoking and lung cancer, when so many studies show the same thing, and when there are mechanisms to explain a causal relationship, it seems capricious to deny that one probably exists.
What many doctors have concluded is what I, too, have learned in my nearly two decades as a heart specialist: the emotional heart intersects with its biological counterpart in surprising and mysterious ways.