Broken heart syndrome: Is bad news bad for your heart?

Charanjit Rihal, M.D.

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Your grandmother learns her husband has passed away and immediately begins complaining of chest pain. This sort of reaction — experiencing chest pain or a heart attack after hearing bad news — is sometimes shown in television and movies. But it's not just fiction. Some people seem to actually get symptoms mimicking a heart attack after hearing bad news or experiencing other types of stress, a phenomenon doctors now refer to as broken heart syndrome.

First described medically in 1991 by Japanese doctors, the condition was originally called takotsubo cardiomyopathy. Takotsubo is a type of pot used by Japanese fishermen to capture octopuses. When doctors take images of a person who's experiencing broken heart syndrome, part of his or her heart resembles the pot. Today, the condition is also referred to as stress cardiomyopathy, stress-induced cardiomyopathy or apical ballooning syndrome. Much about broken heart syndrome is a mystery.

Charanjit Rihal, M.D., a cardiologist and director of Mayo Clinic's Cardiac Catheterization Laboratory, and his colleagues have studied broken heart syndrome. Here he discusses the syndrome.

Signs and symptoms

Skin cancer develops primarily on areas of sun-exposed skin, including the scalp, face, lips, ears, neck, chest, arms and hands, and on the legs in women. But it can also form on areas that rarely see the light of day — the palms, spaces between the toes and the genital area. Skin cancer affects people of all skin tones, including those with darker complexions.

A cancerous skin lesion can appear suddenly or develop slowly. Its appearance depends on the type of cancer.

Basal cell carcinoma
This is the most common skin cancer. It's also the most easily treated and the least likely to spread. Basal cell carcinoma usually appears as one of the following:

• A pearly or waxy bump on your face, ears or neck
• A flat, flesh-colored or brown scar-like lesion on your chest or back

Squamous cell carcinoma
Squamous cell carcinoma is easily treated if detected early, but it's slightly more apt to spread than is basal cell carcinoma. Most often, squamous cell carcinoma appears as one of the following:

• A firm, red nodule on your face, lips, ears, neck, hands or arms
• A flat lesion with a scaly, crusted surface on your face, ears, neck, hands or arms

Melanoma
This is the most serious form of skin cancer and the one responsible for most skin cancer deaths. Melanoma can develop in otherwise normal skin or in an existing mole that turns malignant. Although it can occur anywhere on the body, melanoma appears most often on the upper back or face in both men and women.

Warning signs of melanoma include:

• A large brownish spot with darker speckles located anywhere on your body
• A simple mole located anywhere on your body that changes in color, size or feel or that bleeds
• A small lesion with an irregular border and red, white, blue or blue-black spots on your trunk or limbs
• Shiny, firm, dome-shaped bumps located anywhere on your body
• Dark lesions on your palms, soles, fingertips and toes, or on mucous membranes lining your mouth, nose, vagina and anus

Less common skin cancers
Other, less common types of skin cancer include:

• Kaposi sarcoma. This rare form of skin cancer develops in the skin's blood vessels and causes red or purple patches on the skin or mucous membranes. Like melanoma, it's a serious form of skin cancer. It's mainly seen in people with weakened immune systems, such as people with AIDS and people taking medications that suppress their natural immunity, such as people who've undergone organ transplants.
• Merkel cell carcinoma. In this rare cancer, firm, shiny nodules occur on or just beneath the skin and in hair follicles. The nodules may be red, pink or blue and can vary in size from a quarter of an inch to more than 2 inches. Merkel cell carcinoma is usually found on sun-exposed areas on the head, neck, arms and legs. Unlike basal and squamous cell carcinomas, Merkel cell carcinoma grows rapidly and often spreads to other parts of the body.
• Sebaceous gland carcinoma. This uncommon and aggressive cancer originates in the oil glands in the skin. Sebaceous gland carcinomas — which usually appear as hard, painless nodules — can develop anywhere, but most occur on the eyelid, where they're frequently mistaken for benign conditions.

Precancerous skin lesions, such as an actinic keratosis, also can develop into squamous cell skin cancer. Actinic keratoses appear as rough, scaly, brown or dark-pink patches. They're most commonly found on the face, ears, lower arms and hands of fair-skinned people whose skin has been damaged by the sun.

Not all skin changes are cancerous. The only way to know for sure is to have your skin examined by your doctor or dermatologist.

Basal cell skin cancers are common after age 40, especially in fair-skinned people.

Squamous cell cancers are more common in fair-skinned people who are older than 50.

Melanoma is the least common but most dangerous skin cancer. It can develop anywhere on your body at any age.

Risk factors

These factors may increase your risk of skin cancer:

• Fair skin. Having less pigment (melanin) in your skin provides less protection from damaging UV radiation. If you have blond or red hair, light-colored eyes, and you freckle or sunburn easily, you're much more likely to develop skin cancer than a person with darker features is.
• A history of sunburns. Every time you get sunburned, you damage your skin cells and increase your risk of developing skin cancer. After a sunburn, your body works to repair the damage. Having multiple blistering sunburns as a child or teenager increases your risk of developing skin cancer as an adult. Sunburns in adulthood also are a risk factor.
• Excessive sun exposure. Anyone who spends considerable time in the sun may develop skin cancer, especially if your skin isn't protected by sunscreen or clothing. Tanning also puts you at risk. A tan is your skin's injury response to excessive UV radiation.
• Sunny or high-altitude climates. People who live in sunny, warm climates are exposed to more sunlight than are people who live in colder climates. Living at higher elevations, where the sunlight is strongest, also exposes you to more radiation.
• Moles. People who have many moles or abnormal moles called dysplastic nevi are at increased risk of skin cancer. These abnormal moles — which look irregular and are generally larger than normal moles — are more likely than others to become cancerous. If you have a history of abnormal moles, watch them regularly for changes.
• Precancerous skin lesions. Having skin lesions known as actinic keratoses can increase your risk of developing skin cancer. These precancerous skin growths typically appear as rough, scaly patches that range in color from brown to dark pink. They're most common on the face, lower arms and hands of fair-skinned people whose skin has been sun damaged.
• A family history of skin cancer. If one of your parents or a sibling has had skin cancer, you may be at increased risk of the disease. Some families are affected by a condition called familial atypical mole-malignant melanoma (FAMMM) syndrome. The hallmarks of FAMMM include a history of melanoma in one or more close relatives and having more than 50 moles — some of which are atypical. Because people with this syndrome have an extremely high risk of developing melanoma, frequent screening for signs of skin cancer is crucial.
• A personal history of skin cancer. If you developed skin cancer once, you're at risk of developing it again. Even basal cell and squamous cell carcinomas that have been successfully removed can recur in the same spot, often within two to three years.
• A weakened immune system. People with weakened immune systems are at greater risk of developing skin cancer. This includes people living with HIV/AIDS or leukemia and those taking immunosuppressant drugs after an organ transplant.
• Fragile skin. Skin that has been burned, injured or weakened by treatments for other skin conditions is more susceptible to sun damage and skin cancer. Certain psoriasis treatments and eczema creams might increase your risk of skin cancer.
• Exposure to environmental hazards. Exposure to environmental chemicals, including some herbicides, increases your risk of skin cancer.
• Age. The risk of developing skin cancer increases with age, primarily because many skin cancers develop slowly. The damage that occurs during childhood or adolescence may not become apparent until middle age. Still, skin cancer isn't limited to older people. Basal cell and squamous cell carcinomas are increasing fastest among women younger than 40.

Causes

Most of the time, the cause of the cardiomyopathy is unknown. In some people, however, doctors are able to identify some contributing factors. Possible causes of cardiomyopathy include:

• Long-term high blood pressure
• Heart valve problems
• Heart tissue damage from a previous heart attack
• Chronic rapid heart rate
• Metabolic disorders, such as thyroid disease or diabetes
• Nutritional deficiencies of essential vitamins or minerals, such as thiamin (vitamin B-1), selenium, calcium and magnesium
• Pregnancy
• Excessive use of alcohol over many years
• Abuse of cocaine or antidepressant medications, such as tricyclic antidepressants
• Use of some chemotherapy drugs to treat cancer
• Certain viral infections, which may injure the heart and trigger cardiomyopathy

Hemochromatosis is a disorder in which your body doesn't properly metabolize iron, causing it to build up in various organs, including your heart muscle. This can lead to a weakening of the heart muscle, resulting in dilated cardiomyopathy.

The three types of cardiomyopathy are:

• Dilated cardiomyopathy. This is the most common type of cardiomyopathy. In this disorder, your heart's main pumping chamber — the left ventricle — becomes enlarged (dilated), its pumping ability becomes less forceful, and blood doesn't flow as easily through the heart. Although this type can affect people of all ages, it occurs most often in middle-aged people, and is more likely to affect men. Some people with dilated cardiomyopathy may have a family history of the condition.
• Hypertrophic cardiomyopathy. This type involves abnormal growth or thickening of your heart muscle, particularly affecting the muscle of your heart's main pumping chamber. As thickening occurs, the heart tends to stiffen and the size of the pumping chamber may shrink, interfering with your heart's ability to deliver blood to your body. Hypertrophic cardiomyopathy can develop at any age, but the condition tends to be more severe if it becomes apparent during childhood. Most affected people have a family history of the disease, and some genetic mutations have been linked to hypertrophic cardiomyopathy.
• Restrictive cardiomyopathy. The heart muscle in people with restrictive cardiomyopathy becomes rigid and less elastic, meaning the heart can't properly expand and fill with blood between heartbeats. While restrictive cardiomyopathy can occur at any age, it most often tends to affect older people. It's the least common type of cardiomyopathy and can occur for no known reason (idiopathic). The condition may also be caused by diseases elsewhere in the body that affect the heart, such as amyloidosis, a rare condition in which abnormal proteins present in the blood are deposited into the heart.

Cardiomyopathy occurs when the myocardium, the thick middle layer of your heart muscle, weakens or stiffens. The myocardium is responsible for most of your heart's pumping action.

Complications

Having cardiomyopathy may produce the following complications:

• Heart failure. Heart failure means your heart can't pump enough blood to meet your body's needs. The thickened, stiffened or weakened heart muscle due to cardiomyopathy can become unable to pump or can obstruct blood flow out of the heart.
• Blood clots. Any of the types of cardiomyopathy may make you more susceptible to blood clots in your heart. If clots are pumped out of the heart and enter your circulatory system, they can block the blood flow to vital organs, including your heart and brain. If clots develop on the right side of your heart, they may travel to your lungs. To reduce your risk, your doctor may prescribe a blood thinner (anticoagulant medication), such as aspirin, clopidogrel (Plavix) or warfarin (Coumadin).
• Heart murmur. Because people with dilated cardiomyopathy have an enlarged heart, two of the heart's four valves — the mitral and tricuspid valves — may not close properly, leading to a backflow of blood. This flow creates sounds called heart murmurs. Heart murmurs are not necessarily harmful, but they should be monitored by your doctor.
• Cardiac arrest and sudden death. All forms of cardiomyopathy can lead to abnormal heart rhythms. Some of these heart rhythms are too slow to sustain the circulation, and some are too fast to allow the heart to beat properly. In either case, these abnormal heart rhythms can result in fainting or, in some cases, sudden death from a complete cessation of heartbeats, called cardiac arrest.

Self-care

Your doctor may recommend adopting the following lifestyle changes to help you manage cardiomyopathy:

• Quit smoking.
• Lose excess weight.
• Eat a low-salt diet (less than 2,300 milligrams a day).
• Get modest exercise, after discussing with your doctor the most appropriate program of physical activity.
• Eliminate or minimize the amount of alcohol you drink. Specific recommendations will depend on the type of cardiomyopathy you have.

Signs and symptoms

Melanomas can develop anywhere on your body, but most often develop in areas that have had exposure to the sun, such as your back, legs, arms and face. Melanoma can occur in areas that don't receive much sun exposure, such as the soles of your feet, palms of your hands and on fingernail beds.

The first sign of melanoma is often a change in an existing mole or the development of a new, unusual-looking growth on the skin. But melanoma can also occur on otherwise normal appearing skin.

Normal moles
Normal moles are generally a uniform color, such as tan, brown or black, with a distinct border separating the mole from your surrounding skin. They're oval or round in shape and about 1/4 inch (6 millimeters) in diameter — the size of a pencil eraser.

Most people have between 10 and 40 moles. Many of these develop by age 20, although moles may change in appearance over time — some may even disappear with age. Some people may have one or more large (more than 1/2 inch, or 12 millimeters, in diameter), flat moles with irregular borders and a mixture of colors, including tan, brown, and either red or pink. Known medically as dysplastic nevi, these moles are much more likely to become cancerous (malignant) than normal moles are.

Unusual moles that may indicate melanoma
To detect melanomas or other skin cancers, use this skin self-examination guide, adapted from recommendations by the American Academy of Dermatology:

• A is for asymmetrical shape. Look for moles with irregular shapes, such as two very different-looking halves.
• B is for irregular border. Look for moles with irregular, notched or scalloped borders — the characteristics of melanomas.
• C is for changes in color. Look for growths that have many colors or an uneven distribution of color.
• D is for diameter. Look for growths that are larger than about 1/4 inch (6 millimeters).
• E is for evolving. Look for changes over time, such as a mole that grows in size or that changes color or shape. Moles may also evolve to develop new signs and symptoms, such as new itchiness or bleeding.

Other suspicious changes in a mole may include:

• Scaliness
• Itching
• Change in texture — for instance, becoming hard or lumpy
• Spreading of pigment from the mole into the surrounding skin
• Oozing or bleeding

Malignant moles vary greatly in appearance. Some may show all of the changes listed above, while others may have only one or two unusual characteristics.

Hidden melanomas
Melanomas can also develop in areas of your body that have little or no exposure to the sun, such as the spaces between your toes and on your palms, soles, scalp or genitals. These are sometimes referred to as hidden melanomas because they occur in places most people wouldn't think to check. When melanoma occurs in people of color and those with dark skin tones, it's more likely to occur in a hidden area.

Hidden melanomas include:

• Melanoma under a nail. Subungual melanoma is a rare form of melanoma that occurs under a nail, most often on the thumb or big toe. It's especially common in blacks and in other people with darker skin pigment. The first indication of a subungual melanoma is usually a brown or black discoloration that's often mistaken for a bruise (hematoma). See your dermatologist if you develop a nail discoloration that increases in size, spreads to involve the cuticle or that doesn't heal after two months.
• Melanoma in the mouth, digestive tract, urinary tract or vagina. Mucosal melanoma develops in the mucosal tissue that lines the nose, mouth, esophagus, anus, urinary tract and vagina. Mucosal melanomas are especially difficult to detect because they can easily be mistaken for other, far more common conditions. A melanoma in a woman's genital tract may result in itching and bleeding — signs and symptoms that commonly result from a yeast infection or menstrual irregularities. And symptoms of anorectal melanoma are similar to those caused by hemorrhoids. Your dentist is trained to spot melanomas that occur in your mouth. Regular pelvic exams can help detect melanomas in the vagina.
• Melanoma in the eye. Ocular melanomas sometimes develop in the pigment-containing cells in the back portion of the eye (retina). These melanomas usually don't produce symptoms and are only detected during eye exams. On the other hand, melanomas that occur in the lining of your eyelid (conjunctiva) or the pigmented coating within your eyeball (choroid) may cause a scratchy feeling under your eyelid or a dark spot in your vision. The best way to prevent ocular melanoma, which has been linked to chronic sun exposure, is to wear glasses rated to block 99 percent to 100 percent of ultraviolet A light when you're in the sun.

Moles are usually harmless. They may contain hairs or become raised or wrinkled. Talk to your doctor about any change in the color or size of a mole, or if itching, pain, bleeding or inflammation develops.

Melanoma is the least common but most dangerous skin cancer. It can develop anywhere on your body at any age. Tell your doctor if you have a mole or lesion that looks like this.

Risk factors

Factors that may increase your risk of skin cancer include:

• Fair skin. Having less pigment (melanin) in your skin means you have less protection from damaging UV radiation. If you have blond or red hair, light-colored eyes and you freckle or sunburn easily, you're more likely to develop melanoma than is someone with a darker complexion. Fair-skinned people of Northern European ancestry are particularly at risk. Queensland, Australia, has the highest skin cancer rate in the world because it has unusually high levels of UV radiation and because most of its inhabitants are of English or Irish descent.

  Though less common, melanoma can develop in people with darker complexions, including Hispanics and blacks. For these people, melanoma is often diagnosed in the later stages, when the lesions are deeper and more advanced. Survival from melanoma is related almost entirely to the depth of invasion at the time of diagnosis. So it's important that people of all ethnic backgrounds be aware of melanoma and take precautions against UV radiation.

• A history of sunburn. Every time you burn your skin, you increase your risk of developing skin cancer. People who have had one or more severe, blistering sunburns as a child or teenager are at increased risk of skin cancer as an adult. For that reason, it's particularly important to protect children from the sun, not just with sunscreen but also with a hat, protective clothing and dark glasses. Although sunburns in adulthood also are a risk factor, the greatest damage seems to occur before you're 18. Infants are particularly vulnerable because the melanin in their skin isn't yet fully developed.
• Excessive sun exposure. Exposure to UV radiation is the leading cause of all skin cancers, including melanoma.
• Sunny or high-altitude climates. Living in a sunny climate exposes you to more UV radiation than does living in a cool, cloudy climate. In the United States, skin cancer is far more common in Arizona than in Minnesota. In addition, if you live at a high elevation you're exposed to more UV radiation.
• Moles. Having just one dysplastic mole doubles your risk of melanoma. But it's not only atypical moles that make you more susceptible to melanoma — having more than 50 ordinary moles also increases your risk.
• A family history of melanoma. If a close relative, such as a parent, child or sibling, has had melanoma, you have a greater chance of developing it too. In addition, some families are affected by a condition called familial atypical mole-malignant melanoma (FAMMM) syndrome. The hallmarks of FAMMM include a history of melanoma in one or more close relatives and having more than 50 moles, some of which are atypical. People with this syndrome have an extremely high risk of developing melanoma.
• Weakened immune system. People with weakened immune systems are at greater risk of many diseases, including skin cancer. This includes people who have chronic leukemias, other cancers or HIV/AIDS, and those who have undergone organ transplants or who are taking medications that suppress the immune system.
• Exposure to carcinogens. The American Cancer Society has identified several substances that may contribute to melanoma, including coal tar, the wood preservative creosote, arsenic compounds in pesticides and radium.
• Rare genetic disorder. People with xeroderma pigmentosum, which causes an extreme sensitivity to sunlight, have a greatly increased risk of developing melanoma because they have little or no ability to repair damage to the skin from ultraviolet light.

Causes

If you're like more than half the people with dilated cardiomyopathy, the cause of your condition can't be determined. Such cases are usually called idiopathic dilated cardiomyopathy. An estimated 30 percent to 50 percent of people with idiopathic dilated cardiomyopathy may carry a genetic mutation that causes the disease. Researchers have identified numerous genes associated with dilated cardiomyopathy and continue to search for more.

A number of other factors can change and enlarge your left ventricle. These additional causes of dilated cardiomyopathy include:

• High blood pressure (hypertension)
• Hardening and narrowing of arteries (atherosclerosis)
• Heart valve problems
• Damage to the heart muscle from a previous heart attack
• Chronic rapid heart rate (tachycardia)
• Chronic, excessive alcohol consumption
• Certain chemotherapy drugs for treating cancer
• Abuse of cocaine
• Viral or bacterial infections affecting the heart
• Metabolic disorders, such as thyroid disease or diabetes
• Abnormal metabolism of iron (hemachromatosis)
• Nutritional deficiencies of essential vitamins and minerals
• Inflammation of heart muscle from immune system disorders
• Metals and other toxic compounds, such as lead, mercury and arsenic
• Neuromuscular disorders, such as muscular dystrophy
• Pregnancy (peripartum cardiomyopathy)

Treatment

The goals of treatment for dilated cardiomyopathy are to treat an underlying cause if it's known, improve blood flow, reduce symptoms and prevent further damage to the heart.

Medications
Doctors usually treat dilated cardiomyopathy with a combination of medications. Depending on your symptoms, you might need two or more of these drugs. Several types of drugs have proved useful in the treatment of heart failure and dilated cardiomyopathy. These medications include:

• Angiotensin-converting enzyme (ACE) inhibitors. These drugs help people with dilated cardiomyopathy live longer and feel better. ACE inhibitors are a type of vasodilator, a drug that widens or dilates blood vessels to lower blood pressure, improve blood flow and decrease the workload on the heart. Examples include enalapril (Vasotec), lisinopril (Prinivil, Zestril) and captopril (Capoten). ACE inhibitors also blunt some of the effects of hormones that promote salt and water retention.

  ACE inhibitors cause an irritating cough in some people. It may be best to put up with the cough, if you can, to gain the medication's benefits. Discuss this side effect with your doctor. Switching to another ACE inhibitor or an angiotensin II receptor blocker may relieve the problem.

• Angiotensin II (A-II) receptor blockers (ARBs). These drugs, which include losartan (Cozaar) and valsartan (Diovan), have many of the beneficial effects of ACE inhibitors, but they don't cause a persistent cough. They may be an alternative for people who can't tolerate ACE inhibitors.
• Other vasodilators. For people who can't take ACE inhibitors or ARBs due to poor kidney function, the combination medications of hydralazine and nitrates can be used as vasodilators.

• Beta blockers. This class of drug also improves survival and reduces the risk of sudden cardiac death and abnormal heart rhythms in people with dilated cardiomyopathy. Beta blockers may reduce signs and symptoms of heart failure and improve heart function.

  A beta blocker slows your heart rate, reduces blood pressure and prevents some of the harmful effects of stress hormones, substances produced by your body that can make heart failure worse and can trigger abnormal heart rhythms. Examples of beta blockers include carvedilol (Coreg), metoprolol (Toprol XL) and bisoprolol (Zebeta).

• Diuretics. Often called water pills, diuretics make you urinate more frequently and keep fluid from collecting in your body. The drugs also decrease fluid in your lungs, so you can breathe more easily. Commonly prescribed diuretics for heart failure include bumetanide (Bumex) and furosemide (Lasix).

  Because some diuretics make your body lose potassium and magnesium, your doctor may also prescribe supplements of these minerals. If you're taking a diuretic, your doctor will likely monitor levels of potassium and magnesium in your blood through regular blood tests.

• Aldosterone antagonists. These drugs include spironolactone (Aldactone) and eplerenone (Inspra). They are primarily potassium-sparing diuretics, but they have additional properties that help the heart work better, may reverse scarring of the heart and may help people with severe heart failure live longer. Unlike some other diuretics, spironolactone can raise the level of potassium in your blood to dangerous levels.
• Digoxin (Lanoxin). This drug, also referred to as digitalis, increases the strength of your heart muscle contractions. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms and improves your ability to live with dilated cardiomyopathy.
• Anticoagulants. Your doctor may prescribe anticoagulants, which prevent blood clots. These include aspirin and warfarin (Coumadin).

Devices
Implantable devices that may correct irregular heartbeats include:

• Biventricular pacemakers use electrical shocks to coordinate contractions between the left and right ventricle.
• Implantable cardioverter-defibrillators (ICDs) monitor heart rhythm and deliver electrical shocks when needed to control abnormal, rapid heartbeats, including those that cause cardiac arrest. They can also function as pacemakers.

Heart transplant
You may be a candidate for a heart transplant if medications and other treatments are no longer sufficient to manage heart failure due to dilated cardiomyopathy.