Takotsubo Syndrome (Broken Heart Syndrome)
Takotsubo syndrome overview
Takotsubo syndrome, often called broken heart syndrome or stress cardiomyopathy, is a sudden but usually temporary weakening of the main pumping chamber of the heart, the left ventricle. It typically causes chest pain and breathlessness and can look exactly like a heart attack. In takotsubo syndrome, however, the coronary arteries are not blocked. The heart muscle is stunned, most often after a surge of stress hormones, and pumping function usually recovers within days to weeks.
The name comes from the Japanese word for an octopus pot, which has a narrow neck and a round bottom. During an episode the lower part of the left ventricle balloons while the base contracts strongly, giving the heart that shape on a scan. In the largest international registry nearly 9 in 10 people affected were women, with an average age of about 67. Many episodes follow an emotional or physical stress, but some happen with no obvious trigger.
Although it is often temporary, takotsubo syndrome is an acute heart failure syndrome. Complications such as heart failure, low blood pressure and rhythm problems can occur in the first days, so it needs urgent hospital assessment. It is a different condition from a heart attack, but the two cannot be told apart by symptoms alone.
Takotsubo syndrome symptoms and signs
- Sudden chest pain or tightness, often in the centre of the chest and sometimes spreading to the arm, neck or jaw
- Breathlessness
- Feeling faint or light-headed, or fainting
- Palpitations
- Sweating, nausea or feeling generally unwell
- Tiredness and weakness in the days afterwards
These are the same symptoms as a heart attack, and the two cannot be separated without tests. That is why sudden chest pain always needs emergency assessment. Symptoms often begin within minutes to hours of an emotional or physical stress, but some people have no clear trigger.
Complications
- Heart failure, with fluid on the lungs
- Low blood pressure, and cardiogenic shock in the sickest patients
- Abnormal heart rhythms, including a prolonged QT interval and, rarely, dangerous rhythms
- Narrowing of the outflow from the left ventricle, or a leaking mitral valve, in some people
- A blood clot in the weakened ventricle, with a risk of stroke (uncommon)
- Rupture of the heart wall (very rare)
Most complications occur in the first days, which is why people are monitored in hospital.
Causes and risk factors of takotsubo syndrome
Takotsubo syndrome is thought to be triggered by a surge of stress hormones (adrenaline and related hormones) that temporarily stuns the heart muscle. The exact mechanism is still being studied, and spasm or dysfunction of the small blood vessels of the heart may play a part.
Common triggers
- Emotional: bereavement, relationship breakdown, fear, anger, a frightening event, or financial and work stress. Happy events can occasionally trigger it too
- Physical: acute illness such as a severe infection or a flare of asthma or COPD, an operation, severe pain, a stroke or seizure, and some drugs that act like adrenaline
- No clear trigger: in the International Takotsubo Registry a physical trigger was found in 36% of people, an emotional trigger in 28% and no trigger in 28%
Who is more likely to develop it
- Women, especially after the menopause
- People with neurological conditions, such as epilepsy or a recent stroke, or psychiatric conditions such as anxiety and depression, which were more than twice as common as in people with a heart attack in the registry
- Men account for about 1 in 10 cases
Having takotsubo syndrome does not mean you have coronary artery disease, but the two can exist together, which is why the coronary arteries are always checked.
When to see a doctor about takotsubo syndrome
Takotsubo syndrome cannot be told from a heart attack without hospital tests, so new chest pain should be assessed urgently rather than waited out. If in doubt, call 999 and do not drive yourself.
Arrange a prompt assessment if you have:
- Chest tightness, breathlessness or palpitations that are new, or that return after a diagnosis of takotsubo syndrome
- Increasing breathlessness, or needing more pillows to sleep
- Swollen ankles or legs, or rapid weight gain
- Fainting or near-fainting
- Anxiety or low mood after the episode that is not settling
- Questions about medicines, driving, exercise or work after an episode
Call 999 immediately if you have:
- Sudden, severe chest pain or tightness, or pain that spreads to the arm, neck or jaw
- Chest pain that lasts more than 15 minutes
- Chest pain with breathlessness, sweating, nausea or feeling faint
- Fainting or collapse
- Severe breathlessness at rest, or coughing up pink or frothy phlegm
- Signs of a stroke: face drooping, arm weakness or slurred speech
How takotsubo syndrome is diagnosed
Doctors usually start with an ECG and a blood test for troponin, a marker of heart muscle injury. In takotsubo syndrome the ECG can look like a heart attack, and the troponin rise is usually modest compared with the amount of heart muscle that is not working. Natriuretic peptides (BNP or NT-proBNP), which rise when the heart is under strain, are often raised.
Tests used to confirm the diagnosis
- Echocardiogram to show the typical ballooning pattern and measure pumping function
- Coronary angiography (an X-ray test of the coronary arteries) or, in selected patients, CT coronary angiography to check that no artery is blocked
- Cardiac MRI to confirm the pattern, show swelling of the heart muscle and help exclude myocarditis, which can look similar
- A repeat echocardiogram or MRI after weeks to months to confirm that heart function has returned to normal
The 2018 international consensus criteria require a temporary change in the movement of the left ventricle, usually extending beyond the area supplied by a single coronary artery, often after a stress, and exclude other causes such as myocarditis. Coronary artery disease does not rule the diagnosis out.
Takotsubo syndrome treatment options
No treatment has been proven in randomised trials, so care follows expert consensus and registry data. Most people are admitted to hospital and monitored for rhythm problems and heart failure.
In hospital
- Treatment of heart failure and fluid on the lungs, for example with diuretics (water tablets)
- ACE inhibitors or angiotensin receptor blockers (ARBs) to support the heart
- Beta-blockers, used with care, and not if the blood pressure is very low or the heart rate is slow
- Blood thinners if a clot is seen in the ventricle
- Avoiding adrenaline-type drugs where possible, because they can make takotsubo syndrome worse
- Intensive care and mechanical support only for cardiogenic shock
- Treating the trigger, such as an infection or pain
After discharge
Medicines such as an ACE inhibitor or ARB and a beta-blocker are often continued until a repeat scan confirms recovery. In a study of 519 people in California, beta-blockers were associated with a lower risk of recurrence or death, but this was an observational finding and not proof of benefit, and ACE inhibitors or ARBs showed no clear effect on recurrence. Medicines are individual, so do not stop any without advice.
Living with takotsubo syndrome
Recovery is usually good, but tiredness, breathlessness and anxiety can linger for weeks. Many people find the experience frightening, especially when there was a clear emotional trigger.
- Follow-up: a repeat echocardiogram within a few months confirms that the heart has recovered
- Activity: build up gradually, and ask whether cardiac rehabilitation is available
- Medicines: take them as advised until your cardiologist reviews them
- Stress and mood: relaxation, regular gentle exercise and talking therapies can help. Tell your doctor if anxiety or low mood persist
- Driving and work: advice depends on your recovery. See our DVLA cardiac assessment page
- Future care: tell any doctor treating you that you have had takotsubo syndrome, especially before an operation (pre-operative cardiac assessment) or if you are given adrenaline-type drugs
Takotsubo syndrome prognosis and outlook
Most people recover. Heart pumping function usually returns to normal within days to weeks, and a repeat scan at 3 to 6 months is used to confirm it. However, takotsubo syndrome is not always benign.
- Early risk: in a pooled analysis of 54 studies (4,679 patients), about 2 in 100 people (1.8%) died during the hospital admission. In the International Takotsubo Registry severe early complications such as shock were as common as after a heart attack
- Later outlook: after leaving hospital the pooled death rate was about 3.5% a year, mostly from non-cardiac causes. A Danish nationwide study found that survivors had higher rates of death and of admission with heart failure than the general population
- Recurrence: about 1% a year in pooled data, and 7.5% over about 5 years in one large health-system cohort
- Worse outlook is linked to older age, a physical trigger, male sex and an unusual (atypical) ballooning pattern
Regular follow-up with a cardiologist, a repeat scan and a review of your medicines are the main ways to keep the outlook as good as possible.
Takotsubo syndrome key facts
- Takotsubo syndrome, or broken heart syndrome, is a temporary weakening of the left ventricle with a ballooned lower part.
- It causes symptoms identical to a heart attack, but the coronary arteries are usually not blocked.
- About 9 in 10 people affected are women, usually after the menopause.
- It can follow emotional or physical stress, or happen with no obvious trigger.
- Diagnosis needs an ECG, blood tests, coronary angiography and an echocardiogram, sometimes with cardiac MRI.
- Heart function usually recovers within days to weeks, confirmed by a repeat scan.
- It is not always benign: early complications, recurrence and long-term risks occur.
This page follows the 2018 International Expert Consensus Document on Takotsubo Syndrome (Eur Heart J 2018;39:2032-2046 and 2047-2062), the International Takotsubo Registry (N Engl J Med 2015;373:929-938), a systematic review of long-term outcomes (JACC Heart Fail 2019;7:143-154) and cohort studies of recurrence and survival (Heart 2021;107:1160-1166; J Card Fail 2022;28:1534-1544).
Takotsubo syndrome questions and answers
Is takotsubo syndrome the same as a heart attack?
No. The symptoms are similar, but in a heart attack a coronary artery is blocked by a clot, whereas in takotsubo syndrome the arteries are usually open and the heart muscle is stunned. Hospital tests are needed to tell them apart.
Can stress alone cause it?
Emotional stress is a common trigger, but physical stress such as illness, surgery or severe pain is more common, and in about 3 in 10 people no trigger is found.
Can you die from broken heart syndrome?
Most people recover, but the first days carry a real risk. In a pooled analysis about 2 in 100 people died during the hospital admission, which is why prompt treatment matters.
Will takotsubo syndrome come back?
It can, but not often. The recurrence rate is about 1% a year in pooled data. Recurrence does not always follow the same trigger.
Does the heart recover fully?
In most people pumping function returns to normal within days to weeks, and a repeat scan after a few months confirms it. Some people have lingering tiredness, breathlessness or anxiety for longer.
Can men get takotsubo syndrome?
Yes. About 1 in 10 people affected are men, and they more often have a physical trigger.
Can I exercise or travel after takotsubo syndrome?
Most people return to normal activity gradually once the heart has recovered and your cardiologist agrees. Ask before flying or starting vigorous exercise in the first weeks.
Questions to ask your cardiologist about takotsubo syndrome
- Was my diagnosis confirmed by coronary angiography and imaging?
- What do you think triggered my episode?
- Has my heart function recovered, and when should it be scanned again?
- Do I need medicines now, and for how long?
- Do I need a cardiac MRI to exclude myocarditis?
- What is my risk of it happening again?
- When can I return to work, driving, exercise and flying?
- What help is available for anxiety or low mood after the episode?
- Which symptoms should make me call 999?
Takotsubo syndrome diagrams and visual aids
Why it is called takotsubo
A Japanese octopus pot (takotsubo), with a narrow neck and a round base.
Image: 松岡明芳, Takotubo akasi-si PC012375, Wikimedia Commons. Public domain. Resized.
Takotsubo syndrome is named after the Japanese octopus pot. At the peak of an episode the left ventricle takes a similar shape on a scan, with a strongly contracting base and a ballooned lower part.
Ballooning of the lower heart chamber
Left ventriculogram in systole showing apical ballooning, with a weak lower part and a strongly contracting base.
Image: Tara C Gangadhar, Elisabeth Von der Lohe, Stephen G Sawada and Paul R Helft, Takotsubo ventriculography (from the case report “Takotsubo cardiomyopathy in a patient with esophageal cancer”), Wikimedia Commons. Licensed under CC BY 2.0. Resized.
A ventriculogram is an X-ray picture of the left ventricle taken during coronary angiography. It shows the typical takotsubo pattern, which is why angiography is used to check the arteries and the shape of the heart at the same time.
Apical ballooning in systole
Left ventriculogram during systole showing the characteristic apical ballooning with apical akinesis.
Image: Olagoke Akinwande, Yasmin Hamirani and Ashok Chopra, Takotsubo left ventriculogram (from the case report in Cases Journal 2008, doi:10.1186/1757-1626-1-8), Wikimedia Commons. Licensed under CC BY 2.0. Resized.
Akinesis means the apex does not move. The base keeps contracting, so the ventricle looks narrow at the top and round at the bottom.
ECG changes can look like a heart attack
ECG from a patient with confirmed takotsubo cardiomyopathy, showing a fast sinus rhythm with non-specific ST and T wave changes.
Image: Olagoke Akinwande, Yasmin Hamirani and Ashok Chopra, Takotsubo ECG (from the case report in Cases Journal 2008, doi:10.1186/1757-1626-1-8), Wikimedia Commons. Licensed under CC BY 2.0. Resized.
The ECG in takotsubo syndrome can show ST elevation like a heart attack, T wave inversion or a long QT interval, and it can be near normal, so the diagnosis cannot be made from the ECG alone.
Recovery on a repeat echocardiogram
(A) Echocardiogram in the acute phase showing a dilated left ventricle. (B) Repeat echocardiogram 6 days later showing recovery of left ventricular function.
Image: Tara C Gangadhar, Elisabeth Von der Lohe, Stephen G Sawada and Paul R Helft, Takotsubo ultrasound (from the case report “Takotsubo cardiomyopathy in a patient with esophageal cancer”), Wikimedia Commons. Licensed under CC BY 2.0. Resized.
In most people the heart muscle recovers, often within days to weeks, and a repeat echocardiogram after a few months confirms it.
If you have been diagnosed with takotsubo syndrome, or want specialist follow-up after a hospital admission for chest pain with clear arteries, you can book a video consultation or telephone consultation from anywhere in the UK, or a face to face consultation in Peterborough or Corby. An echocardiogram or cardiac MRI can be arranged.
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Medically reviewed by Dr Salam Salloum, Consultant Cardiologist. Last reviewed: . This page is for general information and does not replace personal medical advice.