Case Study: Abnormal Blood Vessles and Broken Hearts

Diagnosing with EndoPAT

Researchers at the Johns Hopkins Hospital in Baltimore, Maryland noticed something strange. Some female patients who had come to the emergency room with similar heart attack symptoms were not actually having a heart attack. Instead, they were suffering from a condition called stress cardiomyopathy. The mystery heart ailment also goes by the name apical ballooning syndrome, or ABS.
Some doctors started calling ABS “broken heart syndrome.” That’s because extreme sadness, shock, surprise, or anger enough to “break a heart” had recently been experienced by all of these women a short while before suffering their heart symptoms. However, was it possible that these effects alone were enough to make the body “fake” a heart attack?

The Mystery of Broken Heart Syndrome

Doctors don’t know exactly how stressful events cause heart problems for some people—but they have some very good ideas. The body’s stress hormones, when released in large amounts, may cause a spasm in a coronary artery. There could also be some impact on the endothelium, the lining of the blood vessels, which leads to a narrowing of the arteries that supply the heart with blood. Alternatively, the hormone epinephrine (also known as adrenaline) may bind to the heart cells directly, causing large amounts of calcium to enter the cells and render them temporarily dysfunctional.


A study of 19 ABS patients suffering from stress cardiomyopathy, conducted at Johns Hopkins and published in TheNew England Journal of Medicine, reported that during the 12 hours before checking in to the hospital, every one of the patients had experienced some kind of severe emotional stress: a death in the family, an automobile accident, fear over having to speak in public, an intense and angry argument, or even a surprise party. All but one were women, mostly middle aged and older.
Testing of the patients showed no blockages or clots in the coronary arteries and no heart damage—what would usually be found after a heart attack. They did all have a heart problem: the left ventricle, the heart’s main pumping chamber, was failing to pump enough blood. In some cases, the condition became life-threatening, leading to heart rhythm abnormalities and heart failure. Additionally, all 19 patients did have high levels of stress hormones in their blood: 7 to 34 times the normal levels of adrenaline.
Why older women are the group most vulnerable to stress cardiomyopathy? Some heart experts suspect that it may be that estrogen serves to protect the heart cells from the effects of stress hormones like epinephrine. As women age and their estrogen levels decline, their hearts may become more vulnerable to the effects of stress hormones, particularly in large amounts seen in this syndrome.

EndoPAT Testing for Broken Heart Syndrome

In late 2010, a team of Mayo Clinic researchers reported that patients with broken heart syndrome have blood vessels that don’t react normally to stress. Besides stress, estrogen levels and functioning of the blood vessels are other suspected causes of ABS. Their study was published in the Journal of the American College of Cardiology.


The study, conducted by a research team headed by Dr. Amir Lerman, a Mayo Clinic cardiologist, compared blood vessel responses to mental stress in 12 women who had been diagnosed with ABS in the last six months, 12 postmenopausal women control subjects, and four women who had experienced typical heart attacks.
Before the study began, each of the women was given a 15-minute EndoPAT test to check the status of their blood vessels. The test entails putting special PAT sensors on both index fingers, using a blood pressure cuff on one arm to constrict blood at the brachial artery for five minutes, and then having the EndoPAT device automatically chart the differences in how quickly blood flow returns to normal after the occlusion. This final EndoScore, which indicates the health of the endothelium, provides valuable information about the overall health of the body organs, including the heart.
“We believe that what happens in the endothelium of the blood vessels is indicative of what’s going on in the coronaries,” Dr. Lerman says. Blood samples were also taken from the test subjects.

Dr. Lerman’s Test

Although the original stressors in the ABS patients included the death of a husband or family member, divorces, claustrophobia and church fundraising, no such extreme measures were employed for the study.
Instead, to trigger high levels of mental stress, the women were given number and letter memory tests of increasing length and complexity along with subtraction tasks and special word-color conflict tests.

Test and EndoPAT Results

When testing was completed, another EndoPAT test was given and the EndoScores were noted and compared.
In the women with ABS, Dr. Lerman and his fellow researchers found increased vascular reactivity and decreased endothelial function in response to the acute mental stress compared to other postmenopausal women and the women who had regular heart attacks.
“In the women with ABS, rather than the blood vessels getting bigger to provide more blood during mental stress, the blood vessels actually got smaller and prevented the blood from going where it was needed,” says Dr. Lerman.

What the Study Indicates

“This study tells us there is a group of women patients who are more sensitive to mental stress, which is a unique risk factor for them to have an ABS-type heart attack. The body’s response to mental stress plays a significant role in ABS syndrome.”
Dr. Lerman and his team are working to develop treatment options for ABS patients. “It’s possible that we could use an
EndoPAT test and a follow-up mental stress test to identify these stress-sensitive patients,” Dr. Lerman says. “If we discover that some patients are more sensitive to mental stress in this way, we could design specific therapies to aid them if they have an ABS attack.”
In the meantime, until Dr. Lerman and his team develop effective preventive options, there is one thing you can do to keep your heart healthy. To reduce your risk of “broken heart syndrome,” stay physically fit. Regular exercise may reduce the amount of adrenaline your body produces in response to stress. It helps keep your arteries flexible, lowering your risk of arterial spasms when trouble strikes.