Broken heart syndrome – is it a psychosomatic disorder? Cameron Lacey, Roger Mulder, Paul Bridgman, Bridget Kimber, Julie Zarifeh, Martin Kennedy, Vicky Cameron PII: DOI: Reference:
S0022-3999(14)00215-3 doi: 10.1016/j.jpsychores.2014.05.003 PSR 8814
To appear in:
Journal of Psychosomatic Research
Received date: Revised date: Accepted date:
13 March 2014 9 May 2014 11 May 2014
Please cite this article as: Lacey Cameron, Mulder Roger, Bridgman Paul, Kimber Bridget, Zarifeh Julie, Kennedy Martin, Cameron Vicky, Broken heart syndrome – is it a psychosomatic disorder?, Journal of Psychosomatic Research (2014), doi: 10.1016/j.jpsychores.2014.05.003
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Cameron Lacey PhD
SC RI
Roger Mulder PhD
PT
Broken heart syndrome – is it a psychosomatic disorder?
Paul Bridgman MD Bridget Kimber RN
NU
Julie Zarifeh PGDipl Clin Psyc Martin Kennedy PhD
Present Address:
Dr Cameron Lacey Department of Psychological Medicine
PT
Corresponding Author:
ED
MA
Vicky Cameron PhD
AC
CE
University of Otago, Christchurch PO Box 4345 Christchurch, New Zealand Email: [email protected] Phone: +64 3 3720400 Fax:
Running Title: Broken heart syndrome
+64 3 3720407
ACCEPTED MANUSCRIPT Abstract Objective
PT
The development of somatoform illnesses is often associated with prior psychiatric illness and life stress. Broken heart syndrome has been associated with a range of
SC RI
stressors and we aimed to investigate if psychiatric illnesses are risk factors for developing broken heart syndrome.
NU
Methods
We systematically assessed for antecedent psychiatric risk factors in two groups of
MA
cases (people who developed sporadic and earthquake-related broken heart syndrome) and compared them to a control group of healthy volunteers.
ED
Results
PT
We found that of ten psychiatric risk factors examined, only ‘neuroticism’ significantly differed between participants with broken heart syndrome and healthy
AC
Conclusion
CE
volunteers.
There was no association between previous psychiatric illness and development of broken heart syndrome in this study. Clinical assessment of psychiatric risk factors may not identify patients at increased risk of broken heart syndrome.
Key Words Broken heart syndrome; Psychiatric risk factors; Stress cardiomyopathy
ACCEPTED MANUSCRIPT Introduction Broken heart syndrome is also known as stress cardiomyopathy (SCM), or
PT
takotsubo cardiomyopathy and is a recently recognised condition that is proposed to be associated with psychiatric illnesses [1]. The condition is characterised by onset of
SC RI
symptoms mimicking coronary heart disease and is commonly linked with experience of significant stress [2]. A variety of emotional and environmental stressors, including significant earthquakes have been associated this condition [1, 3]. The precise
NU
aetiology of SCM remains unknown, however psychiatric illnesses, such as chronic
MA
anxiety disorders, have been proposed as risk factors for the development of SCM [1,
ED
4-6].
The Christchurch earthquake sequence in 2010-2011 repeatedly exposed the
PT
entire population of Christchurch city, some 350,000 people, to major stress and life disruption. There was an increase in incidence of SCM following the earthquakes,
CE
however the condition remained rare despite the number of people exposed to this
AC
stressor [7]. This led us to hypothesise that there is no difference in antecedent psychiatric risk factors between participants who develop earthquake-related and sporadic SCM compared to age-matched healthy controls.
Method A case-control study was performed among people who developed sporadic and earthquake-related SCM (sp-ECM and eq-SCM). The definition of SCM used was similar to the modified Mayo criteria. All patients were admitted with chest pain with evolving ECG changes, a troponin I rise >0.03µg/l and a recognised transient echocardiographic regional wall motion abnormality (apical ballooning pattern, mid
3
ACCEPTED MANUSCRIPT wall variant or basal segment variant). Mean time to follow up echocardiogram was 10 weeks. 93% (25/27) eq-SCM participants and 74% (23/31) sp-SCM received
PT
cardiac catheterization during the index event. We retrospectively identified thirty patients with eq-SCM who were admitted to Christchurch Hospital within one week
SC RI
after either the September 2010 or February 2011 earthquakes (Richter scale magnitude ≥6.3). Patients with sp-SCM were retrospectively identified from Christchurch Hospital records from 2000-2012 with onset of SCM not related to
NU
experience of an earthquake. The control cohort were selected from the Christchurch
MA
Healthy Volunteers for The Study of Heart Disease (HV), who had been exposed to the same earthquake stressor, attempting to match for age, ethnicity and gender. All
ED
26 control participants had normal echocardiography and ECG. Participants were recruited and assessed in 12 months following the Canterbury Earthquakes. The
PT
Southern Health and Disability Ethics Committee approved this study.
CE
All participants completed a semi-structured clinical interview performed by
AC
clinicians experienced in the assessment of mental disorder in patients with medical illness and also completed structured questionnaires. The semi-structured interview included details of participants’ sociodemographic characteristics, risk factors present at development of SCM (use of psychiatric medications, perceived inadequate social support and alcohol abuse) and lifetime risk factors (lifetime history of depression, lifetime history of any anxiety disorder, lifetime history of any mental disorder, past experience of trauma and history of mental disorder in first degree relatives). The participant’s level of social support and past experience of trauma was assessed by mental health clinicians during the clinical interview and categorized by the clinician into dichotomous variables. Personality characteristics were assessed with the
4
ACCEPTED MANUSCRIPT Eysenck Personality Questionnaire Brief Version (EPQ-BV), which is a 24 item questionnaire producing two subscales: Extroversion and Introversion [8].
PT
Additionally the hospital medical records of each participant were reviewed to assess for previously documented mental disorder and were discussed with the participants
SC RI
during the clinical assessment to clarify lifetime mental illness. Tests for group differences first used ANOVA (continuous data) and chi-squared tests (categorical data) with Bonferroni’s correction to allow for multiple comparisons (alpha=0.003,
NU
0.05/18 comparisons). When group differences were demonstrated, pairwise tests
MA
between SCM groups and HV were performed using student’s t-test, chi-squared or
ED
Fisher’s exact test (when expected cell size was less than five).
Results
PT
The overall completion rate was high (77%), with 27/30 eq-SCM, 31/53 spSCM, and 26/26 HV completing the study. All participants were women and there
CE
was no significant difference in the proportion of participants reporting post-
AC
menopausal status between the three groups (93% eq-SCM, 90% sp-ECM, 100% HV, p=0.3). The healthy volunteers were older than both SCM groups (mean HV=80.9 years, 95% CI: 80.0-81.8, eq-SCM=69.7 years, 95% CI: 66.4-73.0, sp-SCM=66.7 years, 95% CI: 62.0-70.0, p
S0022-3999(14)00215-3 doi: 10.1016/j.jpsychores.2014.05.003 PSR 8814
To appear in:
Journal of Psychosomatic Research
Received date: Revised date: Accepted date:
13 March 2014 9 May 2014 11 May 2014
Please cite this article as: Lacey Cameron, Mulder Roger, Bridgman Paul, Kimber Bridget, Zarifeh Julie, Kennedy Martin, Cameron Vicky, Broken heart syndrome – is it a psychosomatic disorder?, Journal of Psychosomatic Research (2014), doi: 10.1016/j.jpsychores.2014.05.003
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Cameron Lacey PhD
SC RI
Roger Mulder PhD
PT
Broken heart syndrome – is it a psychosomatic disorder?
Paul Bridgman MD Bridget Kimber RN
NU
Julie Zarifeh PGDipl Clin Psyc Martin Kennedy PhD
Present Address:
Dr Cameron Lacey Department of Psychological Medicine
PT
Corresponding Author:
ED
MA
Vicky Cameron PhD
AC
CE
University of Otago, Christchurch PO Box 4345 Christchurch, New Zealand Email: [email protected] Phone: +64 3 3720400 Fax:
Running Title: Broken heart syndrome
+64 3 3720407
ACCEPTED MANUSCRIPT Abstract Objective
PT
The development of somatoform illnesses is often associated with prior psychiatric illness and life stress. Broken heart syndrome has been associated with a range of
SC RI
stressors and we aimed to investigate if psychiatric illnesses are risk factors for developing broken heart syndrome.
NU
Methods
We systematically assessed for antecedent psychiatric risk factors in two groups of
MA
cases (people who developed sporadic and earthquake-related broken heart syndrome) and compared them to a control group of healthy volunteers.
ED
Results
PT
We found that of ten psychiatric risk factors examined, only ‘neuroticism’ significantly differed between participants with broken heart syndrome and healthy
AC
Conclusion
CE
volunteers.
There was no association between previous psychiatric illness and development of broken heart syndrome in this study. Clinical assessment of psychiatric risk factors may not identify patients at increased risk of broken heart syndrome.
Key Words Broken heart syndrome; Psychiatric risk factors; Stress cardiomyopathy
ACCEPTED MANUSCRIPT Introduction Broken heart syndrome is also known as stress cardiomyopathy (SCM), or
PT
takotsubo cardiomyopathy and is a recently recognised condition that is proposed to be associated with psychiatric illnesses [1]. The condition is characterised by onset of
SC RI
symptoms mimicking coronary heart disease and is commonly linked with experience of significant stress [2]. A variety of emotional and environmental stressors, including significant earthquakes have been associated this condition [1, 3]. The precise
NU
aetiology of SCM remains unknown, however psychiatric illnesses, such as chronic
MA
anxiety disorders, have been proposed as risk factors for the development of SCM [1,
ED
4-6].
The Christchurch earthquake sequence in 2010-2011 repeatedly exposed the
PT
entire population of Christchurch city, some 350,000 people, to major stress and life disruption. There was an increase in incidence of SCM following the earthquakes,
CE
however the condition remained rare despite the number of people exposed to this
AC
stressor [7]. This led us to hypothesise that there is no difference in antecedent psychiatric risk factors between participants who develop earthquake-related and sporadic SCM compared to age-matched healthy controls.
Method A case-control study was performed among people who developed sporadic and earthquake-related SCM (sp-ECM and eq-SCM). The definition of SCM used was similar to the modified Mayo criteria. All patients were admitted with chest pain with evolving ECG changes, a troponin I rise >0.03µg/l and a recognised transient echocardiographic regional wall motion abnormality (apical ballooning pattern, mid
3
ACCEPTED MANUSCRIPT wall variant or basal segment variant). Mean time to follow up echocardiogram was 10 weeks. 93% (25/27) eq-SCM participants and 74% (23/31) sp-SCM received
PT
cardiac catheterization during the index event. We retrospectively identified thirty patients with eq-SCM who were admitted to Christchurch Hospital within one week
SC RI
after either the September 2010 or February 2011 earthquakes (Richter scale magnitude ≥6.3). Patients with sp-SCM were retrospectively identified from Christchurch Hospital records from 2000-2012 with onset of SCM not related to
NU
experience of an earthquake. The control cohort were selected from the Christchurch
MA
Healthy Volunteers for The Study of Heart Disease (HV), who had been exposed to the same earthquake stressor, attempting to match for age, ethnicity and gender. All
ED
26 control participants had normal echocardiography and ECG. Participants were recruited and assessed in 12 months following the Canterbury Earthquakes. The
PT
Southern Health and Disability Ethics Committee approved this study.
CE
All participants completed a semi-structured clinical interview performed by
AC
clinicians experienced in the assessment of mental disorder in patients with medical illness and also completed structured questionnaires. The semi-structured interview included details of participants’ sociodemographic characteristics, risk factors present at development of SCM (use of psychiatric medications, perceived inadequate social support and alcohol abuse) and lifetime risk factors (lifetime history of depression, lifetime history of any anxiety disorder, lifetime history of any mental disorder, past experience of trauma and history of mental disorder in first degree relatives). The participant’s level of social support and past experience of trauma was assessed by mental health clinicians during the clinical interview and categorized by the clinician into dichotomous variables. Personality characteristics were assessed with the
4
ACCEPTED MANUSCRIPT Eysenck Personality Questionnaire Brief Version (EPQ-BV), which is a 24 item questionnaire producing two subscales: Extroversion and Introversion [8].
PT
Additionally the hospital medical records of each participant were reviewed to assess for previously documented mental disorder and were discussed with the participants
SC RI
during the clinical assessment to clarify lifetime mental illness. Tests for group differences first used ANOVA (continuous data) and chi-squared tests (categorical data) with Bonferroni’s correction to allow for multiple comparisons (alpha=0.003,
NU
0.05/18 comparisons). When group differences were demonstrated, pairwise tests
MA
between SCM groups and HV were performed using student’s t-test, chi-squared or
ED
Fisher’s exact test (when expected cell size was less than five).
Results
PT
The overall completion rate was high (77%), with 27/30 eq-SCM, 31/53 spSCM, and 26/26 HV completing the study. All participants were women and there
CE
was no significant difference in the proportion of participants reporting post-
AC
menopausal status between the three groups (93% eq-SCM, 90% sp-ECM, 100% HV, p=0.3). The healthy volunteers were older than both SCM groups (mean HV=80.9 years, 95% CI: 80.0-81.8, eq-SCM=69.7 years, 95% CI: 66.4-73.0, sp-SCM=66.7 years, 95% CI: 62.0-70.0, p
