“Happy Heart Syndrome”: How a Joyful Celebration Triggered Takotsubo Cardiomyopathy

Patient: A 65-year-old woman living in Qatar.

Symptoms: The woman had experienced unexplained chest pain for several months, although earlier heart tests had shown no abnormalities. She later stopped attending follow-up appointments for her chest pain.

The patient subsequently developed chest pain and shortness of breath that lasted for three days and worsened with physical activity. The symptoms began shortly after she attended her daughter’s wedding, prompting her to visit a local clinic. Read the case report.

An electrocardiogram (ECG or EKG) detected changes in the electrical activity of her heart. These are among the signs doctors may look for when evaluating a possible heart attack. Because reduced blood flow can damage heart muscle, she was transferred to a hospital emergency department.

What happened next: By the time the patient reached the emergency room, her chest pain had improved. However, a repeat ECG revealed electrical abnormalities that differed from those recorded at the local clinic.

Blood tests showed elevated levels of troponin, a protein released into the bloodstream when heart muscle is damaged. An echocardiogram showed that the left ventricle—the heart’s main pumping chamber—was not contracting normally. Her ejection fraction, a measure of the heart’s pumping strength, had fallen from 58% five months earlier to 35%. A healthy ejection fraction is generally between 50% and 70%. The tip of the left ventricle was also enlarged and misshapen.

Doctors then performed an angiogram, a test that uses a catheter and contrast dye to examine the coronary arteries. The results showed that her arteries were clear, with no significant blockages.

A chest X-ray confirmed the unusual bulging shape seen on the echocardiogram. A cardiac MRI found no evidence of permanent heart muscle damage, scarring or a silent heart attack.

Diagnosis: Doctors diagnosed the patient with Takotsubo cardiomyopathy, also known as stress cardiomyopathy or broken heart syndrome. This temporary condition weakens the heart muscle and can cause the left ventricle to balloon, producing symptoms and test results that closely resemble those of a heart attack.

Takotsubo cardiomyopathy is believed to involve a sudden surge of stress hormones, including adrenaline, which can temporarily affect the heart’s ability to contract. The diagnosis was supported by diagnostic criteria used for broken heart syndrome, including the absence of a significant coronary artery blockage and the need to rule out other causes, such as myocarditis.

The diagnostic criteria also require the affected area of the heart to extend beyond the territory supplied by a single coronary artery. This distinguishes Takotsubo cardiomyopathy from a typical heart attack, which commonly damages the portion of heart muscle supplied by one blocked blood vessel. New ECG changes and moderately elevated troponin levels may also be present.

Treatment and recovery: The woman received standard medication used to manage heart failure, including a beta blocker. After her condition stabilized, she was discharged and scheduled for follow-up at a heart failure clinic. She later returned to her usual daily activities without restrictions. A follow-up ECG showed that her heart’s pumping function had improved, with her ejection fraction recovering to 56%.

What makes this case unusual? Takotsubo cardiomyopathy is often associated with an upsetting event, such as the death of a loved one or a serious medical diagnosis. In this case, however, the suspected trigger was a joyful event: the patient’s daughter’s wedding.

This rare presentation is sometimes called “happy heart syndrome”. It illustrates how intense positive emotions can activate some of the same physical stress pathways as fear, grief or other distressing experiences. The term was first described in research published in 2016.

Takotsubo cardiomyopathy accounts for approximately 1% to 3% of acute coronary syndrome cases, a group of conditions involving a sudden reduction in blood flow to the heart. Positive emotional triggers are much less common. An analysis of the International Takotsubo Registry, which included more than 1,700 patients, found that positive emotional events triggered approximately 4.1% of emotionally triggered cases.

Compared with classic broken heart syndrome, happy heart syndrome may involve a different pattern of heart muscle movement. The bulging can affect the tip, middle or base of the left ventricle. In this patient, the abnormality involved the tip of the ventricle.

Some studies suggest that people with happy heart syndrome may experience milder symptoms and better short-term outcomes than those whose Takotsubo cardiomyopathy follows a negative emotional event. However, researchers say more evidence is needed to confirm whether positive emotional triggers consistently lead to better outcomes.

Can you identify the diagnoses in unusual medical cases? Test your knowledge with our diagnostic dilemma quiz.