One of the best tips on how to write an all-time classic work of fiction comes from E.M. Forster, who advised: “‘The King died, and then the Queen died’ is a story; ‘the King died and then the Queen died of grief’ is a plot.” It’s also, the novelist might be surprised to learn if he were alive today and up to speed on cutting-edge cardiology, an increasingly recognized medical reality.
For centuries, people have intuitively grasped that extreme emotional states have the power to trigger an untimely death. The earliest Greek literature, for example, tells of people whose psychological anguish proves too much for their mortal bodies to bear — Narcissus, drops dead (gorgeously), for example, when he realizes his own image can never love him back. But it’s only been in the last few decades that serious scientific research has begun to hone in on the heart as the organ that seems critically vulnerable to psychological turmoil, and has confirmed as medical fact what myths and fairy tales have been telling us since the year dot: That it really is possible to die from a broken heart.
A condition that has been receiving its fair share of attention in recent years is “broken-heart syndrome,” in which people suffer a sudden weakness in the heart’s upper walls, often following an overwhelming emotional event such as the death of a loved one, or in a statistically significant number of cases, a surprise birthday party. Christened “takotsubo cardiomyopathy” by the Japanese doctors who identified it in 1990 (because the heart distorts into the shape of a takotsubo, or octopus trap), the condition is relatively rare — it usually occurs in women over the age of 55 and in Western countries is diagnosed in only 2 to 3 percent of heart attacks. While it can be fatal, only 5.6 percent of patients don’t survive an initial episode (although recent research suggests mortality rates might be much higher over the longer term).
More worrying for the rest of us is what’s being uncovered by ongoing research into the hidden mechanisms that allow our feelings to inflict more gradual, insidious damage on our hearts. What’s emerging is a picture of an organ that’s subtly susceptible to its owner’s distress, where a whole range of emotional disturbances can have a serious impact. For some of us, they are all-too-familiar features of our daily lives. Implicated in putting people at higher risk of heart disease “are buckets of psycho-social stressors,” according to Leo Pozuelo, M.D., who runs the consultation-liaison psychiatry service at the Cleveland Clinic in Ohio, a facility that’s routinely involved in heart patients’ recovery programs. Among the culprits he lists are “interpersonal conflict, relationship issues, issues of their work environment, finances and how much you control or don’t have control over that situation.”
Pozuelo believes modern approaches to cardiology need to look beyond physical and surgical solutions and pay much closer attention to patients’ emotional wellbeing — and he’s by no means alone. Both in mitigating existing heart conditions and in preventing them in the first place, there’s a growing appreciation in medical practice across the U.S. that a healthy heart might well rely on a healthy head.
Sense of Humors — What Tudor Doctors Got (Sorta) Right
The pre-history of investigations into how the heart itself interacts with matters of the “heart” is a fairly hit-and-miss affair. But, perhaps taking their cue from literature, physicians of yore were at least occasionally jabbing at the right place on people’s chests, even if they were speculating wildly about the pathology.
In all of Shakespeare’s plays there are at least six characters who die of a broken heart, including King Lear and Romeo’s mother, Lady Montague. The most famous, though, is the jolly knight Sir John Falstaff, Henry V’s old drinking buddy; when he is coldly ejected from royal favor he becomes mortally ill because, according to his friends, “the king hath killed his heart.” In the same year the play Henry V was written (and quite possibly performed at the court of Queen Elizabeth I), 1599, real royal life weirdly imitated art when one of the Queen’s ladies-in-waiting, Margaret Ratcliffe, died that November having suffered “extreame griefe” following the death of her brother. Doctors, performing an autopsy on the Queen’s orders, “opened” her body and “found it all well and sound, saving certyne strings striped all over her harte.”
Further evidence that heartache at that time was taken to be a genuine, and fairly mundane, disease comes from London’s Bills of Mortality, an annual record of deaths in the city that was inaugurated three decades after Lady Ratcliffe’s sad demise. In the Bills’ burials tally for 1632, 11 souls were said to have expired from “Grief.” This was more deaths than had been caused by gangrene (three) and gout (four) put together. That said, in the same year, the Bills listed 470 deaths the coroners simply attributed to “Teeth.” Well, this was England, after all.
Routine cases of death-by-sadness would have made complete sense to 17th-century doctors, given that medicine of the era was based on a theory of the “four humors” — a system the Tudors inherited from the Ancient Greeks, in which good health relied on maintaining a balance between the body’s four governing elements: Blood, phlegm, yellow bile and black bile. While to modern minds it can seem like naive guesswork, the colorful terminology of the time does seem to have hit on something in assigning to patients with an excess of black bile – the humor most strongly associated with diseases and death – a general “temperament” of “melancholy” (that word itself a compound of the Greek for black, “melas,” and “kholé,” meaning bile).
While conventional medical opinion in this period, following Greek forebears such as Hippocrates and Galen, defined melancholia primarily as an affliction of the brain or bones, some physicians were making downbeat associations with the heart. “Sorowe hath kylled many,” wrote the influential medical scholar Thomas Elyot in 1536, adding that it was known to “annoye the harte of a man,” and by such sunken moods, “deth is hastened.”
Heartstopping Discoveries — Where Psychology Meets Cardiology
In a modern clinical setting, of course, a “melancholic temperament” might well be treated under another name: Depression. And, bringing the humoralists’ quaint conjectures full circle, the notion that a depressive disposition can interfere with the heart’s ability to function has recently been accepted back into serious medical discourse.
“What’s matured in the last five to seven years,” says Pozuelo, “is that, while it’s complex, aspects of depression itself indicate that it’s cardio-toxic.” The more depression lingers, he says, the more physical damage it can do. The link was established by a number of studies conducted in the early 2000s, which tracked patients who had suffered cardiac events such as myocardial infarction (a.k.a. a heart attack). Those who were also diagnosed with depression — who either developed it as a result of their heart attack or who were depressed to begin with — “did worse,” says Pozuelo. “Did worse in terms of mortality, did worse in adherence to medication, participation in cardiac rehab…” The conclusion was: “If you have depression, compared to somebody that doesn’t, and you continue with that depression untreated, you’re at a higher risk of cardiovascular disease.”
And the prognosis for the public at large gets worse. According to the findings of Jeff Huffman and Christopher Celano, psychiatrists who work at the Massachusetts General Hospital in Boston, aside from depression, anxiety is also “associated with increased risk of mortality in patients with CAD [coronary artery disease].” While they point out that anxiety’s relationship to this condition isn’t as strongly defined as its links with clinical depression, they recommend screening for anxiety disorders as a routine part of CAD treatment.
Yet another psychological condition that has led to calls for routine talk-therapy treatments for cardiac patients is PTSD. Research by Ian Kronish of Columbia University has noted a striking tendency among cardiac patients who have suffered from post-traumatic stress — especially those who have undergone harrowing experiences in the E.R. — to actively avoid follow-up treatment. “Because it’s very traumatic for them,” explains Pozuelo. “They don’t take their medications or their refills of their medications like they should.”
This focus on the patient’s diligence in aiding their own recovery raises a central question tormenting the psychological side of heart health: Is it the negative emotions themselves that are contributing to cardiovascular decline, or is it the behavioral symptoms that go along with them — such as smoking, poor diet, lethargy, a general lack of self-care? Pozuelo describes this as the “Holy Grail” of current research. “All these psycho-social variables” — as he calls them — “how much do they convey toxicity versus the pure anxiety or the pure depression?”
One potential culprit for toxic effects that originate within the body is corticotropin-releasing hormone (CRH) — a substance produced in the brain that controls the flow of cortisol, the hormone that stimulates our body’s response to stress. A study in 2012 claimed to replicate the link between stress regulation and cardiovascular conditions in rats, while in 2017 a team of researchers at Nagoya University School of Medicine discovered that a particular protein found on the surface of the heart that’s involved in the CRH system “plays a critical role in the development of heart failure,” and that inhibiting its ability to activate “prevents cardiac dysfunction in model mice.”
All of which suggests that you might not even need a full-blown psychiatric diagnosis for your heart to be accruing emotional damage. Regular, unmanaged stress could, deep inside your ribcage, be taking its toll — people with personalities that are prone to feelings of anger and hostility have long been identified as being at higher risk of coronary heart disease.
Even the constant background stress of loneliness might have serious cardiac implications. “A big area of the research also is social isolation,” says Pozuelo. “It’s huge. Social isolation clearly, clearly has toxic effects on the heart — in terms of its inflammatory effects, as well as in adherence to wellness behaviors.” While the jury’s still out on whether CRH in humans really is the single, culpable biological agent that makes stress hurt the heart, it might gratify doctors of the Shakespearean era to note that the influential psychiatrist Charles Nemeroff has called corticotropin-releasing hormone “the black bile of depression.”
All Heart — Where Cardio Healthcare Is Headed
It’s hardly worth a reminder that for most of us, normal daily life is a rolling boulder of stresses, both micro and macro, from corrosive work and money worries to the unrelenting cortisol firehose of managing social media accounts. And by now we can legitimately add anxiety over our heart’s inbuilt fragility to the pile. So what does this all mean in practical terms for our poor, emotionally bruised tickers?
As far back as 2009, Pozuelo, in a paper surveying the field of behavioral cardiology, was calling for clinicians to “routinely screen for depression in cardiac patients and not hesitate to treat it.” Has that been taken up by the medical establishment? “Not as robustly as we would have liked,” says Pozuelo. He puts this down to the traditionally siloed approach of healthcare. Traditionally when someone sees a cardiologist, he says, “What happens is: ‘Okay, we’ll screen for depression, but I’m going to send you across the street or across town to see a psychiatrist.’ That doesn’t work. What works is if you integrate it into your delivery.”
What Pozuelo has been moving toward at the Cleveland Clinic — and is glad to see being tentatively introduced in more and more hospitals across the country — is a system of “collaborative care.” This he defines as healthcare that delivers psychiatric therapy, or any form of support a patient might need, in the same setting (ideally the same room) as their surgical consultations. In a collaborative approach, the patient is also monitored and navigated through all their treatments and follow-ups by a single, dedicated health professional “who is very well versed in both cardiac medicine and in behavioral medicine,” including the psychological aspects of their care.
For Pozuelo, it’s a welcome, if slow-moving, shift in emphasis from the refer-and-forget system we’re used to — though he admits it’s being driven not so much by patient wellbeing as by the medical sector’s creaking bottom line. One trend he identifies in U.S. healthcare is a rise in the numbers of patients that medical institutions and individual physicians are becoming responsible for, which in turn, he says, multiplies the financial risk for the insurers who foot the bill. “What they’re realizing is that the patients that are overtly anxious, overtly depressed, they’re higher utilizers of healthcare; they generate more costs and have worse outcomes,” he says.
In contrast, following up on cardiology procedures in a collaborative manner, “is what has proven to have the best outcomes for the patient. And that becomes very interesting because when we see those good outcomes for the patient, the insurers see that too, and they see that the cost of medicine is actually going down.”
On the preventative side of heart-care, as those benefits become better understood by the public, Pozuelo can envisage a future where all of us are booking our regular emotional-wellbeing check-ups as routinely as we might visit the dentist. “As long as we continue to destigmatize mental health,” he sees psychiatric or psychological screening as being widely accepted as “paramount” for maintaining our overall bodily vigor. “Unfortunately, for the cardiologist it may be very easy for him or her to correct the person’s cholesterol by giving medication for it,” says Pozuelo, “but it’s a lot more difficult to minimize the stress of the home environment, look at modifications of the place where they work or promote social connectedness.”
In the meantime, it’s worth sparing a thought for the wife of Malcolm III, King of Scotland, yet another real historical victim of fatal heartbreak. When Malcolm and their son Edward were both killed in battle against the Normans in 1093, according to the Annals of Ulster, “His queen, Margaret… died of sorrow for him within nine days.”
Now, Malcolm III, it turns out, also has a walk-on part in Shakespeare — he’s the rightful heir who takes the Scottish throne at the end of Macbeth. And here is what English literature’s greatest behavioral cardiologist has Malcolm say in Act IV, Scene III: Uncannily anticipating 21st-century advice about the importance of talk therapy to coronary medicine, he counsels that we should always, “Give sorrow words; the grief that does not speak whispers the o’er-fraught heart, and bids it break.”