Heartache = heart injury?

I got this question from a former student: 

Hey doc! I have a random medical question and you're the only person I could think of that could possibly explain it in a way I can understand. What is the physiology of heartache? What causes the physical "ache" or "pain" a person feels in their chest/heart area when they're grieving or experiencing heartache?

I'm really interested in this, actually, because the chest pain I get from the depression is the same as the chest pain I had when I broke up after long relationships.

When Carrie Fisher died, and her mother Debbie Reynolds died the next day, I saw a lot of news reports saying Debbie died of "Broken Heart Syndrome" aka Takotsubo Cardiomyopathy, which led to a number of as-usual-totally-wrong news reports that heartache you get after a breakup is actually a heart attack and will kill you.

First, let's keep in mind that when she died, Debbie Reynolds was 84.  Also the autopsy showed she'd died of a stroke.  So the heartache idea is totally wrong.  That being said, if you are 84, you probably have some narrowed vessels or cholesterol plaques or areas of weakened artery walls (called aneurysms) in your brain and your daughter dying might stress you out and cause an increase in blood pressure and heart rate that might cause one of those weak spots to blow.  Very sad. But not a heart problem.

I spent a little time looking up "Broken Heart Syndrome" at the time and the idea is that stress causes a big surge in norepinephrine and heart rate and blood pressure and this leads to a weird shift in coronary blood flow that can lead to something like a vasospastic angina.  However, EKGs done during a bona fide episode of Takotsubo cardiomyopathy shows signs of reduced oxygenation, like angina or an MI (heart attack).  So yes, severe stress can trigger some coronary blood flow weirdness.  But it's super rare and I challenge you to find someone who has never had heartache.  

But "heartache" doesn't mean "you are dying of a heart attack".  That would be spectacularly counter-evolutionary, for one thing.  The whole point of even having heartache is to encourage you to stay with your mate and clan so they can help raise your (unreasonably helpless human) baby. The emotional pain of losing someone you love is like withdrawal of a drug (love).  Love makes you want to mate, which makes more babies, which eventually leads to your species being in charge and a bunch of crazy weirdos becoming leaders of countries and the planet.

...speaking of chest pain...

Anyway, I've seen some pseudoscience sites say the stress increases norepinephrine (NE) and so of course that causes the broken heart syndrome.  I expect it sounds logical, but then why do I (and others) get that same chest pain when we are depressed?  Surely if constant chest pain for years on end was due to inadequate oxygenation of heart tissue people with depression would eventually get heart failure and die.  (I just coincidentally had a stress test with echo that showed my heart is A-Okay despite years of depression).The monoamine hypothesis suggests depression occurs when there is too little NE, or serotonin or dopamine.  That's why drugs that increase or mimic those neurotransmitters help relieve depression.  So... feeling depressed after a break up is due to levels of NE being too high and being too low?  Doesn't make sense.

Looking around the web and medical websites it looks like no one knows why depression and breakups cause chest pain.  A press release from Emory describes a prospective study of over 5000 adults in North Carolina that showed depressed people have chest pain and it happens in the absence of coronary artery disease. Yeah, duh. 

I've also seen a lot of people quoting a Scientific American "Ask the Experts" article written by Robert Emery and Jim Coan (two PhDs, not medically trained) talking about emotional pain triggering "the anterior cingulate cortex [that] may respond by increasing the activity of the vagus nerve—the nerve that starts in the brain stem and connects to the neck, chest and abdomen. When the vagus nerve is overstimulated, it can cause pain and nausea."

My students know that any reference to the vagus nerve causing angina makes me infuriated.  The vagus nerve slows heart rate.  Any pain or nausea caused by the vagus nerve would have to be referred stomach or esophageal pain.  Not the heart.

So the answer, I think, is that no one knows why heartbreak and depression cause chest pain. 

I expect that folks will keep studying the phenomenon because that chest pain totally sucks, even if you only count the cost of ER visits due to MI false alarm.  And depression is the top reason for disability in America and disability means lost time working and paying taxes.  And our government definitely wants us all to work and pay taxes.  So stop with the chest pain already!

 Today's Norwegian Vocabulary Word: hjertesorg
  Pronounced: (yer-tuh-sore).
   (Translation: heart sorrow or heartache)
 Exercise: Use "hjertesorg" in a sentence:
 Example: Da rotte Smough døde, hadde jeg hjertesorg.
  (When my rat Smough died, I had heartache.)

Two legs good, four legs bad (Things I think about in the shower pt. 4)

I have this really cool sweater coat I bought at Lucky about a decade ago.  It's obviously inspired by historical Chinese fashions with wide sleeves and a mandarin collar.  It's gorgeous.  I used to wear it all the time until I heard about "cultural appropriation".  Now I NEVER wear it, and I also never wear in public other clothing or jewelry that someone might claim as their own domain.  This includes some dangling earrings my sister got me in India, or a Mah Jong tile bracelet (although maybe I could argue that they represent my connection with old Jewish ladies, I suppose?), or a Halo T-shirt with the word "Hola" on it, or my Korean-inscribed T-shirt...

I feel really confused by the extent to which "cultural appropriation" is used as an accusation or even a threat in the US now, so much so that I'm afraid to wear anything or do anything someone might see as not of my own heritage (which so far, according to my sister's 23andMe DNA testing includes mostly Scotland, England, Ashkenazi Jew, a dash of Native American and a dash of West African.)  I realize I look like a white Anglo-Saxon (I think I look equally British and Norwegian and would look even more so if only my mother hadn't used all that over-the-counter benzedrine in 1963), so I've been far less likely to buy "ethnic" goods like fair trade fabrics from India. If I wear my African-made earrings of little giraffes is that cultural appropriation?  Will someone call the news about it and get me fired from my pathetic two-hours-a-week job?  

I thought maybe I was taking it too far until an Asian-American colleague at work told me I shouldn't wear mandarin-collar clothing to work because it was insensitive cultural appropriation. So I won't. Similarly I don't want to be on TV getting beaten up because I wore an embroidered blouse for Cinco de Mayo. 

That's the thing I find so sad about it.  I mean, I know in my heart of hearts that I love the fact that in the US we have all different cultures represented, and I know in my heart of hearts that I love my non-white friends and relatives as much as I love my white friends and relatives.  And I know that the majority of people do not give a crap if I wear a mandarin-collared outfit, or a kimono-styled blouse to work.  So I know that I mean utterly no offense by wearing objects I find beautiful.  I know that I will go above and beyond to help my students no matter what their race, religion or sexual identity.  So the only reason I don't wear the giraffe earrings my Korean-American BFF brought me from her two month stint on the African continent is because I don't want to get fired or reported on or beaten up by social justice warriors.  The SJWs of the world seem to think it is absolutely okay to destroy anyone they've decided must be a bad person for the most innocent of acts they've decided are offensive.

I also find utterly baffling the apparent desire by (mostly young) Americans of varying cultural backgrounds to segregate themselves from fellow Americans of different genetic heritage.  That they want to get rid of the white people they live with.  I honest-to-god don't get that at all.   I remember rampant mainstream racism from the 1960s.  My WASP-grandparents belonged to a restricted country club (no blacks or Jews allowed). Didn't my hero Martin Luther King Jr die specifically because he was calling an end to the evil of segregation?  I saw a news story that a college student group in Michigan wanted a place on campus that didn't allow whites. Don't they realize that if they get the legal right to discriminate by skin color that the crazy white supremacists will then have the legal precedent to do the same?   And then we'd see students demanding whites-only days at school.  It would be a disaster that I think would spur terrible violence and tragedy.

Back in the 1970s, the message my parents taught me was that in America we should accept all cultures and races and bring them into our own lives with acceptance and understanding. America was the "great melting pot" and as new waves of immigrants arrived we took those cultural influences and made them part of our greater picture.  Each culture had its own national pride, sure.  And each wave of immigrants sadly had to put up with some fear and bigotry...  the Irish faced it, the Italians faced it, the Jews faced it, the Chinese, the Mexicans, the Muslims...  It sucks but it isn't specific to non-whites by any means.  

Here In Chicago the Irish and Polish were big influences when I was growing up, but there was also Chinatown and Greektown and areas of the city where you could go have a meal where English wasn't on the menu.  Those places are still here;  just in the last year I've gone to restaurants where the staff and customers all spoke Lithuanian,  Korean, Japanese and Bulgarian. Do I have the right to take a selfie while I enjoy a meal at a Korean BBQ?  Should I feel scared to tell people I really like a particular Japanese Ramen shop?  I honestly don't know.  And I hate feeling I've lost the right to free speech.  Especially since everything I think usually comes out of my mouth without a filter.  ACLU all the way, baby.

The vitriol on the news and on social networks make me actually afraid I might be offending someone who cannot control their violence or vindictiveness.  I've been teaching at Oakton for ten years and there is usually someone in every class who thinks I've said something typically sexist or racist or whatever (usually because I talk about pharmacology issues intertwined with genetics or gender).  For example, every year I get someone who says, "I looked up BiDil on the internet and what you were saying about it being only useful to African-American patients was actually true!"  

*Insert Facepalm Here*   Why would I make up stuff in lecture that is easily checkable?  Students have such weird ideas about instructors...

Anyway, I was thinking about this whole issue in the shower after watching this video about some protest because white people were wearing kimonos.  The conclusion I came to is to not wear or talk about anything the young SJWs of the world might decide I shouldn't because it just isn't worth getting publicly scorned or beaten because I wanted to wear my dangly earrings. 

If you really want to bring people together it has to be in a loving, welcoming way.  Educating people is far more likely to change minds than threatening ever will.   Trump is a hot mess but I know intelligent, liberally-minded people who voted for him in part due to fear.  Not fear of people of color or Muslims or LGBTQs, but rather fear of those social justice warriors. Because those people are f*cking terrifying.  

The pigs' slogan "Two legs bad, four legs good!" was a powerful motivator on the farm, but it didn't work out at all for the horse.  Just sayin'...

 Today's Norwegian Prhase: koreansk grillrestaurant
  Pronounced: (Core-yi-ahnsk greel-fest).
   (Translation: Korean barbecue restaurant)
 Exercise: Use "Koreansk grillfest" in a sentence:
 Example: Jeg spiste bulgogi på den koreanske grillrestauranten; det var deilig!
   (I ate bulgogi at the Korean barbecue restaurant; it was delicious!)

Another day, another dying cat.

I have the reputation in my family as "the person you call to come and get the dead bird on the patio"...  this is because I used to take care of the rats in my high school biology class with Mr. Holzer, and several years later I had a summer job at the U of Illinois "Biologic Resources Lab" where all the experimental animals for the entire campus were housed.  I was on the rodent floor and spent every day moving animals into clean cages with fresh food and water.  I looked after mice, nude mice, rats, gerbils, hamsters, chinchillas, rabbits and inexplicably: turtles, frogs and two sloths.

An unpleasant part of the job was finding animals that had perished, and with the hundreds of animal cages that happened almost every day.  (At that job I learned how to distinguish what type of animal had died by the smell alone.  I could tell a dead mouse from a dead hamster just by odor.  This, I was disappointed to learn, was not a skill potential employers were interested in.

But because of that job, I became the de facto animal coroner for my mother.  Hence the phone call every time one of her cats murdered a mouse.

Then after med school, when I reported having to dissect cadavers and later pronounce people dead, I became the angel of death for all pets in my mom's view.  Any time an animal was super sick it was on me to make the call.

In December my mother, who at that time lived alone in Pittsburgh, was discovered by her visiting nurse in a very confused state, initially thought to be due to a stroke.  (It wasn't a stroke.  Or a seizure.  Or a UTI.   My own theory is that her confusion is due to a combination of depression and  diabetes for which she was taking either no medication - thanks to Dr Oz for convincing her to use his snake oil supplements instead of metformin - or the wrong dose.

So I went out to Pittsburgh and discovered her cat Bonnie was skeletal and lethargic as my mother had been too sick or confused to take her to the vet.  I talked to her and then I and my youngest sister took Bonnie to be euthanized, which was very sad as I'd known Bonnie for many years.  

Selfie with Honey the Cat.  Her eyes reflect oddly for a cat.  If she were a human that would be how nuclear cataracts might look... as far as I recall.   :-(

Now my mom is too sick for her current place and is moving to a place with a higher level of nursing where she can't have cats.  So I drove out last weekend to get Honey, a 13-year-old tortie. When I got there Honey looked trembly and poorly groomed.  I drove back to Chicago with Honey hanging out in the back seat (being in the car doesn't seem to bother her much) and took her in to see the vet.  She had a battery of tests and unsurprisingly has bad kidney failure.  But she still eats and drinks and walks around so I talked it over with the vet and we're going to switch her to a kidney health diet and I'll give her SC saline once a week and check her again in a month.  He thinks she could have up to a year left if she responds to treatment.  Poor baby. 

Okay, anyway, here's the point.  Just because I had a job where I had to inventory dead animals, and another job where I had to declare people dead, that doesn't mean I like doing that!  Or that it doesn't affect me.  I cried for a week after finding one of the neighborhood squirrels dead after being struck by a car.  (I of course wrapped him in a towel and put him in a box before disposing him in the manner suggested by the local animal control officer because yes I called her because dead squirrel.)  I realize this makes me a crazy person and that I will be one of the first to die in the coming apocalypse, but it is what it is.

Anyway, I mean, maybe other people are different, but I never got used to telling people they were going to die or go blind.  What I did learn how to do is to not be emotional about it in front of the patient.  I mean, it's happened that I teared up with a patient if I was tired or some such and not braced to resist crying. But my old mentor in medical school, Dr. Byron Ruskin, once told me (I think wisely) that when a patient is frightened and getting bad news, their job should not be to comfort their doctor.  I think nurses have it a little easier in this regard.  Nurses work so closely with patients that if they cry with a patient it's seen as a form of comfort and support.  But our job as doctors (at least when I was practicing) is to comfort our patients, not the other way around.  I think that is scary to the patient.  I once saw one of my doctors very upset about my illness and I felt terrible.  I didn't want that guilt... that my situation was wrecking my life was bad enough.  It shouldn't make my doctor cry too, especially when I knew he had done his absolute best for me.  He'd saved my life at least once.  Some patients just don't respond to treatment or get an unintended side effect.  I understand that.  It isn't worth ruining someone else's day.

On a tangential note, it occurs to me that I've also seen a lot of naked people as a doctor.  That doesn't mean I want to see you naked.  Or that it won't bother me to look at the rash on your butt you are trying to show me four minutes after I've met you at a social event.  What I can do is look at your naked body and go into that weird doctor mode where it doesn't emotionally affect me. The same goes for you telling me a revolting story about the time you had that armpit abscess drained just as I take my first sip of creamed soup.   I can go to doctor mode and then make a point of never interacting with you ever again.

This is an image from a children's book I picked up in Norway.  The scene depicts the main character's pet cat Mimmi's death after being struck by a car.  Awwwww...ahhhHHHH!

 Culture shock, right?

What was the point of this entry?  Uhhhh...  oh, right.  Don't call me to take away a dead animal (or person) because I hate that.  

 Today's Norwegian Vocabulary Word: dør
  Pronounced: (due-r).
   Translation:   noun: door
   verb present tense: die (to die= å dø))
 Exercise: Use "dør" in a sentence:
 Example: Katten dør.
   (The cat dies)