Why men with broken heart syndrome are more likely to die, according to experts

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A 59-year-old man arrived at the Peking University First Hospital in Beijing for a procedure when he started having severe chest pain and shortness of breath.
Four months earlier, he had cancerous tumors removed from his bladder. Around his family, he tried his best to appear strong and avoided discussions of his health. Privately, his severe anxiety over the possibility of a cancer recurrence kept him awake at night.
Doctors said the man was experiencing takotsubo cardiomyopathy — also known as broken heart syndrome, as documented in a 2021 case study. The rare stress-induced heart condition has been observed primarily in women, but a study published in the Journal of the American Heart Association in May found that the illness may be more deadly for the men who get it.
Thought to be caused by extreme emotional or physical events — such as learning about the death of a loved one, winning the lottery or lifting a heavy sofa — takotsubo cardiomyopathy, or TC, occurs when the heart muscle is flooded with stress hormones, causing part of it to 'freeze' in place. As the heart struggles to properly pump blood, symptoms resemble those of a heart attack, including chest pain, heart palpitations and irregular heartbeat.
The new study analyzed data from nearly 200,000 patients hospitalized for TC in the United States between 2016 and 2020. While women accounted for 83% of the cases, men were more than twice as likely to die from the condition — with a mortality rate of 11.2%.
'The differences between men and women are a very striking finding,' said study coauthor Dr. Mohammad Reza Movahed, a clinical professor of medicine at the University of Arizona in Tucson. 'It raises a new, interesting question that should really be studied.'
Similar to differences between men's and women's cardiovascular health more generally, the discrepancies in TC death rates are not well understood, Movahed said, especially because they counter trends in other heart diseases. It's widely theorized, however, that differences in hormone levels play a role.
Stressful situations trigger the adrenal glands to release our fight-or-flight hormones, called catecholamines. They are meant to increase our blood pressure and raise our heart rate, but extreme levels can temporarily 'stun' cells in the heart's tissue, leading to TC, Movahed explained.
Men are thought to produce more catecholamines during stressful situations compared with women, possibly leading men to present with more severe cases of TC, he suggested.
Estrogen, a sex hormone produced at higher levels in women, may also have a protective effect on the cardiovascular system, making it easier to manage an extreme influx of catecholamines and reducing the risk of severe complications from TC, said Dr. Louis Vincent, a noninvasive-cardiology research fellow at the University of Miami, who coauthored a similar, multiyear study investigating discrepancies in men and women who had TC. Vincent was not involved in the new study.
Beyond biological differences, social factors may play a role as well.
'Most (physicians) know about takotsubo, but they may think of it as a disease just affecting women, so the diagnosis might be overlooked in men,' said Dr. Deepak Bhatt, a cardiologist and the director of Mount Sinai Fuster Heart Hospital who was not involved in the study. 'With misdiagnosis, care is delayed, and that can sometimes lead to worse outcomes.'
Men may also seek care at a later stage of illness, believing that their symptoms are manageable or may pass, said Dr. Alejandro Lemor, an assistant professor of interventional cardiology at the University of Mississippi Medical Center who was also not involved in the study.
Deadly complications from TC include blood clots, stroke, cardiac arrest and heart failure, Lemor said. If the condition is caught early, medications can reduce the risk of having these complications, restore proper heart function and allow for full recovery within weeks, he added.
Movahed's team was able to factor for important variables like age, race, income, chronic lung disease, hypertension and diabetes in the findings.
However, there was no patient data on other comorbid diseases, such as a history of stroke or the presence of a Covid-19 infection, Vincent said.
Additionally, the new study included in-patient diagnostic data only for those hospitalized with TC, so those who received outpatient care or died later from complications outside the hospital were likely not counted in the analysis, Movahed noted.
To establish a firmer explanation for the differences in mortality rates between men and women and further test treatment methods, a more detailed dataset would be needed, Vincent said.
'People should be aware in studies like this, we're presenting findings that are based on diagnostic codes, and we're not looking at patient procedures or lab results,' Vincent said. 'But it's powerful in the sense that it lets us look at large populations and look at trends. And I think that this trend of a higher mortality in men is worth taking a deeper look into.'
Sudden, severe chest pain or shortness of breath should always be treated as a medical emergency, warned Bhatt, who is also a professor of cardiovascular medicine at the Icahn School of Medicine at Mount Sinai in New York City.
'It's not a time to tough it out at home or get on the internet to figure it out. … Don't try to track down your primary care provider. Call emergency services,' Bhatt said. 'Time matters. By winning those few hours, you could save yourself irreparable damage to your heart.'
Symptoms following physical stressors — a common cause of TC in men — should not be ignored, Movahed said, especially preceding medical events such as asthma attacks, seizures or complications from drug use.
And while TC is caused by sudden stress, Bhatt said that managing chronic stress with daily meditation or exercise can lead to better cardiovascular health overall while giving you routines to fall back on in unexpected situations.