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No other organ,

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perhaps no other object in human life,

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is as imbued with metaphor
and meaning as the human heart.

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Over the course of history,

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the heart has been a symbol
of our emotional lives.

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It was considered by many
to be the seat of the soul,

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the repository of the emotions.

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The very word "emotion" stems in part
from the French verb "émouvoir,"

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meaning "to stir up."

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And perhaps it's only logical
that emotions would be linked to an organ

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characterized by its agitated movement.

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But what is this link?

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Is it real or purely metaphorical?

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As a heart specialist,

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I am here today to tell you
that this link is very real.

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Emotions, you will learn,

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can and do have a direct
physical effect on the human heart.

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But before we get into this,

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let's talk a bit about
the metaphorical heart.

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The symbolism of the emotional heart
endures even today.

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If we ask people which image
they most associate with love,

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there's no question that the Valentine
heart would the top the list.

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The heart shape, called a cardioid,

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is common in nature.

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It's found in the leaves,
flowers and seeds of many plants,

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including silphium,

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which was used for birth control
in the Middle Ages

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and perhaps is the reason why
the heart became associated

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with sex and romantic love.

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Whatever the reason,

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hearts began to appear in paintings
of lovers in the 13th century.

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Over time, the pictures
came to be colored red,

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the color of blood,

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a symbol of passion.

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In the Roman Catholic Church,

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the heart shape became known
as the Sacred Heart of Jesus.

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Adorned with thorns
and emitting ethereal light,

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it became an insignia of monastic love.

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This association between the heart
and love has withstood modernity.

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When Barney Clark, a retired dentist
with end-stage heart failure,

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received the first permanent
artificial heart in Utah in 1982,

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his wife of 39 years
reportedly asked the doctors,

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"Will he still be able to love me?"

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Today, we know that the heart
is not the source of love

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or the other emotions, per se;

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the ancients were mistaken.

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And yet, more and more,
we have come to understand

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that the connection between the heart
and the emotions is a highly intimate one.

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The heart may not originate our feelings,

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but it is highly responsive to them.

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In a sense, a record of our emotional life

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is written on our hearts.

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Fear and grief, for example,
can cause profound cardiac injury.

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The nerves that control unconscious
processes such as the heartbeat

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can sense distress

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and trigger a maladaptive
fight-or-flight response

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that triggers blood vessels to constrict,

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the heart to gallop

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and blood pressure to rise,

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resulting in damage.

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In other words,

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it is increasingly clear

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that our hearts are extraordinarily
sensitive to our emotional system,

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to the metaphorical heart, if you will.

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There is a heart disorder
first recognized about two decades ago

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called "takotsubo cardiomyopathy,"
or "the broken heart syndrome,"

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in which the heart acutely weakens
in response to intense stress or grief,

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such as after a romantic breakup
or the death of a loved one.

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As these pictures show,
the grieving heart in the middle

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looks very different
than the normal heart on the left.

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It appears stunned

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and frequently balloons into
the distinctive shape of a takotsubo,

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shown on the right,

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a Japanese pot with a wide base
and a narrow neck.

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We don't know exactly why this happens,

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and the syndrome usually resolves
within a few weeks.

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However, in the acute period,

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it can cause heart failure,

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life-threatening arrhythmias,

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even death.

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For example, the husband
of an elderly patient of mine

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had died recently.

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She was sad, of course, but accepting.

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Maybe even a bit relieved.

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It had been a very long illness;
he'd had dementia.

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But a week after the funeral,
she looked at his picture

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and became tearful.

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And then she developed chest pain,
and with it, came shortness of breath,

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distended neck veins, a sweaty brow,

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a noticeable panting
as she was sitting up in a chair --

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all signs of heart failure.

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She was admitted to the hospital,

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where an ultrasound confirmed
what we already suspected:

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her heart had weakened
to less than half its normal capacity

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and had ballooned into
the distinctive shape of a takotsubo.

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But no other tests were amiss,

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no sign of clogged arteries anywhere.

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Two weeks later, her emotional state
had returned to normal

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and so, an ultrasound confirmed,

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had her heart.

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Takotsubo cardiomyopathy has been linked
to many stressful situations,

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including public speaking --

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(Laughter)

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(Applause)

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domestic disputes, gambling losses,

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even a surprise birthday party.

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(Laughter)

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It's even been associated
with widespread social upheaval,

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such as after a natural disaster.

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For example, in 2004,

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a massive earthquake devastated a district
on the largest island in Japan.

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More than 60 people were killed,
and thousands were injured.

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On the heels of this catastrophe,

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researchers found that the incidents
of takotsubo cardiomyopathy

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increased twenty-four-fold in the district
one month after the earthquake,

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compared to a similar
period the year before.

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The residences of these cases

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closely correlated with
the intensity of the tremor.

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In almost every case,
patients lived near the epicenter.

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Interestingly, takotsubo cardiomyopathy
has been seen after a happy event, too,

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but the heart appears
to react differently,

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ballooning in the midportion,
for example, and not at the apex.

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Why different emotional precipitants
would result in different cardiac changes

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remains a mystery.

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But today, perhaps as an ode
to our ancient philosophers,

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we can say that even if emotions
are not contained inside our hearts,

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the emotional heart overlaps

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its biological counterpart,

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in surprising and mysterious ways.

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Heart syndromes, including sudden death,

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have long been reported in individuals
experiencing intense emotional disturbance

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or turmoil in their metaphorical hearts.

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In 1942,

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the Harvard physiologist Walter Cannon
published a paper called "'Voodoo' Death,"

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in which he described
cases of death from fright

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in people who believed
they had been cursed,

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such as by a witch doctor
or as a consequence of eating taboo fruit.

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In many cases, the victim, all hope lost,
dropped dead on the spot.

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What these cases had in common
was the victim's absolute belief

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that there was an external force
that could cause their demise,

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and against which
they were powerless to fight.

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This perceived lack of control,
Cannon postulated,

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resulted in an unmitigated
physiological response,

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in which blood vessels
constricted to such a degree

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that blood volume acutely dropped,

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blood pressure plummeted,

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the heart acutely weakened,

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and massive organ damage resulted
from a lack of transported oxygen.

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Cannon believed that voodoo deaths

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were limited to indigenous
or "primitive" people.

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But over the years, these types of deaths
have been shown to occur

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in all manner of modern people, too.

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Today, death by grief has been seen
in spouses and in siblings.

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Broken hearts are literally
and figuratively deadly.

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These associations hold true
even for animals.

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In a fascinating study in 1980
published in the journal "Science,"

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researchers fed caged rabbits
a high-cholesterol diet

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to study its effect
on cardiovascular disease.

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Surprisingly, they found that some rabbits
developed a lot more disease than others,

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but they couldn't explain why.

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The rabbits had very similar diet,
environment and genetic makeup.

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They thought it might have
something to do with

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how frequently the technician
interacted with the rabbits.

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So they repeated the study,

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dividing the rabbits into two groups.

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Both groups were fed
a high-cholesterol diet.

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But in one group, the rabbits
were removed from their cages,

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held, petted, talked to, played with,

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and in the other group,
the rabbits remained in their cages

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and were left alone.

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At one year, on autopsy,

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the researchers found
that the rabbits in the first group,

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that received human interaction,

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had 60 percent less aortic disease
than rabbits in the other group,

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despite having similar cholesterol levels,
blood pressure and heart rate.

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Today, the care of the heart has become
less the province of philosophers,

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who dwell upon the heart's
metaphorical meanings,

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and more the domain of doctors like me,

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wielding technologies
that even a century ago,

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because of the heart's exalted
status in human culture,

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were considered taboo.

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In the process, the heart
has been transformed

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from an almost supernatural object
imbued with metaphor and meaning

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into a machine that can be
manipulated and controlled.

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But this is the key point:

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these manipulations, we now understand,

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must be complemented
by attention to the emotional life

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that the heart, for thousands of years,
was believed to contain.

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Consider, for example,
the Lifestyle Heart Trial,

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published in the British journal
"The Lancet" in 1990.

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Forty-eight patients with moderate
or severe coronary disease

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were randomly assigned to usual care

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or an intensive lifestyle
that included a low-fat vegetarian diet,

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moderate aerobic exercise,

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group psychosocial support

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and stress management advice.

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The researchers found
that the lifestyle patients

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had a nearly five percent reduction
in coronary plaque.

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Control patients, on the other hand,

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had five percent more
coronary plaque at one year

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and 28 percent more at five years.

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They also had nearly double
the rate of cardiac events,

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like heart attacks,
coronary bypass surgery

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and cardiac-related deaths.

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Now, here's an interesting fact:

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some patients in the control group
adopted diet and exercise plans

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that were nearly as intense
as those in the intensive lifestyle group.

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Their heart disease still progressed.

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Diet and exercise alone were not enough
to facilitate coronary disease regression.

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At both one- and five-year follow-ups,

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stress management
was more strongly correlated

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with reversal of coronary disease

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than exercise was.

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00:13:02,001 --> 00:13:05,618
No doubt, this and similar
studies are small,

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00:13:05,642 --> 00:13:08,823
and, of course, correlation
does not prove causation.

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00:13:08,847 --> 00:13:13,205
It's certainly possible that stress
leads to unhealthy habits,

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00:13:13,229 --> 00:13:16,508
and that's the real reason
for the increased cardiovascular risk.

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00:13:16,532 --> 00:13:20,133
But as with the association
of smoking and lung cancer,

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when so many studies show the same thing,

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and when there are mechanisms
to explain a causal relationship,

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it seems capricious to deny
that one probably exists.

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What many doctors have concluded
is what I, too, have learned

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in my nearly two decades
as a heart specialist:

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the emotional heart intersects
with its biological counterpart

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in surprising and mysterious ways.

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And yet, medicine today continues
to conceptualize the heart as a machine.

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This conceptualization
has had great benefits.

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Cardiology, my field,

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is undoubtedly one of the greatest
scientific success stories

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of the past 100 years.

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00:14:05,170 --> 00:14:10,818
Stents, pacemakers, defibrillators,
coronary bypass surgery,

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00:14:10,842 --> 00:14:12,162
heart transplants --

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00:14:12,186 --> 00:14:16,135
all these things were developed
or invented after World War II.

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00:14:16,159 --> 00:14:18,270
However, it's possible

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00:14:18,294 --> 00:14:23,580
that we are approaching the limits
of what scientific medicine can do

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00:14:23,604 --> 00:14:25,202
to combat heart disease.

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00:14:25,226 --> 00:14:28,591
Indeed, the rate of decline
of cardiovascular mortality

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00:14:28,615 --> 00:14:32,304
has slowed significantly
in the past decade.

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We will need to shift to a new paradigm

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00:14:36,316 --> 00:14:40,311
to continue to make the kind of progress
to which we have become accustomed.

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00:14:40,335 --> 00:14:45,760
In this paradigm, psychosocial factors
will need to be front and center

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00:14:45,784 --> 00:14:47,908
in how we think about heart problems.

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00:14:48,685 --> 00:14:50,823
This is going to be an uphill battle,

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00:14:50,847 --> 00:14:54,790
and it remains a domain
that is largely unexplored.

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00:14:55,956 --> 00:15:01,121
The American Heart Association
still does not list emotional stress

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00:15:01,145 --> 00:15:04,936
as a key modifiable risk factor
for heart disease,

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00:15:04,960 --> 00:15:09,763
perhaps in part because blood cholesterol
is so much easier to lower

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00:15:09,787 --> 00:15:12,462
than emotional and social disruption.

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There is a better way, perhaps,

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00:15:15,998 --> 00:15:20,875
if we recognize that when
we say "a broken heart,"

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we are indeed sometimes talking
about a real broken heart.

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We must, must pay more attention to
the power and importance of the emotions

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in taking care of our hearts.

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Emotional stress, I have learned,

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is often a matter of life and death.

256
00:15:41,048 --> 00:15:42,208
Thank you.

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(Applause)