How your emotions change the shape of your heart

No other organ,

perhaps no other object in human life,

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

Over the course of history,

the heart has been a symbol
of our emotional lives.

It was considered by many

to be the seat of the soul,

the repository of the emotions.

The very word "emotion"

stems in part

from the French verb "émouvoir,"

meaning "to stir up,"

and perhaps it's only logical

that emotions would be linked
to an organ characterized

by its agitated movement.

But what is this link?

Is it real, or purely metaphorical?

As a heart specialist,

I am here today to tell you

that this link is very real.

Emotions, you will learn,

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

But before we get into this,

let's talk a bit about
the metaphorical heart.

The symbolism of the emotional heart

endures even today.

If we ask people

which image they most associate with love,

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

The heart-shape, called a cardioid,

is common in nature.

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

including silphium,

which was used for birth control
in the Middle Ages

and perhaps is the reason why
the heart became associated

with sex and romantic love.

Whatever the reason,

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

Over time, the pictures
came to be colored red,

the color of blood,

a symbol of passion.

In the Roman Catholic Church,

the heart shape became known
as the sacred heart of Jesus.

Adorned with thorns
and emitting ethereal light,

it became an insignia of monastic love.

This association between the heart
and love has withstood modernity.

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

received the first permanent
artificial heart in Utah in 1982,

his wife of 39 years

reportedly asked the doctors,

"Will he still be able to love me?"

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

or the other emotions, per se --

the ancients were mistaken --

and yet more and more
we have come to understand

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

The heart may not originate our feelings,

but it is highly responsive to them.

In a sense, a record of our emotional life

is written on our hearts.

Fear and grief, for example,

can cause profound cardiac injury.

The nerves that control
unconscious processes

such as the heartbeat

can sense distress

and trigger a maladaptive
fight-or-flight response

that triggers blood vessels to constrict,

the heart to gallop,

and blood pressure to rise,

resulting in damage.

In other words,

it is increasingly clear

that our hearts are extraordinarily
sensitive to our emotional system,

to the metaphorical heart, if you will.

There is a heart disorder

first recognized about two decades ago

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

in which the heart acutely weakens

in response to intense stress or grief

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

As these pictures show,
the grieving heart in the middle

looks very different
than the normal heart on the left.

It appears stunned
and frequently balloons

into the distinctive shape
of a takotsubo, shown on the right,

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

We don't know exactly why this happens,

and the syndrome usually resolves
within a few weeks.

However, in the acute period,

it can cause heart failure,

life-threatening arrhythmias,

even death.

For example, the husband
of an elderly patient of mine

had died recently.

She was sad, of course, but accepting,

maybe even a bit relieved.

It had been a very long illness.
He had had dementia.

But a week after the funeral,

she looked at his picture

and became tearful,

and then she developed chest pain

and with it came shortness of breath,

distended neck veins, a sweaty brow,

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

all signs of heart failure.

She was admitted to the hospital

where an ultrasound confirmed
what we already suspected:

her heart had weakened
to less than half its normal capacity

and had ballooned into
the distinctive shape of a takotsubo.

But no other tests were amiss,

no sign of clogged arteries anywhere.

Two weeks later, her emotional state
had returned to normal

and so, an ultrasound confirmed,

had her heart.

Takotsubo cardiomyopathy has been linked
to many stressful situations,

including public speaking.

(Laughter)

(Applause)

Domestic disputes, gambling losses,

even a surprise birthday party.

It's even been associated
with widespread social upheaval,

such as after a natural disaster.

For example, in 2004 a massive earthquake

devastated a district
on the largest island in Japan.

More than 60 people were killed
and thousands were injured.

On the heels of this catastrophe,

researchers found that the incidents
of takotsubo cardiomyopathy

increased 24-fold in the district
one month after the earthquake

compared to a similar
period the year before.

The residences of these cases

closely correlated with
the intensity of the tremor.

In almost every case,

patients lived near the epicenter.

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

but the heart appears
to react differently,

ballooning in the mid-portion,
for example, and not at the apex.

Why different emotional precipitants

would result in different cardiac changes

remains a mystery,

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

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

the emotional heart overlaps
its biological counterpart

in surprising and mysterious ways.

Heart syndromes, including sudden death,

have long been reported in individuals
experiencing intense emotional disturbance

or turmoil in their metaphorical hearts.

In 1942,

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

in which he described
cases of death from fright

in people who believed
they had been cursed,

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

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

What these cases had in common

was the victim's absolute belief

that there was an external force
that could cause their demise

and against which
they were powerless to fight.

This perceived lack of control,
Cannon postulated,

resulted in an unmitigated
physiological response

in which blood vessels
constricted to such a degree

that blood volume acutely dropped,

blood pressure plummeted,

the heart acutely weakened,

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

Cannon believed that voodoo deaths

were limited to indigenous
or "primitive" people,

but over the years,

these types of deaths have been shown

to occur in all manner
of modern people too.

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

Broken hearts are literally
and figuratively deadly.

These associations hold true
even for animals.

In a fascinating study in 1980

published in the journal "Science,"

researchers fed caged rabbits
a high-cholesterol diet

to study its effects
on cardiovascular disease.

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

but they couldn't explain why.

The rabbits had very similar diet,

environment, and genetic makeup.

They thought it might have something to do

with how frequently the technician
interacted with the rabbits,

so they repeated the study,

dividing the rabbits into two groups.

Both groups were fed
a high-cholesterol diet,

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

held, petted, talked to, played with,

and in the other group
the rabbits remained in their cages

and were left alone.

At one year, on autopsy,

the researchers found

that the rabbits in the first group

that received human interaction

had 60 percent less aortic disease

than rabbits in the other group,

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

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

who dwell upon the heart's
metaphorical meanings

and more the domain of doctors like me

wielding technologies
that even a century ago,

because of the heart's exalted status
in human culture, were considered taboo.

In the process, the heart
has been transformed

from an almost supernatural object

imbued with metaphor and meaning

into a machine

that can be manipulated and controlled.

But this is the key point:

these manipulations, we now understand,

must be complemented

by attention to the emotional life

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

Consider for example
the "lifestyle heart trial"

published in the British journal
The Lancet in 1990.

Forty-eight patients with moderate
or severe coronary disease

were randomly assigned to usual care

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

moderate aerobic exercise,

group psycho-social support,
and stress management advice.

The researchers found

that the lifestyle patients

had a nearly five percent reduction
in coronary plaque.

Control patients, on the other hand,

had five percent more
coronary plaque at one year

and 28 percent more at five years.

They also had nearly double
the rate of cardiac events

like heart attacks,
coronary bypass surgery,

and cardiac-related deaths.

Now, here's an interesting fact:

some patients in the control group

adopted diet and exercise plans

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

Their heart disease still progressed.

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

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

stress management
was more strongly correlated

with reversal of coronary disease
than exercise was.

No doubt this and similar
studies are small,

and of course correlation
does not prove causation.

It's certainly possible that stress
leads to unhealthy habits,

and that's the real reason
for the increased cardiovascular risk.

But as with the association
of smoking and lung cancer,

when so many studies show the same thing,

and when there are mechanisms
to explain a causal relationship,

it seems capricious to deny
that one probably exists.

What many doctors have concluded
is what I too have learned

in my nearly two decades
as a heart specialist:

the emotional heart intersects
with its biological counterparts

in surprising and mysterious ways.

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

This conceptualization
has had great benefits.

Cardiology, my field,

is undoubtedly one of the greatest
scientific success stories

of the past 100 years.

Stents, pacemakers, defibrillators,
coronary bypass surgery,

heart transplants,

all these things were developed
or invented after World War II.

However, it's possible

that we are approaching the limits
of what scientific medicine can do

to combat heart disease.

Indeed, the rate of decline
of cardiovascular mortality

has slowed significantly
in the past decade.

We will need to shift to a new paradigm

to continue to make the kind of progress
to which we have become accustomed.

In this paradigm, psycho-social factors
will need to be front and center

in how we think about heart problems.

This is going to be an uphill battle,

and it remains a domain
that is largely unexplored.

The American Heart Association
still does not list emotional stress

as a key modifiable risk factor
for heart disease,

perhaps in heart because blood cholesterol
is so much easier to lower

than emotional and social disruption.

There is a better way, perhaps.

If we recognize that when
we say "a broken heart,"

we are indeed sometimes talking
about a real broken heart.

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

in taking care of our hearts.

Emotional stress, I have learned,

is often a matter of life and death.

Thank you.

(Applause)