Jul 14 - Chest Pain

Don't tell my heart, my achy breaky heart
I just don't think it'd understand
Cause if you tell my heart, my achy breaky heart
It might blow up and kill this man...
-B. Cyrus






This mornings case was a patient admitted with substernal chest pain and pressure radiating to the left arm and jaw.  The symptoms developed shortly after hearing some traumatic news about a family member.  She had a known history of CAD with a prior MI, CABG, and later Stent to an occluded SVG.  Her initial ECG revealed antero-septal q waves and ST elevations (similar to old ECGs)

Her initial cardiac enzymes were negative, but the second set at 6 hours revealed a significantly elevated troponin of 22.  Urgent cardiac catheterization was peformed which revealed intact bypass grafts and no obstructive coronary disease.  LV-gram revealed apical ballooning sonsistent with Tako-tsubo cardiomyopathy.

Teaching points:
Review this article on the evaluation of acute chest pain.  All acute chest pain presentations must be rapidly screened for immediately life threatening diagnoses - MI, PE, dissection, and pneumothorax.  The differential diagnosis of chest pain is vast, but concentrate initial efforts at ruling in or out the four mentioned above.  Most ED chest pain protocols trigger immediate ECGs, chest X-rays, cardiac enzymes, and oxygen saturation measurements that can give you clues to PE, MI, and PTX.  Dissection is a little more tricky, and high clinical suspicion is key.

Takotsubo cardiomyopathy, also known as apical ballooning syndrome, stress induced cardiomyopathy, and broken heart syndrome, is reviewed in this NEJM Clinical Decision Making article from 2009 - their case has many features similar to the one discussed today.

The optimum evaluation and treatment of acute coronary syndromes is constantly in evolution, and this editorial summarizes the current optimum approach to patient management.  Key point - risk stratify patients using a valid tool such as the TIMI risk score, and reserve coronary angiography for those in the high risk category.

Finally - use caution in treating women with heart disease the same as men.  This study and review of prior trials suggests that using a routine invasive diagnostic strategy in women is of no benefit and may in fact be harmful.  This data is in clear contradiction to results demonstrated in men.