Emergency Medicine: Heart pain not always result of heart attack

The medics radioed in that they wanted us to look at a possible STEMI before they activated an alert and took the patient straight to the catheterization lab.

STEMI, or "ST elevation myocardial infarction," is a type of acute heart attack that frequently is fatal if not treated right away. A more colloquial name for it is "the big one."


In terms of treating heart attacks, "time is muscle." That is why rapid evaluation is performed to determine whether the likely cause of symptoms is a blocked coronary vessel that could respond to acute intervention.

The most-effective treatment is balloon angioplasty, or PCI - percutaneous coronary intervention - which can unblock blood vessels and directly restore circulation to the oxygen- and blood-starved portion of heart muscle.



Once the patient arrived, I could see why the medics were uncomfortable about sending her directly to the catheterization lab for PCI.

It is one thing to have a 50-year-old man who is overweight, has high cholesterol, high blood pressure and diabetes, and was shoveling snow suddenly feel as if an elephant is sitting on his chest.



But this patient was an 80-year-old woman who was feeling weak and dizzy, somewhat nauseated and "just not right" since her husband had died two weeks before. She had some chest pain, but it was vague and, in her words, "not-the-end-of-the-world kind of pain."

Her vital signs showed borderline low blood pressure and low oxygen. Her EKG did look concerning, but it was almost too bad to be real. Although she appeared to have blockages in two arteries, I thought it unlikely that she was having "the big one."


That's why I decided to perform additional tests before sending her to have her arteries opened.


The further workup showed some evidence of fluid buildup in her lungs, likely from early heart failure, and slight elevations of her cardiac markers, proteins that are released by a stressed heart.


However, these findings neither confirmed nor ruled out a heart attack.

We continued and got a cardiac echocardiogram, an ultrasound evaluation of the heart.


That ultrasound made the diagnosis. It was not a heart attack.

This woman had takotsubo cardiomyopathy, a condition also known as transient apical ballooning syndrome, which can mimic a heart attack.

The syndrome is defined as a sudden weakening of the heart muscle because of coronary spasm. In other words, it is not caused by decreased circulation as a result of blockages or ruptured plaques within the arteries.

These spasms can be brought on by high levels of adrenaline, well explained by the recent death of her husband.

The ultrasound findings in these cases show a ballooning or bagginess in the lower tip of the left ventricle. The disease, named for ceramic Japanese octopus traps, causes a narrow constriction between the ventricles and the atria, or the upper, smaller chambers of the heart.

The diagnosis generally is made once other causes are ruled out.

My patient eventually underwent catheterization so we could examine her coronary arteries.


She fit the picture of a "typical" takotsubo patient. She had just gone through extreme emotional distress and exhibited symptoms of heart failure.

The patient illustrated perfectly the alternative name for this diagnosis: "broken-heart syndrome."

Dr. Diane Gorgas is an emergency physician at Ohio State University

Medical Center.