Question

A 65 y/o woman presents with severe chest discomfort and mild dyspnea for 30 min, which started soon after she learned that her husband died in a car accident.

She was in good health previously, with no known medical conditions. Her surgical history is significant only for an appendectomy at age 25.

Answer 1

Exam:
Looks Ill
Not pale
Mildly dyspneic

Vital Signs:
Pulse: 110 bmp, regular
BP: 100/65 mmHg
JVP: not elevated
Lung sounds: clear
Heart: no abnormalities
Other systems: unremarkable

Answer 2

Here are the options you can choose from to investigate the patient:

EKG
Cardiac Troponins
Bedside Echocardiogram
Coronary Angiography

Answer 3

I will tell results to you when you perform tests

Answer 4

@Somy I got bored here is another one.

Answer 5

@Abhisar

Answer 6

I think
EKG - to see how the cycle is going
Cardiac Troponins - not sure but could be of some use i guess
Coronary Angiography - to show if there is a potential blocked or partially blocked artery
should be done

Answer 7

ECG - The ECG is in sinus rhythm, with a rate of 104 bpm. There are ST - segment elevations of 3 mm in Leads V1-V3, Lead I, and aVL.

Answer 8

Troponin - T: 3.3 ng/mL (< 0.1 ng/mL)
Troponin - I 5.9 ng/mL (< 0.2 ng/mL)

Answer 9

Wasn't sure if you decided to do the bedside ECG but there is regional systolic dysfunction of the left ventricle, with hypokinesis of the middle and apical segments and the hyperkinesis of the base. The ejection fraction is 40%. No other abnormalities are noted.

Answer 10

Coronary Angiography - All coronary arteries are patent, with no evidence of spasm or thrombosis. Ventriculography shows apical ballooning with hyperkineses of the basal segments and hypokinesis of the apical segments of the left ventricle.

Answer 11

Once you come up with a diagnosis post it here and decide on treatment here are the options:

Beta Blockers
Thrombolysis
ACE Inhibitors
Inotropes

Answer 12

By the way to investigate all of those tests should have been performed.

Answer 13

If you would like further explanations of results please say so. I have already come up with a diagnosis. Once you have yours please treat with given tools appropriately.

Answer 14

"It is the mark of an educated mind to be able to entertain a thought without accepting it."

Answer 15

i gotta get this all through my brain

Answer 16

When i was deciding with the testings i was thinking of the fact that she got a shock
and also considering the fact that she doesnt have any previous history of heart condition, it could be a new thing, like a mini heart attack.
Now her pulse is a little elevated but regular you said, so i assumed that its not the issue of main electrical impulses like a SA block or AV block, so aside that we have ST segment that is pretty much a marking point for ischemia/injury cases (as far as i know). Thus i wanted Electrocardiogram ECG/EKG (whatever it is called since i see it to be with c or k <.<) to be performed to see the waves.

The other thing that i have learnt is that when a patient experiences a mini heart attack, its like a signal that a next major cardiac arrest may occur. So considering that, and the fact that she is fine now, i was assuming that there was a temporary blockage in one of her coronary arteries, agewise its pretty normal that she would have slight or a good amount of fat deposition on her arterial wall and hardening of the walls. Thus i wanted to see if there was a vessel that was at least partially blocked or so. Therefore i thought of using Coronary Angiography, this one sorta was for a safety of the case kinda.

I didnt think using Echocardiogram would do much since i started with thinking it was an ischemic heart attack case, and as i read about Cardiac Troponins (im not familiar with this one as of yet so i had to read about it) it seems to be fast and pretty good , which i think is important. But i'd want to know a little more about it so i gotta do some more reading.
From the results you gave it seems the values are high, though an underlying cause is most probably the shock she got it seems she indeed did have a heart attack/injury.

"Wasn't sure if you decided to do the bedside ECG but there is regional systolic dysfunction of the left ventricle, with hypokinesis of the middle and apical segments and the hyperkinesis of the base. The ejection fraction is 40%. No other abnormalities are noted." Since i did read a little more about the other test i would definitely go with Echocardiogram. From the results it seems her heart attack was around her left ventricle so it makes sense that her ejection fraction is low.

"Ventriculography shows apical ballooning with hyperkineses of the basal segments and hypokinesis of the apical segments of the left ventricle." I've always found Broken Heart Syndrome to be interesting but to my surprise (i dont generally let go of my curiosity) i havent read much about it, but it seems that it is or has to do with apical ballooning. I guess id like to know what exactly it means to be happening in the heart?

Answer 17

In regards with diagnosis
it looks like the name given to it would be something like "Left ventricular dysfunction (LVD) with subsequent congestive heart failure (CHF)"
I dont know if im really using a correct term here, but i agree with the dysfunction part and the heart failure (dont know about severity level of the case that is suitable for this term)
Could as well have some other name idk, all i see for now is the fact that she did have an injury due to her shock, of which nature it is (ischemia or not) I am not really sure but im inclined to ischemia.

Answer 18

Considering her ejection fraction and the pain, Id go with Beta Blockers.
Thrombolysis - not sure about this, though i do think it was an ischemic case, but the blockage was probably temporary since Coronary Angiography results are showed not blockage. So most probably no need for this one.
ACE Inhibitors - also not completely sure about this, it doesnt look like she does have blood pressure issues to the point of using a drug to retain water, increase the volume of blood and widen the vessels. Though it does seem to be of some use, i fear that it will increase the preload and thereby the afterload which is a given and so put more pressure on her left ventricle. But thinking of it from the other perspective, it would in someway compensate for her amount of blood ejected in normal case, meaning the more volume of the blood, the higher chances of getting somewhat enough blood out to her system, i am referring to the blood that will stay back in her ventricle due to ventricular dysfunction which does decrease ejection fraction. ( i hope im making sense to you) So here im somewhat between yes and no
Inotropes - positive or negative, whichever it is, it probably can be used if its a problem with pure dysfunction with no underlying ischemia, but if the ischemia was the cause, then i dont know.

Answer 19

If we assume that the case purely was due to "Takotsubo cardiomyopathy", then i would go with negative inotropes (im going with logic here, thinking that i dont want to rupture her ventricle), and beta blockers. If we decrease the force of contraction im guessing we dont need the ACE Inhibitors.

Answer 20

So whatever was in between, whether it was ischemia or broken heart syndrome, the result seems to be as i termed it before: LVD with subsequent CHF

Answer 21

Firstly VERY good job with this.

Answer 22

This elderly lady had presented with acute chest discomfort and dyspnea following a stressful event, this should be considered an acute coronary syndrom or ACS until you prove otherwise.

Answer 23

Her ECG shows ST-segment elevations in the left and anterior leads, suggesting t an anterior ST- segment elevation myocardial infarction STEMI; the positive cardiac troponins are further supportive in this regard.

Answer 24

suggesting at*

Answer 25

As she has presented relatively early, the next step should be urgent angiography (a preclude to revascularization and stenting); a bedside echocardiogram may also be considered while facilities are being prepped.

Answer 26

The echocardiogram shows regional systolic dysfunction of the left ventricle (LV), predominantly affecting the apex and middle segments; while not typical for a STEMI, this is still compatible with the clinical diagnosis.

However, angiography reveals an unexpected finding: the coronary arteries which are virtually pristine. This is not an ACS!

Answer 27

Furthermore, ventriculography reveals apical ballooning with hyperkinesis of the basal segments and hypokinesis of the apical segments. This is almost pathognomonic of Takotsubo cardiomyopathy (also known as transient apical ballooning syndrome or stress induced cardiomyopathy), one of the few reversible cardiomyopathies.

Answer 28

Thus, her management should mainly be supportive in nature. Angiotensin- converting enzyme (ACE)- inhibitor and beta-blocker therapy will aid with the LV systolic dysfunction.

Note that intropes are not currently indicated, as she is hemodynamically stable. Thrombolytic administration is not only useless, but potentially harmful.

Answer 29

Therefore our treatment should conclude of:
Beta-blockers and ACE Inhibitors not Thrombolysis or inotropes.

Answer 30

Our diagnosis if I wasn't clear is Takotsubo Cardiomyopathy

Answer 31

But very good job!

Answer 32

oo i see :) thank uuuu both for the clinical case as well as praising :D this too was an interesting case!

Answer 33

i just realized that if i put both beta blockers and negative inotropes together it wouldnt be as good, since by using beta blockers we are practically reducing force of contraction either way since we are blocking adrenergic activity so if we were to use negative inotropes we would decrease it even further i assume so it will have a negative effect on her ejection fraction. So yeah i think i understood my mistake :D

Answer 34

Very good! :)