By Van Wall, EM3
CODE STEMI called by EMS on a 76 year old woman with 15 minutes of retrosternal chest pain and dizziness that began while washing her car. EMS forwarded the EKG, CCU was notified and in the trauma bay awaiting patient arrival. She received 324mg ASA and nitroglycerin 0.4mg SL x 3 prior to arrival with no change in symptoms.
VS: HR 120, BP 140/88, O2 98%, R 18
Upon arrival, patient appears in moderate distress. She states a history of A Fib, not on anticoagulants, and denies other history of cardiac disease or MI. She has no associated nausea/vomiting, diaphoresis or shortness of breath. She describes the pain as sharp, constant and radiating to her back.
pCXR: unremarkable. No evidence of widened mediastinum.
STEMI vs pericarditis were at the top of our differential.
Based on her EKG and continued chest pain, she was given a heparin load 5000U IV and taken emergently to the cath lab. She was hemodynamically stable through her ED course.
Cath findings showed no coronary obstruction. Her ventricular function was consistent with Takotsubo cardiomyopathy.
She was transferred to the step down unit, started on apixiban and beta blockers.
Troponin resulted at 0.06.
Takotsubo or Broken Heart Syndrome most often occurs in post-menopausal woman following either an emotional or physical stressor. Treatment is supportive, usually with beta blockers, diuretics or, in severe cases, IABPs. Pressors may worsen symptoms. These patients will usually have a good outcome, but may have recurrent events in the future. They may go into cardiogenic shock or have ventricular aneurysms so watch their pressures and do an echo if considering this diagnosis.
References and additional reading