A Patient ECG Case: When a STEMI is not a STEMI
Patient: A 60-year-old female presented to the emergency department with acute chest pain and shortness of breath. She was in a motor vehicle accident today. Although she was not physically injured, she was very upset and began to experience the chest pain shortly after the police arrived on the scene. She has no history suggestive of coronary disease, nor does she have any risk factors for arthrosclerosis. Her initial blood pressure was 90/60, heart rate 48 BPM and O2 sat 92%. Her initial ECG was:
There is a wide complex bradycardia with a right bundle branch block configuration, prominent ST elevation across anterior leads associated with anteroseptal Q waves. There is also ST elevation in the inferior leads.
On coronary angiography, left ventriculography demonstrated apical ballooning. No obstructive coronary disease was seen. She was diagnosed as “Takotsubo Cardiomyopathy.”
Key Points:
Takotsubo Cardiomyopathy (TCM) is also known as "Broken Heart Syndrome," or “Stress-Induced Cardiomyopathy.”
Incidence and Prevalence: TCM accounts for about 1-2% of suspected acute coronary syndrome cases. It predominantly affects postmenopausal women.
Symptoms: TCM mimics a STEMI with chest pain, breathlessness, and sometimes syncope.
ECG Findings: ECG typically shows ST-segment elevation resembling STEMI.
Pathophysiology: Thought to be due to a combination of sympathetic nervous system activation and microvascular spasm. TCM may be complicated by associated left ventricular outflow tract obstruction impairing hemodynamics.
Short-term Outcomes: With appropriate medical management and supportive care, most patients recover. Rarely, complications like cardiogenic shock, ongoing LV dysfunction and death occur.
Long-term Outcomes: Long-term prognosis is generally favorable. Most patients experience complete recovery of heart function. However, there is a risk of recurrence.
In summary, TCM is difficult to distinguish from STEMI on presentation and no ECG criteria can differentiate between the two conditions. If in doubt, you should activate the code STEMI protocol.
