S6E2: The Heart of the Matter

Written By Admin User

Welcome back to another episode of TheCase.Report!

Mohammed joins Nicola and Paula in resus as they work through a tricky presentation of chest pain... How will they untangle this one?

Alright, let's get to it!

Pre-alert

  • 36 F, collapse at home, chest pain, vomiting, ?STEMI, but cath lab said no

  • HR 118 BP 168/94 RR 24 SpO2 95% Temp 37.3

  • ETA 5mins

  • Review on arrival requested


On review at ambulance triage

  • Still diaphoretic, pale, lethargic

  • Pain in chest improving, but persistent interscapular pain

  • Prehospital crew show you ECG: 1mm STE V2-4; CROC not convinced when ECG sent for review

  • Move to resus as unhappy w/ appearance


History

  • Name: Carla 

  • 36

  • 1 week postpartum following uncomplicated delivery of 1st child

  • Sudden onset “ripping” chest pain and presyncope while lifting baby’s car seat out of car 30mins ago

  • Partner noted pallor, weakness, diaphoresis

  • Called ambulance

  • Vomit x 1 en route

  • Now reporting decreased chest pain but still feels weak and has a dull pain between shoulder blades and in right shoulder


Exam & Vitals:

Endofbedogram: LLS score = 1; anxious, clammy, pale

  • A: patent, verbalising

  • B: Tachypnoeic RR22, SpO2 93% RA; clear to auscultation

    • Supplemental O2

  • C: Tachycardic; HR118, BP 154/88; No murmurs, JVP not elevated

    • Abdomen SNT; normal postpartum uterus

    • 2x IVC; bloods sent - discuss what to send

      • FBC, coag, biochem + trop (?d-dimer)

  • D: GCS 15; BM 5.1

  • E: No rash; apyrexial 37.4


Bedside diagnostics:

  • VBG: unremarkable (pH 7.37, pO2 14, pCO2 4.7, HCO3 22, normal electrolytes, lactate 1.8)

  • ECG: STE V2-V4 but >2mm now with TWI in leads I and aVL

    • CROC called immediately, asked to activate cath lab

  • Bedside echo: hypokinetic anterior wall


Immediate management

  • Analgesia

  • Antiplatelets? Thrombolysis (if not near cath lab?)?

    • Yes to DAPT, no to lytics


Differentials

  • Myocarditis: 

    • Can present with chest pain and troponin rise, but ECG is less likely to show focal ST-elevation

  • Atherosclerotic STEMI: 

    • Less likely given age, gender, and lack of risk factors

  • Aortic Dissection: 

    • The radiating "ripping" pain is a key feature, but the ECG and echo findings point directly to coronary ischemia

  • Peripartum Cardiomyopathy: 

    • Typically presents with heart failure symptoms, not focal ischemic chest pain or ST-elevation

  • Pulmonary Embolus: 

    • Can cause tachycardia and shortness of breath, but not typically this ECG pattern

    • or…


SCAD - but what is it?

  • SCAD is an emergency condition where a tear forms in the wall of a coronary artery

  • This creates a false lumen where blood pools, causing a blockage that can lead to ischaemic symptoms, arrhythmias or cardiac arrest

  • Patients often healthy with no cardiac risk factors


It’s a women’s health issue

  • Makes up 1-4% of ALL ACS presentations, but predominantly affects women (87-95% of cases)

    • Had been thought to be very rare, but unfortunately was just underappreciated

  • Leading cause of heart attacks in women under 50 with no risk factors

    • Mean age 44-53 years

    • 8.7-35% of all ACS in women under 50

  • Hormonal and life stage links:

    • Pregnancy associated SCAD: Occurs in late stages of pregnancy or more commonly in the early weeks after birth (~30% of cases)

      • Most common cause of MI in pregnant and postpartum patients

    • Menopause: Many women have a SCAD around the time of menopause

    • Link to hormonal fluctuations posited.

  • Fibromuscular dysplasia found in over 50% of SCAD patients

  • Other potential causes/risk factors:

    • Connective tissue disorders (marfans, EDS)

    • Extreme physical exertion/emotional stress

    • Valsalva activities

    • Hypertension

    • Cocaine/amphetamine use

    • Previous SCAD (10-30% risk of recurrence)

Diagnostic challenge

  • Can be tricky to pick up even on angiogram (IVUS often needed for definitive diagnosis)

  • Many patients misdiagnosed or discharged without full workup due to age and lack of risk factors

  • Important thing for us is suspecting it, so always consider it in ACS presentations in women of child bearing age, especially those that are pregnant, postpartum or perimenopause 

    • Key takeaway 

  • Normal ECG doesn’t rule it out, but most of the time ischemic (OMI/nOMI/reperfusion) findings on ECG

    • Not just STEMI (26-87% will though)

    • Focal ST depression, diffuse ST depression with aVR elevation, HATW etc.. 

  • Initial troponin may be normal; importance of serial data.


Management

  • If suspected, important to follow routine ACS management

    • DAPT

    • Analgesia

    • Oxygen

    • Angio

      • Has sometimes been avoided in pregnancy due to risk of radiation to foetus, but maternal mortality risk has to outweigh that

    • NO thrombolysis

      • Can cause extension of dissection or haematoma

    • Most managed conservatively, PCI or CABG only if ongoing ischaemia or instability

  • Long term: 

    • a retrospective study has shown lower rates of recurrence with beta blocker use

    • Cardiac rehab

    • Psychosocial and lifestyle impact

    • Recurrence risk


That’s a wrap!

That’s it for this month’s episode of thecase.report. A massive thank you to our guests for joining us on this month’s episode.

Until next time, may your coffee be strong, and your rounds be grand.

Admin User
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S6E1: The Pitt Season 1 Review