Downloaded from http://emj.bmj.com/ on July 29, 2015 - Published by group.bmj.com
EMJ Online First, published on May 6, 2015 as 10.1136/emermed-2014-204359
Short answer question: a distracting ECG
SAQs
Questions
be assessed with a chest radiograph. An aortic dissection should be considered in the setting of back pain with tachycardia, but typically occurs in the setting of hypertension. A thorough examination should be done for other findings such as unequal pulses, differing BPs in the arms and neurological deficits, which would increase the pretest probability of a dissection. Although chest radiography can often detect evidence of a dissection, further testing with echocardiography or CT is often required when suspicion is high. Given the patient’s age, risk factors and ECG with ST-segment changes in V2–V6, II, III, and aVF, there was concern for an acute myocardial infarction (AMI). 2. In cases of suspected AMI, patients should be given aspirin, analgesia and oxygen. Although nitrates have not been shown to improve outcome,1 they are often helpful for symptom relief, and the patient was given sublingual glyceryl trinitrate. In addition, a platelet aggregation inhibitor such as clopidogrel, prasugrel or ticagrelor should be given as results from multiple trials demonstrate a decreased risk of death, reinfarction or cardiac arrest when these agents were given to patients with STEMI.1 Per protocol, the patient was given ticagrelor and transferred to a tertiary centre for primary percutaneous coronary intervention (PCI).
1. What is the differential diagnosis? 2. What is your initial management?
PART 2
1. The differential diagnosis would include acute ST-elevation myocardial infarction (STEMI), pericarditis, dissecting thoracic aneurysm, pneumonia and pneumothorax. Pneumonia is unlikely given the absence of a cough or fever, normal lung examination and normal room air oxygenation. An acute pneumothorax is unlikely given the history and normal lung examination. Both, however, could
At the tertiary centre, the patient had an angiogram, which revealed no acute coronary occlusion. However, Takotsubo cardiomyopathy was diagnosed. He was transferred back to the referring hospital and reassessed in the ED. Here, his vital signs were: BP 95/57 mm Hg, HR 95 bpm. His heart sounds were normal, his chest was clear and his abdomen was soft. He is still complaining of pain.
PART 1 A 76-year-old man with a past medical history of chronic obstructive pulmonary disease is brought to the emergency department (ED) with suspected sepsis. He is a smoker of 15 cigarettes per day who has an exercise tolerance of approximately 30 m. He saw his general practitioner who treated him with antibiotics and steroids. He has rung for an ambulance complaining of increasing shortness of breath and back pain. His initial vital signs were: BP 100/87 mm Hg, HR 120 bpm, RR 24 breaths per minute, oxygen saturations 100% on room air and normal temperature. He appeared sweaty and clammy, but his heart and chest were normal on examination. An ECG is done (figure 1).
Figure 1 Twelve-lead ECG at initial presentation. Lyddon K, et al. Emerg Med J Month 2015 Vol 0 No 0
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://emj.bmj.com/ on July 29, 2015 - Published by group.bmj.com
SAQs Questions
DISCUSSION
1. What is Takotsubo cardiomyopathy? 2. What is the differential diagnosis now?
The typical ECG findings of Takotsubo cardiomyopathy can lead to the misdiagnosis of STEMI. The time-critical transfer of patients with STEMI for PCI can lead to other diagnoses being missed. The ECG, in this case, lacked ST-segment depression. This reciprocal change (seen in leads other than AVR and V1) strongly suggests STEMI over other causes of ST elevation. ST segments in leads II and III are of equal magnitude. STEMI is associated with ST-segment elevation of greater magnitude in lead III than II. The morphology of the ST segments is saddleshaped or concave upwards. STEMI is associated with morphology that is horizontal (table top) or convex upwards (tombstone).6 In this case, the AAA may have been diagnosed sooner by careful scrutiny of the ECG and the use of bedside ultrasound.
1. Takotsubo cardiomyopathy, also known as transient apical ballooning syndrome,2 apical ballooning cardiomyopathy,3 stress-induced cardiomyopathy, Gebrochenes-Herz-Syndrom and stress cardiomyopathy, is a type of non-ischaemic cardiomyopathy, in which there is a sudden temporary weakening of the myocardium. Because this weakening can be triggered by emotional stress, such as the death of a loved one, a break-up or constant anxiety, it is also known as broken heart syndrome. In Japanese, ‘tako-tsubo’ means ‘fishing pot for trapping octopus’, and the left ventricle of a patient diagnosed with this condition resembles that shape. Most cases occur in postmenopausal women (approximately 90%), and the average ages at onset are between 58 and 75 years. Less than 3% of cases occur in patients under age 50.4 Treatment is supportive and left ventricular function normalises within 2 months.5 2. The differential diagnosis now would include pneumonia, pneumothorax, biliary sepsis, pyelonephritis, psoas abscess or a leaking abdominal aortic aneurysm (AAA). Biliary sepsis would be suggested by a fever with raised inflammatory markers together with deranged liver function tests. Gall bladder wall thickening can be seen on ultrasonography. Pyelonephritis would also be associated with a fever and raised inflammatory markers. Loin tenderness would also be expected together with a urine test strip that is positive for nitrates and white blood cells. Psoas abscesses are typically diagnosed on CT; however, AAA’s can be diagnosed with bedside ultrasound, which is within the capabilities of many emergency physicians.
K Lyddon,1 M Thevendra2 1
Department of Medicine, Countess of Chester Hospital, Chester, UK Emergency Department, Countess of Chester Hospital, Chester, UK
2
Correspondence to Dr M Thevendra, Emergency Department, Countess of Chester Hospital, Chester CH1 2UL, UK; [email protected] Acknowledgements The authors would like to thank Dr T Jang, Associate Professor of Clinical Medicine, David Geffen School of Medicine at UCLA, for his suggestions in the modification of this article. Collaborators Dr Timothy Jang. Contributors The article was conceived and written by KL and MT. Competing interests None declared. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed. To cite Lyddon K, Thevendra M. Emerg Med J Published Online First: [ please include Day Month Year] doi:10.1136/emermed-2014-204359 Emerg Med J 2015;0:1–2. doi:10.1136/emermed-2014-204359
CASE: PART 3
REFERENCES
He was given intravenous fluids, broad spectrum intravenous antibiotics and had a CXR, which was unremarkable. A bedside ultrasound revealed an aortic aneurysm of 5.1 cm in diameter. He then had a second intravenous cannula inserted, blood was cross-matched and an urgent CT of the abdomen and surgical review were arranged. The CT showed a 7.5 cm infrarenal AAA with active contrast extravasation. The iliac vessels were not involved, and the thoracic aorta was normal with no evidence of dissection. He was taken to the operating theatre and had an emergency endovascular aneurysm repair. He made a good recovery and was discharged home after 12 days.
1
2
2
3 4
5 6
Steg G, James SK, Atar D, et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012;33:2569–619. Eshtehardi P, Koestner SC, Adorjan P, et al. Transient apical ballooning syndrome— clinical characteristics, ballooning pattern, and long-term follow-up in a Swiss population. Int J Cardiol 2009;135:370–5. Bergman BR, Reynolds HR, Skolnick AH, et al. A case of apical ballooning cardiomyopathy associated with duloxetine. Ann Intern Med 2008;149:218–19. Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J 2008;155:408–17. Nyui N, Yamanaka O, Nakayama R, et al. ‘Tako-Tsubo’ transient ventricular dysfunction: a case report. Jpn Circ J 2000;64:715–19. Mattu A. A stepwise approach to distinguishing pericarditis vs STEMI vs early repolarization. 31 Aug 2012. In ERcast.org blog [internet]. http://blog.ercast.org/ st-elevation-its-not-just-for-mis-anymore/
Lyddon K, et al. Emerg Med J Month 2015 Vol 0 No 0
Downloaded from http://emj.bmj.com/ on July 29, 2015 - Published by group.bmj.com
Short answer question: a distracting ECG K Lyddon and M Thevendra Emerg Med J published online May 6, 2015
Updated information and services can be found at: http://emj.bmj.com/content/early/2015/05/06/emermed-2014-204359
These include:
References Email alerting service
Topic Collections
This article cites 5 articles, 1 of which you can access for free at: http://emj.bmj.com/content/early/2015/05/06/emermed-2014-204359 #BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Cardiomyopathy (26) Stroke (225) Acute coronary syndromes (186) Clinical diagnostic tests (996) Radiology (945) Radiology (diagnostics) (852) Pain (neurology) (954) Pneumonia (infectious disease) (72) Pneumonia (respiratory medicine) (61) TB and other respiratory infections (150) Hypertension (281) Drugs: infectious diseases (268) Echocardiography (60) Percutaneous intervention (13) Tachyarrhythmias (65)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
EMJ Online First, published on May 6, 2015 as 10.1136/emermed-2014-204359
Short answer question: a distracting ECG
SAQs
Questions
be assessed with a chest radiograph. An aortic dissection should be considered in the setting of back pain with tachycardia, but typically occurs in the setting of hypertension. A thorough examination should be done for other findings such as unequal pulses, differing BPs in the arms and neurological deficits, which would increase the pretest probability of a dissection. Although chest radiography can often detect evidence of a dissection, further testing with echocardiography or CT is often required when suspicion is high. Given the patient’s age, risk factors and ECG with ST-segment changes in V2–V6, II, III, and aVF, there was concern for an acute myocardial infarction (AMI). 2. In cases of suspected AMI, patients should be given aspirin, analgesia and oxygen. Although nitrates have not been shown to improve outcome,1 they are often helpful for symptom relief, and the patient was given sublingual glyceryl trinitrate. In addition, a platelet aggregation inhibitor such as clopidogrel, prasugrel or ticagrelor should be given as results from multiple trials demonstrate a decreased risk of death, reinfarction or cardiac arrest when these agents were given to patients with STEMI.1 Per protocol, the patient was given ticagrelor and transferred to a tertiary centre for primary percutaneous coronary intervention (PCI).
1. What is the differential diagnosis? 2. What is your initial management?
PART 2
1. The differential diagnosis would include acute ST-elevation myocardial infarction (STEMI), pericarditis, dissecting thoracic aneurysm, pneumonia and pneumothorax. Pneumonia is unlikely given the absence of a cough or fever, normal lung examination and normal room air oxygenation. An acute pneumothorax is unlikely given the history and normal lung examination. Both, however, could
At the tertiary centre, the patient had an angiogram, which revealed no acute coronary occlusion. However, Takotsubo cardiomyopathy was diagnosed. He was transferred back to the referring hospital and reassessed in the ED. Here, his vital signs were: BP 95/57 mm Hg, HR 95 bpm. His heart sounds were normal, his chest was clear and his abdomen was soft. He is still complaining of pain.
PART 1 A 76-year-old man with a past medical history of chronic obstructive pulmonary disease is brought to the emergency department (ED) with suspected sepsis. He is a smoker of 15 cigarettes per day who has an exercise tolerance of approximately 30 m. He saw his general practitioner who treated him with antibiotics and steroids. He has rung for an ambulance complaining of increasing shortness of breath and back pain. His initial vital signs were: BP 100/87 mm Hg, HR 120 bpm, RR 24 breaths per minute, oxygen saturations 100% on room air and normal temperature. He appeared sweaty and clammy, but his heart and chest were normal on examination. An ECG is done (figure 1).
Figure 1 Twelve-lead ECG at initial presentation. Lyddon K, et al. Emerg Med J Month 2015 Vol 0 No 0
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://emj.bmj.com/ on July 29, 2015 - Published by group.bmj.com
SAQs Questions
DISCUSSION
1. What is Takotsubo cardiomyopathy? 2. What is the differential diagnosis now?
The typical ECG findings of Takotsubo cardiomyopathy can lead to the misdiagnosis of STEMI. The time-critical transfer of patients with STEMI for PCI can lead to other diagnoses being missed. The ECG, in this case, lacked ST-segment depression. This reciprocal change (seen in leads other than AVR and V1) strongly suggests STEMI over other causes of ST elevation. ST segments in leads II and III are of equal magnitude. STEMI is associated with ST-segment elevation of greater magnitude in lead III than II. The morphology of the ST segments is saddleshaped or concave upwards. STEMI is associated with morphology that is horizontal (table top) or convex upwards (tombstone).6 In this case, the AAA may have been diagnosed sooner by careful scrutiny of the ECG and the use of bedside ultrasound.
1. Takotsubo cardiomyopathy, also known as transient apical ballooning syndrome,2 apical ballooning cardiomyopathy,3 stress-induced cardiomyopathy, Gebrochenes-Herz-Syndrom and stress cardiomyopathy, is a type of non-ischaemic cardiomyopathy, in which there is a sudden temporary weakening of the myocardium. Because this weakening can be triggered by emotional stress, such as the death of a loved one, a break-up or constant anxiety, it is also known as broken heart syndrome. In Japanese, ‘tako-tsubo’ means ‘fishing pot for trapping octopus’, and the left ventricle of a patient diagnosed with this condition resembles that shape. Most cases occur in postmenopausal women (approximately 90%), and the average ages at onset are between 58 and 75 years. Less than 3% of cases occur in patients under age 50.4 Treatment is supportive and left ventricular function normalises within 2 months.5 2. The differential diagnosis now would include pneumonia, pneumothorax, biliary sepsis, pyelonephritis, psoas abscess or a leaking abdominal aortic aneurysm (AAA). Biliary sepsis would be suggested by a fever with raised inflammatory markers together with deranged liver function tests. Gall bladder wall thickening can be seen on ultrasonography. Pyelonephritis would also be associated with a fever and raised inflammatory markers. Loin tenderness would also be expected together with a urine test strip that is positive for nitrates and white blood cells. Psoas abscesses are typically diagnosed on CT; however, AAA’s can be diagnosed with bedside ultrasound, which is within the capabilities of many emergency physicians.
K Lyddon,1 M Thevendra2 1
Department of Medicine, Countess of Chester Hospital, Chester, UK Emergency Department, Countess of Chester Hospital, Chester, UK
2
Correspondence to Dr M Thevendra, Emergency Department, Countess of Chester Hospital, Chester CH1 2UL, UK; [email protected] Acknowledgements The authors would like to thank Dr T Jang, Associate Professor of Clinical Medicine, David Geffen School of Medicine at UCLA, for his suggestions in the modification of this article. Collaborators Dr Timothy Jang. Contributors The article was conceived and written by KL and MT. Competing interests None declared. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed. To cite Lyddon K, Thevendra M. Emerg Med J Published Online First: [ please include Day Month Year] doi:10.1136/emermed-2014-204359 Emerg Med J 2015;0:1–2. doi:10.1136/emermed-2014-204359
CASE: PART 3
REFERENCES
He was given intravenous fluids, broad spectrum intravenous antibiotics and had a CXR, which was unremarkable. A bedside ultrasound revealed an aortic aneurysm of 5.1 cm in diameter. He then had a second intravenous cannula inserted, blood was cross-matched and an urgent CT of the abdomen and surgical review were arranged. The CT showed a 7.5 cm infrarenal AAA with active contrast extravasation. The iliac vessels were not involved, and the thoracic aorta was normal with no evidence of dissection. He was taken to the operating theatre and had an emergency endovascular aneurysm repair. He made a good recovery and was discharged home after 12 days.
1
2
2
3 4
5 6
Steg G, James SK, Atar D, et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012;33:2569–619. Eshtehardi P, Koestner SC, Adorjan P, et al. Transient apical ballooning syndrome— clinical characteristics, ballooning pattern, and long-term follow-up in a Swiss population. Int J Cardiol 2009;135:370–5. Bergman BR, Reynolds HR, Skolnick AH, et al. A case of apical ballooning cardiomyopathy associated with duloxetine. Ann Intern Med 2008;149:218–19. Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J 2008;155:408–17. Nyui N, Yamanaka O, Nakayama R, et al. ‘Tako-Tsubo’ transient ventricular dysfunction: a case report. Jpn Circ J 2000;64:715–19. Mattu A. A stepwise approach to distinguishing pericarditis vs STEMI vs early repolarization. 31 Aug 2012. In ERcast.org blog [internet]. http://blog.ercast.org/ st-elevation-its-not-just-for-mis-anymore/
Lyddon K, et al. Emerg Med J Month 2015 Vol 0 No 0
Downloaded from http://emj.bmj.com/ on July 29, 2015 - Published by group.bmj.com
Short answer question: a distracting ECG K Lyddon and M Thevendra Emerg Med J published online May 6, 2015
Updated information and services can be found at: http://emj.bmj.com/content/early/2015/05/06/emermed-2014-204359
These include:
References Email alerting service
Topic Collections
This article cites 5 articles, 1 of which you can access for free at: http://emj.bmj.com/content/early/2015/05/06/emermed-2014-204359 #BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Cardiomyopathy (26) Stroke (225) Acute coronary syndromes (186) Clinical diagnostic tests (996) Radiology (945) Radiology (diagnostics) (852) Pain (neurology) (954) Pneumonia (infectious disease) (72) Pneumonia (respiratory medicine) (61) TB and other respiratory infections (150) Hypertension (281) Drugs: infectious diseases (268) Echocardiography (60) Percutaneous intervention (13) Tachyarrhythmias (65)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
