1051 Case Study - Carmen Meyette

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Case Study: A Distinctly Feminine Heart Attack Carmen Meyette Biology Department, Trent University BIOL 1051: Human Physiology Dr. Liliane Dableh March 30 2023

1 Introduction and Case Report Vivian is a 46-year-old lawyer who noted that she has been increasingly fatigued over the last four months, and despite feeling tired she is not sleeping well. This week she has experienced a burning sensation in her chest. As she has been working long hours and choosing fast, convenient food options she attributes her chest pain to heart-burn resulting from low- quality food. She becomes nauseous, starts vomiting and does not improve while resting at home. Two hours after the nausea begins her husband suggests she should go to the local emergency department. At the hospital she is given an electrocardiogram (ECG) and an irregular rhythm is noted, a blood draw is taken for testing and cardiac magnetic resonance imaging (Cardiac MRI) is performed. Her tests return the following results: Heart rate: 65 BPM ECG: ST-segment depression (6.5 mm), t-wave inversion (2 mm) Blood Pressure: 145/95 Temp: 38.5 o Cardiac MRI: Reduced cardiac function Blood troponin levels: 0.44 ng/mL The choice to perform these tests in response to the symptoms described above highlights the health care team’s knowledge of how beneficial early detection and intervention is for myocardial infarction (heart attack) and other cardiac events. The focus now that these results have returned should be to restore optimal cardiac function and identify, if possible, the cause of Vivian’s cardiac event. Discussion Heart attacks are often related to plaque building up in the arteries and dislodging, causing an obstruction. They may also be related to a coronary artery spasm, spontaneous coronary artery dissection, or a supply and demand mismatch (Khan et al., 2022).

2 Research suggests that heart attack symptoms differ between men and women. In a study that examined the cases of women who experienced heart attacks the women reported feeling fatigued for up to six months, and a reduced quality of sleep in the last month precipitating a heart attack. In fact, many of these women reported that they never experienced the aching, tightness and pressure in their chest that is traditionally associated with a heart attack (Nakazawa, 2004). These variations away from the traditionally known symptoms of a heart can also fool health care professionals. In one case a woman reported to her primary provider complaining of low sleep quality and increased burning sensation in her chest over the course of a few days. The nurse practitioner assessed that these symptoms, in combination with the patient’s obese status and low-quality diet (fast food) suggested she was experiencing acid reflux. They recommended an appropriate medication for this and sent her home. When she followed up to report the symptoms had not subsided there was no appointment available, and she was advised to continue the acid reflux medication. She later died of a heart attack (Latner, 2016). In Vivian’s case her health care team at the emergency department decided to perform the appropriate tests that would detect or rule out a heart attack. An ECG quickly and succinctly identifies the real-time function of the heart and can reveal important alterations to the rhythm. In this case the ST-segment depression and t-wave inversion indicate that there is a problem. (Ojha & Dhamoon, 2023). Blood troponin levels would normally be so low they would be border-line undetectable. Troponin in the blood indicates damage to the heart. However the levels at which blood troponin indicates specifically a heart attack, and not another concern, fluctuates depending on the test. Levels that indicate a heart attack range from 0.12 ng/mL to 0.34 ng/mL (Juliano & Watson, 2017). Lastly the cardiac MRI would allow the medical team to visualize

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3 both the structure and function of the heart. In doing so they can assess the thickness of the heart walls, obstructions, and tissue death along with the flow of blood through the heart. (Ojha & Dhamoon, 2023). The results of Vivian’s tests clearly indicate that she has had a heart attack. As a woman Vivian is part of a group that often delays seeking medical attention in the presence of heart attack symptoms. Leslie et al., (2000) found that often delayed care-seeking is related to a lack of knowledge about what signs and symptoms to watch out for. They identify education as key to reducing this delay. Finnegan, et al., (2000) further identified that many women mistakenly assume that men are more at-risk, and in assuming this they severely underestimate their own risk of experiencing a heart attack and thus do not believe their symptoms warrant urgent action and medical attention. Conclusions While all heart attacks are ultimately the result of reduced blood supply to the heart tissue that leads to a lack of oxygen reaching those tissues and subsequent apoptosis the experience of people having heart attacks can vary widely. Women and men differ substantially in the signs and symptoms they may experience. In cases where symptoms are non-traditional or mild patients may underestimate the severity of their symptoms and choose to wait before seeking care. Strong public education programs about the range of symptoms and benefits of early interventions may reduce negative outcomes. Discussion Questions 1. Would myocardial infarction without coronary obstruction (caused by alternate pathophysiology) result in better long-term outcomes than a typical coronary obstruction- induced heart attack?

4 While it is tempting to think that because patients with heart attacks caused by something such as a supply-and-demand issue or arterial spasm might have better long-term outcomes than those with plaque build-up research contradicts this assumption. The damage done by the heart attack increases the patient’s risk of death or future cardiac events regardless why the initial heart attack happened (Lindahl, et al., 2021) 2. Why are heart attacks sometimes more difficult to diagnose and treat in women versus men? Women present heart attacks differently from men. Further complicating the matter when it comes to treatment, women are often excluded or underrepresented in clinical trials. Therefore, the best practices regarding drug therapy and alternatives are typically based on men. Given that the heart attack itself can present differently it should be unsurprising that response to treatment would vary as well. Women are therefore at a disadvantage in terms of therapeutic benefit. (Ski et al., 2020) 3. How can a heart attack be differentiated from “Broken Heart Syndrome” or Takotsubo Cardiomyopathy? Most common in post-menopausal women and often triggered by stress takotsubo cardiomyopathy is a neuroradiological disorder that can appear very similar to a heart attack. Table 1 demonstrates the similarities and differences between “broken heart syndrome” and a heart attack. It can be noted that coronary artery disease is not typically a factor in takotsubo cardiomyopathy. Additionally in takotsubo cardiomyopathy regional wall motion abnormalities appear without relation to coronary territories, and this is not typically seen with heart attacks. (Nussinovitch et al., 2011) Understanding these types of differentiations and having a confident understanding of how to assess patients to determine which is more likely can reduce the instance of misdiagnosis.

5 Table 1 Summary of differences between Takotsubo Cardiomyopathy and Myocardial Infarction.

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6 References Finnegan, J. R., Meischke, H., Zapka, J. G., Leviton, L., Meshack, A., Benjamin-Garner, R., Estabrook, B., Hall, N. J., Schaeffer, S., Smith, C., Weitzman, E. R., Raczynski, J., & Stone, E. (2000). Patient Delay in Seeking Care for Heart Attack Symptoms: Findings from Focus Groups Conducted in Five U.S. Regions. Preventive Medicine , 31 (3), 205– 213. https://doi.org/10.1006/pmed.2000.0702 Juliano, & Wason, C. (2017). Comparison of Point-of-Care Versus Laboratory Troponin Testing in an Emergency Department Setting. Military Medicine , 182 (7), e1938–e1940. https://doi.org/10.7205/MILMED-D-16-00387 Khan, A., Lahmar, A., Riasat, M., Ehtesham, M., Asif, H., Khan, W., Haseeb, M., & Boricha, H. (2022). Myocardial Infarction With Non-obstructive Coronary Arteries: An Updated Overview of Pathophysiology, Diagnosis, and Management. Cureus , 14 (3). https://doi.org/10.7759/cureus.23602 Latner, A. W. (2016). Chest pain in a woman: a woman has a myocardial infarction after her chest symptoms are misdiagnosed as acid reflux. Clinical Advisor , 19 (12), 58+. https://link-gale-com.proxy1.lib.trentu.ca/apps/doc/A474660319/AONE? u=ocul_thomas&sid=bookmark-AONE&xid=29f8b574 Leslie, W. S., Urie, A., Hooper, J., & Morrison, C. E. (2000). Delay in calling for help during myocardial infarction: reasons for the delay and subsequent pattern of accessing care. Heart (British Cardiac Society) , 84 (2), 137–141. https://doi- org.proxy1.lib.trentu.ca/10.1136/heart.84.2.137 Lindahl, Baron, T., Albertucci, M., & Prati, F. (2021). Myocardial infarction with non- obstructive coronary artery disease. EuroIntervention , 17 (11), e875–. https://doi.org/10.4244/EIJ-D-21-00426 Nakazawa, L. (2004, July-August). Feminine hearts: women should not underestimate their risk of developing heart disease. American Fitness , 22 (4), 62+. https://link-gale- com.proxy1.lib.trentu.ca/apps/doc/A119445258/AONE?u=ocul_thomas&sid=bookmark- AONE&xid=c292e6c1 Nussinovitch, U. , Goitein, O. , Nussinovitch, N. & Altman, A. (2011). Distinguishing a Heart Attack From the "Broken Heart Syndrome" (Takotsubo Cardiomyopathy). The Journal of Cardiovascular Nursing, 26 (6), 524-529. doi: 10.1097/JCN.0b013e31820e2a90. Ojha, N & Dhamoon, A. S. (2023). Myocardial Infarction [Updated August 8 2022). StatPearls. National Library of Medicine: National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK537076/

7 Ski, C. F., King-Shier, K., & Thompson, D. R. (2020). Women are dying unnecessarily from cardiovascular disease. The American Heart Journal, 230 , 63-65. https://doi.org/10.1016/j.ahj.2020.09.013

1051 Case Study - Carmen Meyette

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