Case Study 9 Activity
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University of North Carolina, Charlotte *
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Medicine
Date
Apr 29, 2024
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Part I – The heart of the matter
You recently graduated from Brody School of Medicine in East Carolina and have just started your
first year of residency at UNC Medical Center. You and your co-residents are on a cardiology
rotation. You all are in the lounge and are studying and quizzing each other on some typical
cardiology terms and diagnoses.
Questions
1. Match the lettered term to the correct definition listed below.
A. Infarction
B. Ischemia
C. Hypoxia
D. Cardiac Arrest
E. Stroke
F. Heart
attack
B
Deficient supply of blood to a body part (such as the heart or brain) that is due to
obstruction of the inflow of arterial blood.
C
A deficiency of oxygen reaching the tissues of the body.
E
When blood flow to the brain is impaired, resulting in oxygen deprivation and death of
brain cells.
D
Temporary or permanent cessation of the heartbeat.
F
When blood supply to the heart muscle is severely reduced or cut off.
A
Injury or death of tissue (as of the heart or lungs) resulting from inadequate blood
supply especially because of obstruction of the local circulation by a thrombus or
embolus.
2. Using the definitions, you just learned above, let us create a sentence or small paragraph below
that correctly relates and uses all the terms above (some terms have already been used and
might be used more than once!). A Heart attack (e.g., myocardial infarction, acute coronary syndrome) is a kind of infarction
where some form of blockage in the (coronary arteries) vessels feeding the heart causes ischemia
in the heart muscle resulting in hypoxia and tissue damage. Stroke is hypoxia of the brain. While
infarction, stroke , heart attack and cardiac arrest are all associated with infarction
, cardiac arrest is
defined by lack of blood flow due to no pumping action of the heart (an ‘electrical’ problem!) whereas
stroke and myocardial infarction aree both associated with ischemia and are considered to be
infarctions (a ‘circulation’ problem!) 3. What do you think happens to the heart when its blood supply is severely reduced, restricted, or
entirely cut off?
It can lead to tissue damage or death of heart muscle cells which can cause symptoms ranging from chest
pain to cardiac arrest or even death. 4.
Watch the video below on myocardial infarction and then briefly describe what disrupts cardiac
blood flow during a heart attack. (Note: dyspnea is labored or difficult breathing.)
A blockage, tobacco toxins, plaques. •
An Osmosis Video: Heart Attack Explained. Produced by Osmosis.org, 2018.
<https://youtu.be/2kLlhlsesRQ>
5. In the video, you learned about symptoms of a heart attack. List those here. Then, use the
resource below to note which three symptoms are more common in women compared to men.
Chest pain and pressure, abnormal sweating, nausea, fatigue, shortness of breath, tingling or pain in
left arm. Women: back and jaw pain, nausea, fatigue, shortness of breath. •
American Heart Association. (n.d.). Heart attack symptoms in women [webpage].
<https://www.heart.org/en/health-topics/heart-attack/warning-signs-of-a-heart-attack/heart-attack-
symptoms- in-women>
6.
Formulate a hypothesis about what type of tests would be useful in detecting a heart attack. You
do not need to know specific names of tests (if you do, that is fine), but list the type of information
you would want to gather. List two to three possible tests or procedures.
Tests that would be useful in detecting a heart attack may include electrocardiogram which is an
ECG/EKG to assess heart rhythm and electrical activity. Cardiac biomarker tests like troponin and CK-
MB can be used to detect heart muscle damage, and imaging tests like echocardiography or coronary
angiography to visualize the hearts’ structure and blood flow. Part II – The patient
The hospital is alerted that an ambulance is on the way with a patient, George Menezes, age 64, chest
pains, with lightheadedness; suspected heart attack via a 12 lead ECG that was taken enroute to the
hospital. The EMTs notify your team that they started an IV and collected blood samples for cardiac
biomarker labs. You and your team run down to the emergency room to meet the ambulance, help
transfer the patient, and get the blood samples sent to the lab. Your attending physician says that the
ECG reveals myocardial infarction (MI), and the patient will immediately need to be transferred to the
catheterization (cath) lab so that a coronary angiogram can be performed. While you are waiting, you
pull out your handy cardiac testing sheet primer [get this from your instructor] to quiz yourself on what
other tests could have been useful if an MI were not already confirmed.
Questions
7.
Using the primer and your answers from Question 6 in Part I, choose four tests you think would
be good identifiers of an MI. In the table below, provide a brief justification for, and the predicted
results from, the tests.
Test
Wh
y
Predicted
result
Troponin levels
Troponin is released into the
bloodstream when heart muscle
is damaged, which could indicate
myocardial injury. Elevated troponin levels CK-MB levels
CK-MB is an enzyme released
into the bloodstream during heart
muscle damage
Elevated CK-MB levels Electrocardiogram
(ECG)
ECG can show characteristic
changes
like
ST-segment
elevation
indicative
of
myocardial infarction. ST-segment elevation or other ischemic
changes
Coronary angiography Allow direct visualization of
coronary arteries to identify
blockages or occlusions Presence of blockages or stenosis 7.
Draw a graph showing predicted troponin I, troponin T, and CK-MB levels in the bloodstream
after a suspected myocardial infarction. For the x-axis use time and include hours 2–4, 24, and 48, as
well as 7 days; for the y-axis you can list relative concentration.
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Part III – Arrival
Mr. Menezes has arrived at the hospital; the emergency department (ED) staff has taken him to the
cath lab. You obtain the vitals, 12-lead ECG, and history from the EMTs. It is 8:55 a.m. You thank the
EMTs, and rush to the cath lab, not far behind your patient. While the team preps Mr. Rodriquez for
the angiogram and waits for the interventional cardiologist to arrive, you and your attending review
the history the EMTs took in transit.
George
Menezes;
64
yrs
old;
male
Arrived to work at 7:00 a.m. Shortly after arrival, he felt severe chest and neck
pains, discomfort in his left shoulder, and became lightheaded. His employees
became very worried and after some persuading, George allowed them to call
911. Vitals taken enroute are listed below. George was given oxygen in the
ambulance.
•
Family history of cardiovascular disease
•
Currently not on medication; no recent phosphodiesterase inhibitor use
•
No surgeries in the last year
•
No known allergies
•
No history of blood clotting disorders
•
History of untreated pre-diabetes and hypertension
•
Four children
•
Works many hours a week as manager; job stress; often works overtime
•
No time to exercise
•
Diet includes lots of fast food and convenience items
•
Long-term smoker; one pack per day for 20 years
Table 1
.
Vitals of
George
Menezes;
taken
enroute to
ED.
Question
Test
Normal Male Value
G. Menezes
Blood
Pressure
(mmHg)
120/80
155/95
Pulse (bpm)
60–100
110, regular
Oxygen Saturation (%)
95–100
89
8. Are any of Mr. Menezes’s vitals out of typical range? If so, which ones and in which direction?
Mr. Menzes’s blood pressure and pulse are out of typical range. His blood pressure is elevated (155-95
mmHg) and his pulse is elevated (110 bpm). You now compare Mr. Menezes’s results with a typical reference ECG. Figure 1 is the ECG tracing from
Mr. Menezes and Figure 2 is a typical ECG for comparison.
Figure 1
. ECG from G. Menenzes.
Figure 2
. Normal ECG. P: depolarization of the atria. QRS: depolarization of the ventricles;
repolarization of atria. T: repolarization of ventricles.
Question
9. Compare the two images. Describe the differences between the typical ECG and Mr. Rodriquez’s ECG.
How do these images compare to those you saw in the video in Part I? Explain.
The normal ECG shows a typical rhythm will all of the waves present. Mr. Rodriguez’s ECG is quite the
opposite. His atria is not depolarizing the correct way, the same is present in his ventricles, there is
simply no “triangle” shape in the ECG. As far as T and U waves, it doesn’t look like there is any indication
on his ECG. The ECG also shows there is an elevation in the S and T waves.
The cardiac biomarkers blood test results are in. Even though everyone is fairly certain Mr. Rodriquez is
having an MI, your attending physician wants you to analyze the labs for good measure.
Below are the results that you ordered for cardiac isoenzyme and protein testing. It is now 9:00 a.m.
Table 2
. Test results for G. Menezes, 9:00 a.m.
Test
Normal Value
G. Menezes
High or Low?
cTnI (ng/mL)
< 0.04
1.5
High
cTnT (ng/mL)
< 0.014
0.72
High
CK-MB (IU/L)
5–25
37
High
CK-MB2:CK-MB1
1:1
2.5:1
High
Question
10.
Are any of the cardiac biomarkers out of typical range? If so, list them and describe what these
results suggest.
CK-MB levels are elevated (37 IU/L) and CK-MB2:CK-MB1 ratio is elevated (2:5:1). They likely indicate
that the heart has been damaged. Just before the coronary angiogram procedure begins, your attending physician explains that Mr.
Menezes’s ECG results reveal ST elevation in the anterior leads. These results suggest early
repolarization of the ventricles and this ECG pattern is an indication of a heart attack. The blood work
also shows consistent biomarker signatures of a heart attack. During the angiogram, the interventional
cardiologist will restore blood flow to the heart via an angioplasty- balloon or a stent placement; this is
typically paired with medication to diffuse the clot and open the occluded artery. After the procedure,
Mr. Menezes will be transferred to the cardiac care unit (CCU) to monitor for arrhythmias, returning
symptoms, and bleeding.
Mr. Menezes is nervous; he asks what an angiogram is and why it is being done. Your attending
physician asks you to explain.
Questions
11.
Explain the procedure to the patient. What is an angiogram and why would it be helpful here?
What results to do you expect from this test?
A coronary angiogram is a diagnostic procedure where a special dye is injected into the coronary
arteries, followed by X-ray imaging to visualize any blockages or abnormalities in the blood vessels
supplying the heart. This procedure is helpful here to identify the location and extent of blockages
contributing to Mr. Menezes's myocardial infarction. Results expected from this test include the
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identification of any blockages or stenosis in the coronary arteries, guiding further treatment decisions
such as angioplasty or stent placement.
The risks and benefits were explained and informed consent for the procedure was obtained from the
patient. Being mindful of time, you tell Mr. Menezes that you will have further updates for him following
the procedure. It is now 9:15 a.m. and it is time for the coronary angiogram to begin.
The angiogram shows 90% occlusion of the left anterior descending coronary artery, likely due to plaque
rupture followed by formation of a clot.
The attending physician asks you what you expect for Mr. Menezes’s further treatment and recovery
plan. You explain that we will know more after thoroughly reading the angiogram, but Mr. Menezes
should be able to return to work within two to six weeks. Mr. Menezes will be ordered cardiac
rehabilitation and receive an exercise prescription from an exercise physiologist. While in cardiac
rehabilitation, the nurse and dietitian will construct an individualized treatment plan addressing
behavioral modifications, including diet, stress reduction techniques, smoking cessation, and the
importance of taking medications as prescribed. Mr. Rodriquez will come to the rehab center and will be
monitored during exercise three times a week for 8 to12 weeks.
Your attending physician is satisfied with your response and tells you to follow up with Mr. Menezes
after his procedure.
Part IV- The next patient
Now that Mr. Menezes will be monitored by CCU staff, you decide to get a bite to eat before visiting him
in recovery and providing his update. As you walk to the cafeteria, you pass the neurology wing where
you see a woman holding her back and looking very uneasy. You ask her if she is alright and she says she
is short of breath, has back and upper chest pain, and is feeling a little nauseous. You immediately call a
rapid response, which provides you with help to transfer the woman to the emergency room. It is 9:45
a.m.
As you and the nurses are rushing to the ER, you ask the women when she started to feel this way and
try to take down her patient history as best as you can.
Her name is Susan Spencer, and she is here today with her husband Mike Spencer. Mike was diagnosed
with an inoperable brain tumor yesterday; today’s tests show the tumor is an aggressive form of cancer.
Susan says that she was having trouble processing what the doctor was saying so she stepped out of the
room to get a drink of water; she also felt
like she was going to throw up. About 10 minutes before you saw Susan, she had received a call that her
25-year-old daughter had been in a severe car accident and was undergoing surgery in a different state.
Susan did her best to explain that she had felt overwhelmed at Mike’s diagnosis, but shortly after
hearing her daughter’s condition she became very short of breath, lightheaded, and had intense back
pain. That is when she ran into you.
Susan is in her late fifties and works as an accountant. She goes to Jazzercise four times a week and does
her best to eat healthy.
Question
12.
You think back to the quizzing you were doing with your fellow residents earlier. What
symptoms would you expect to see in a woman presenting with a heart attack? Do the ones Susan
mention match up?
Symptoms of a heart attack in women may include chest discomfort or pain, upper back or neck pain,
shortness of breath, nausea, vomiting, indigestion, extreme fatigue, and dizziness. The symptoms Susan
Spencer mentions (shortness of breath, upper chest and back pain, feeling nauseous) do match some of
these symptoms, particularly shortness of breath and chest/back pain.
Due to the classic coronary symptoms, you immediately do an ECG, perform a physical assessment, run
a cardiac biomarker panel, and administer oxygen. You page your attending physician to meet you at the
cath lab where you will review the results and discuss the next step. It is 9:55 a.m.
Figure 3 below is the readout from Susan’s ECG.
Figure 3. ECG from S. Spencer.
13.
What do you notice about Mrs. Spencer’ ECG? Is it normal? Is her ECG trace like or different
from Mr. Menezes’s ECG?
Mrs. Jones' ECG shows the presence of P, QRS, and T waves, indicating normal electrical activity in the heart. However, her S wave suggests that she is not repolarizing the atria as effectively as she could. Additionally, the T wave indicates that ventricle repolarization is happening too quickly after the beat. Despite these findings, her ECG is considered better than Mr. Rodriguez's. Mrs. Jones also has ST elevation present on her ECG.
Seeing the ST elevation on the ECG tracing, the attending asks the nurses to begin prepping Mrs.
Spencer for a coronary angiogram because this has a high probability of being an MI. You expect to see
similar results to Mr. Menezes’s workup. Here is Mrs. Spencer’ cardiac biomarker panel.
Table 3. Cardiac biomarker panel for S. Spencer.
Test
Normal Female Value
S. Spencer
Blood
pressure
(mmHg)
120/80
140/90
Pulse (bpm)
60-100
120
Oxygen saturation (%)
95-100
90
CK-MB (IU/L)
5-25
28
CK-MB2:CK-MB1
1:1
1.1:1
CRP (C-reactive protein test) (mg/L)
<3
10
cTnI (ng/mL)
<
0.04
0.05
cTnT (ng/mL)
<
0.014
0.016
Questions
14.
Are any of Mrs. Spencer’ values out of the typical range? If so, which ones and in which
direction?
In Mrs. Jones' case, all of her values are high. This includes her blood pressure (hypertensive) and heart rate (tachycardic). Additionally, her cardiac enzyme levels are elevated, but only slightly out of the typical range. This combination of high values indicates potential health concerns.
15.
How do her values compare to Mr. Menezes’s values? Complete Table 4 below.
The values in Table 4 show the comparison between G. Rodriguez and S. Jones in terms of cardiac
biomarkers. In this case, S. Jones has significantly lower levels of cardiac troponin I (cTnI), cardiac
troponin T (cTnT), and creatine kinase-MB (CK-MB) compared to G. Rodriguez. The ratios of CK-MB2 to
CK-MB1 are also lower in S. Jones. These lower values suggest that S. Jones likely experienced a minor
myocardial infarction (MI) compared to G. Rodriguez.
Table 4. Comparison of values between G. Menezes and S. Spencer.
Test
Normal
value
G. Menezes
S. Spencer
Comparison
cTnI (ng/mL)
<
0.04
1.5
.05
G. Menezes is higher
cTnT (ng/mL)
<
0.014
0.72
.016
G. Menezes is higher
CK-MB (IU/L)
5-25
37
28
G. Menezes is higher
CK-MB2:CK-MB1
1:1
2.5:1
1:1:1
G. Menezes is higher
Ultimately, they have almost opposite results from each other. Part V- The hunch
You are a bit puzzled by the fact that Mrs. Spencer’ biomarker levels are not that high; you expected
them to be higher. However, you start thinking that Mrs. Spencer’ cardiac event just started, and so it is
still early in the process. Mr.
Menezes did not come to the ER right away and his blood sample was taken about 90 minutes after the
onset of symptoms. Mrs. Spencer’ blood sample was collected about 20 minutes after onset. You
present the results and the ECG to your attending physician. While the two of you are discussing why
the results could look this way, a nurse overhears you and says that she was just speaking to the
husband of Mrs. Spencer, and he mentioned Susan had said, “I feel scared to death, I think I’m going to
puke,” right after hearing her husband’s diagnosis. Your attending physician immediately straightens up,
runs to the computer, and starts typing. She pulls up an article about takotsubo cardiomyopathy and
tells you she has a hunch that this is what Mrs. Spencer is suffering from.
You begin reading what this condition entails and watch a video as well.
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•
Harvard Health Publishing. (2020). Takotsubo cardiomyopathy (broken-heart syndrome).
[Webpage]. <https:// www.health.harvard.edu/heart-health/takotsubo-cardiomyopathy-broken-heart-
syndrome>
•
ECG and Echo Learning. (n.d.). Takotsubo cardiomyopathy (broken-heart syndrome, apical
ballooning syndrome, stress-induced cardiomyopathy). Section 3, Chapter 10. [E-book]. [Note: you do
not need to read the whole page; scroll down to #11.] <https://ecgwaves.com/topic/ecg-st-elevation-
segment-ischemia-myocardial-infarction-stemi/>
•
Takotsubo Cardiomyopathy (short version). [Video]. Running time: 1:58 min. Produced by Celine
Yoo, Molei Fu, and Sumin Lee, 2014. <https://youtu.be/g0c0TQKZdPk>
Questions
16.
Read the documents listed above and watch the video. Pay particular attention to the
mechanism of action of this condition, how it presents in the patient, and how it is like and different
from a heart attack. Jot down your notes about these topics below.
Notes on Takotsubo Cardiomyopathy:
Mechanism: Takotsubo cardiomyopathy, also known as broken-heart syndrome, is believed to
be triggered by extreme stress or emotional trauma, leading to a surge of stress hormones that
stun the heart muscle.
Presentation: It presents similarly to a heart attack with symptoms such as chest pain, shortness
of breath, and ECG changes including ST-segment elevation. However, unlike a heart attack,
there may not always be evidence of obstructive coronary artery disease.
Similarities to a heart attack: Both conditions can result in chest pain, ECG changes such as ST
elevation, and elevated cardiac biomarkers.
Differences from a heart attack: Takotsubo cardiomyopathy typically occurs in the absence of
significant coronary artery blockages and may involve reversible left ventricular dysfunction with
characteristic apical ballooning seen on echocardiography.
Notes:
17.
Which test do you think will differentiate between a heart attack and takotsubo
cardiomyopathy?
Echocardiogram. Both conditions show similar symptoms and even ECG changes, an echocardiogram
can reveal structural abnormalities like apical ballooning or wall motion abnormalities consistent with
myocardial infarction. Part VI- Diagnosis and recovery
Your attending physician agrees that once the coronary angiogram is done an echocardiogram will
confirm Mrs. Spencer’ diagnosis. The angiogram shows that there are no blockages in the coronary
arteries, but the ejection fraction (the volume of blood pumped out of the left ventricle with each
contraction) is low. Low ejection fraction suggests Susan’s heart is not pumping efficiently, which could
be due to damaged heart muscle tissue. Current research suggests echo- cardiogram provides the most
accurate readings for assessing left ventricular function. You order the echocardiogram post coronary
angiogram to visualize left ventricle function but are almost certain Susan has suffered from takotsubo
cardiomyopathy.
After Mrs. Spencer is settled into a room and being monitored, you and your attending physician come
in to explain the results and treatment plans. You tell Mrs. Spencer that she suffered from a condition
commonly known as broken heart syndrome, which is thought to be caused by a rush of epinephrine or
other stress-responsive hormones due to extreme stress. Takotsubo cardiomyopathy is often
misdiagnosed as a heart attack due to the similar results from an ECG and cardiac biomarker panels. The
ECG revealed an ST elevation, which is the first indicator of a myocardial infarction.
The panel showed slightly elevated levels of cardiac biomarkers, but levels were below those typically
seen with myocardial infarction. These low levels are at least partially explained by time course of
symptom onset and blood sample collection. The coronary angiogram showed no blockages in the
arteries, but low ejection fraction, which helped lead to ordering an echocardiogram. This test identified
the ballooning left ventricle, a tell-tale characteristic of takotsubo cardiomyopathy. The attending
physician adds that Mrs. Spencer’ treatment plan will include medication such as beta blockers (to
decrease effects of epinephrine on the heart) and ACE inhibitors (to decrease blood pressure), which will
help promote heart muscle recovery. Learning stress reduction techniques are important and follow-up
echocardiograms to monitor the left ventricle status will be performed.
Susan stays in the hospital for two more days so you can monitor her progress and ensure she remains
asymptomatic. Mr. and Mrs. Spencer later contact you to say that their daughter is still healing and will
begin physical therapy in a few weeks but has made amazing strides.
Adapted from content created by S.K.Thomas, K.N.Harris and B.N.Harris (Texas Tech University)