Acute Coronary Syndrome in Women

We’ve known for some time now that women suffering from acute coronary syndrome frequently do not present with chest pain, but rather non-specific symptoms. These more subtle presentations have been and continue to be a problem in identifying and treating a very time sensitive medical emergency in a timely manner. Three recent cases have dramatized the reality of this challenge for me and some of my colleagues. These cases also served to further emphasize the importance of index of suspicion and diligence in performing a comprehensive patient assessment. A patient assessment focused on attempting to identify the underlying cause of non-specific complaints can be critical. Or, as my mentor Bob Ward used to say, “Beware the patient who can only offer, ‘I just don‘t feel right.’”

Case #1

It was a busy Monday afternoon at the local supermarket. A 47-year-old female is working the cash register when she experiences a sudden fullness-type pressure in her ears and becomes dizzy. She calls her manager for help. The manager notices her speech is slow and tentative. The manager calls 9-1-1 and has the patient sit down.

The patient has a history of hypertension and is an insulin dependent diabetic. Her fellow employees, knowing her diabetic history, immediately suspect her blood sugar is low and give her some orange juice. The patient has had hypoglycemic episodes before and said this feels different, but drinks the orange juice anyway hoping it will help.

As luck would have it, the deputy chief of the local EMS agency happens to be shopping in the store when the call is dispatched. The chief locates the patient and starts an assessment. Like the manager, he also notices the patient’s speech is slow and tentative, and recognizes the potential significance of the patient’s complaint of pressure-type discomfort in her ears. He performs a quick Cincinnati stroke screen and based on the patient’s speech interprets the test as positive. Shortly thereafter the ambulance arrives. The chief passes along what information he’s acquired, along with his working diagnoses of a possible stroke.

The duty medic checks the patient’s radial pulse but cannot feel one. The patient’s skin is slightly pale but dry, and her capillary refill is delayed. The patient is placed on the litter and moved into the ambulance where the cardiac monitor is attached and a full set of vital signs are obtained. The patient’s pulse rate is 47, respiratory rate 16, BP 92/56 and pulse ox is 98% on room air. The cardiac monitor reveals a sinus bradycardia with a wide QRS, with bizarre looking elevated T waves.

The patient denies any cardiac history. The blood glucose comes up 326 mg/dL. The medic believes the glucose is too high, too fast for just a small glass of orange juice ingested just prior to his arrival for the patient to have been hypoglycemic. He also reasons that stroke typically results in an increase in blood pressure, not hypotension, and the cardiac monitor seems to be tipping the balance of suspicion more toward cardiac. Pursuing that suspicion, a 12-lead ECG is performed and transmitted, and an IV line is established and fluid bolus administered en route to the hospital. The ECG shows a right bundle branch block which the medic presumes is new and what looks like very subtle depression in the lateral heads of I & AVL, as well as depression in V2. Just as the medic completes his interpretation of the ECG they arrive at the hospital.

The patient is taken into an exam room where care is transferred and the medic expresses his new found concern for myocardial ischemia. The nurse performs a follow-up 12-lead and the ER tech takes it to the ER physician. A moment later the ER doc shows up with both ECGs in hand. The medic asks the doc if he saw the ischemia. The doc hands the ER’s ECG to the medic and says it looks like inferior wall injury. The medic looks at the just-acquired ECG and indeed sees that in the short time between wheeling the patient in and the rapid hospital 12-lead being acquired, the patient has developed clear elevation in leads II and AVL with the subtle ST depression he initially saw in I & AVL now representing the reciprocal changes of an inferior wall STEMI. He also notes significant depression has also developed in leads V1 and V2 which fits perfectly into the posterior extension or right ventricular wall injury which now explains the bradycardia and hypotension.

The patient was whisked up to the cath lab where extensive three vessel disease with 100% occlusion of the right coronary artery was identified. Given those circumstances, a CABG was deemed the better treatment for this patient and the patient was transferred to the surgical suite where successful emergency bypass surgery was performed.

Case #2

It was change of shift at the rural EMS substation. A call was dispatched for an unresponsive in the vehicle just about one mile from the station. EMS arrived to find the 62-year-old female patient lying back on the reclined front passenger seat of the car. Her husband states the patient has not been feeling well since yesterday and he was in the process of driving her home from 200 miles away where they were visiting relatives. They are only about three miles from home but when the patient stopped responding to the husband and appeared to be staring straight ahead, he pulled over and called 9-1-1. When asked, the husband states the patient has no past medical history and is not taking any meds, but has not seen a doctor in a few years. He also related the patient’s earlier suspicion that she felt like she had the flu.

The patient is now conscious, responsive to verbal stimuli and complains of just feeling cold and weak. She denies any nausea or vomiting but admits to having diarrhea all day long. The patient looks pale and feels cool to the touch, a radial pulse is undetectable and her capillary refill is absent with peripheral cyanosis noted. The patient is hooked up the cardiac monitor and found to be in sinus tachycardia at a rate of 110 with wide, low amplitude QRS’s. A full 12-lead is performed and shows a right bundle branch block. The blood pressure is 89/70, respiratory rate is 20, a pulse ox is unobtainable due to her cool digits, blood sugar is 185, wheezes are heard in the bilateral bases and there is noticeable jugular vein distension after the patient sits upright. Four liters of nasal cannula O₂ is administered and IV access is attempted twice unsuccessfully. We arrive at the hospital 10 minutes later. During transfer of care the patient suffers a seizure similar to what the husband described earlier where the patient goes unresponsive, her body tenses in a tonic-like state but her eyes remain open with her gaze, fixed and deviated superiorly and to the left. The seizure ceases spontaneously after about a minute, but the patient remains unresponsive.

IV access is obtained with some difficulty. A fluid bolus is administered and bloods are drawn. The patient is also intubated. A short time later the patient’s Troponin I level comes back at 100. The patient had emergent PCI performed with stent placement in her LAD. She was then transferred to CCU for treatment of cardiogenic shock.

Case #3

Our medic unit is dispatched for a fall patient at the midpoint of the shift, about 14:10 hours. Upon our arrival we meet a gentleman who appears to be in his 40s, who identifies himself as the patient’s son. “I stopped by to visit my mother and found her lying on the floor,” he explains. “She seems weak and a little confused and it looks like she fell more than once.” As we enter the living room, the son points out a table lamp laying on the floor, as well as a dining room chair laying on its side. The son directs us to the second floor bedroom where we find an 84-year-old female lying in bed. The patient presents conscious and alert and does not appear to be in any distress. I introduce myself and start asking questions to establish her mental status. The patient knows her name, date of birth, the present year and who the president is, but is confused as to present and recent events—she is unaware of how the lamp or chair got knocked over and does not remember being on the floor or her son arriving. She also has no recollection of the apparent falls she suffered despite multiple bruises and abrasions on her arms and legs. The patient denies any chest pain, pain of any type or any complaints at all. A quick Cincinnati stroke screen comes up negative for facial droop, aphasia or arm drift. When asked, the patient cannot recall having any medical problems, although her son reports she has a history of hypertension and high cholesterol. When asked, he denies any knowledge of her having diabetes.

While my partner hooks the patient up to the cardiac monitor and starts to acquire vital signs, I continue my exam. Her radial pulse feels very weak, but palpable at 120. Her capillary refill is good and her skin is warm, dry and her skin color looks good. Her pupils are 3mm. There is no jugular vein distention. Her tongue and mucus membranes of her mouth appear pale and slightly dry. Her lung sounds are clear, her abdomen is soft and non-tender and she has no noticeable pedal edema. On further exam of her injuries, I discover multiple abrasions and contusions on her right shoulder and thoracic back, as well as bilateral knees. My partner reports a blood pressure of 117/84. The cardiac monitor shows a sinus tachycardia at a rate of 121, her pulse ox is 94% on room air with a good pleth wave, her blood sugar comes up 232 mg/dL and her temp is 99.5 deg F PO. Dehydration and possible cerebellar stroke pop into my mind as differentials, but failing to find any obvious cause of the patient falls and confusion, I have my partner perform a 12-lead ECG while I establish an IV.

I start administering a small fluid challenge and am planning to check the patient’s balance by having her stand and take the couple steps to the stair chair when my partner hands me the 12-lead. The tracing reveals elevation in the inferior leads with reciprocal changes in the lateral leads. Recognizing the time sensitive emergency we’ve now identified, we immediately pick up the pace and give the patient four baby aspirin and instruct her to chew them up. I call the hospital requesting a STEMI alert as we expedite moving the patient down the stairs and out of the house.

The STEMI was confirmed by cardiology with a Troponin T level of 4.9 and a left ventricular ejection fraction of 32%—normal election fraction is 55–70%; an ejection fraction of less than 20% is considered cardiogenic shock. The patient went to the cath lab, had a stent placed in her RCA and made an excellent recovery.

According to the American Heart Association, one third of all heart attacks die before they reach the hospital and that statistic has not changed appreciably since it was first reported nearly two decades ago. It’s also been reported that up to one-third of heart attacks may not present with classic chest pain. While these two statistics may not be a perfect one-to-one match, given the fact that most people now recognize the potential seriousness of chest pain but not always the more subtle symptoms of a heart attack, there is probably a very strong relationship between the two. There are a couple key changes which need to take place if we ever hope to make a dent in that one-third of out-of-hospital-cardiac-arrests (OOHCA). First and foremost we need to educate the public as to the other more subtle signs of a heart attack and encourage early activation of 9-1-1. And practice-wise we need to emphasize increased index of suspicion and encourage providers to more aggressively search for the underlying causes of non-specific symptoms, including early acquisition of 12-lead ECGs.

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service agencies in northeastern Pennsylvania. He has 30 years' experience in EMS. Contact Joe at jhayes763@yahoo.com.