I recently treated a 64 yo female, with very little medical issues and was not on any home meds, who had presented to ER with 6-8 hrs of chest pain going across her chest, graded as about 6-8/10 pain. In the ER, the ECG/EKG (German origin), showed a possible early Inferior (lower part of the heart) Wall MI (aka heart attack). It was 1 mm elevation for those of you who care.
The cath lab was called in and in the interim, her “cardiac enzymes” aka Troponin, came back elevated. Troponin, is muscular protein component of primarily Heart Muscle. It resides in and contributes to the architecture of the muscle and when activated, contributes to the contraction of sed muscle. When deprived of oxygen, however, the muscle becomes damaged and Troponin is then seen in the blood, usually indicating “injury”, also known as “MI”, Myocardial Infarction or a Heart Attack.
There is a very “High Sensitivity”Trifecta, (medicine talk for the ability to rule out a hoax, or fake disease), for people who present with chest pain. Kind of like; if she walks like a duck, swims like a ducks end quacks like a duck, it’s a duck!
1-Typicalness of the pain ie…is it heartburny, or a muscular injury (chest workout), or is a hot gallbladder!
Or is it actually, inside the chest, affected by exertion or rest and does it have dyspnea components( breathing is impaired), like a heart attack!
2-EKG changes; the Elecrical signal that the heart makes is technically unique to every human being! But, there are thousands and thousands of “normal” and much less fewer are the “abnormal” patterns. So, luckily, when the electrical singles in the heart are perturbed, such as from being deprived of nutrients and oxygen, like an MI, where the vessel is blocked off causing a lack of circulation to the heart itself! (more to come on this important topic of Coronary Artery Disease).
3-Elevated cardiac enzymes, Troponin in the blood above a locally accepted normal indicating damage is ongoing to the heart muscle.
When all three of the above are present it is virtually impossible not to be having a heart attack and the only way to confirm and possible treat is with an Angiogram. (A lot more on this later!)
But basically, dye is injected in the heart arteries aka “Coronaries” to look for blockages and the Left Ventricle, the inner muscular chamber that pumps the blood, to evaluate the heart function.
The normal heart function is about 60% EF, Ejection Fraction. So, about 60% of the blood that comes in from the lungs with fresh oxygen is “ejected” leaving 40% in the ventricle, keeping it in a partially contracted and partially relaxed position (kind of like a half drawn crossbow), ready to receive more blood the next beat and eject 60% of the total again and again for hundreds of liters a day (2000 gallons/7500 liters per day!).
Normal Left Ventricular Angiogram has the heart (normally football-shaped when seen in profile), contracts symmetrically in 3 dimensions to expel the blood through the Aortic Valve, the door way to the entire vascular system (which laid end to end extends 60, 000 miles, twice the earth’s circumference!).
A Normal Contraction looks like this:
Before Contraction: Diastole
(Greek, “dilation”)
During Contraction: Systole
(Greek, contract or squeeze)
Back to the patient; she continued to have chest pain and we performed the Coronary Angiogram to reveal open arteries, no sign of an MI or heart attack. Indeed, her coronaries looked relatively disease free by the over all flow seemed slightly sluggish and when we performed her Left Ventricular (LV) Angiogram, we were surprised!
The patient’s heart in Diastole looks fairly normal (pic 3).
Full of blood, depicted above, with contrast we injected.
But in Systole (Pic 4):
A-heart (anterior), B-bottom (inferior) and C-Apex (front) contract Vigorously with Middle not contracting at all!
Even the Base of the Heart was fine, but this was still not normally contracting heart, it was a sickened heart, a Cardiomyopathy.
The LV contraction, pictured below, usually looks like a closed Pac Man configuration,
Now the Left Ventricle has adopted a weird “donut shape” where blood, behaves like being stuck in the middle of squabbling siblings!
This, as a turns out, is a rare variation of a rare Entity which I have encountered many times over the past almost 20 years. It makes up about 1% of people presenting like heart attack and it is usually preceded by a stress full event, hence the name:
Stress Induced Cardiomyopathy.
It’s seems to cluster in middle age and elderly woman, but I’ve seen it in young people too. Some mothers with high stress jobs, some younger guys with high stress at jobs and home life, or a tough divorce, several middle aged woman who had their dogs attacked in front of their eyes, or bitten by a dog, several with kidney stones, a few with colon obstructions and at least two when their husbands had heart attacks in the preceding hours…which leads to its other names: “Broken Heart Syndrome”
Aka: Takotsubo Cardiomyopathy, because it was first recognized by Japanese researches who noted the sick heart’s appearance resembles an octopus caught in a trap pot!
That appearance is the classic dilated Anterior and Apical portions, describing its other name “Apical Ballooning Syndrome”, its most recognized and frequent configuration.
While I have seen other configurations, this was my first Mid Ventricular variant of the Stress Induced Cardiomyopathy.
So I asked the lady about stressors in her life and if there were any recent or dramatic events or circumstances. She simply replied “not more than most people’s….normal stresses”.
The Pathophysiology is not perfectly understood, hence the “syndrome”, ie collection of clustered symptoms that present in a pattern (sort of our way of saying we need more research).
The idea is such; the person perceives an event (or thought, indistinguishable to the brain’s limbic system-aka “fight or flight”, aka “lizard brain”) and the body responds with huge surge of adrenaline (aka, epinephrine/norepinephrine) and the heart is flooded with these hormones that cause the heart to contract vigorously and causing some parts of the circulation to spasm worse than other parts of the heart.
It is believed that, through genetics and conceivably through lifestyle, some parts of the muscle become deprived of a type of Beta receptors which act as a landing zone for impulses from our VAGAL NERVE (definitely more on this later, a lot more!), which normally serves to calm things down again by counteracting the Adrenaline and is the cornerstone of why breathing and meditation techniques work (again more on this later in a separate discussion).
So, people that lack receptors in the Apex get “apical ballooning syndrome”,
and our lady lacked them in the middle hence the “Mid-Ventricle” Variant of Stress Induced Cardiomyopathy!
Treatment is usually supportive, just Beta Blocker medication and Heart Failure precautions; low salt diet and water pills as needed and most importantly STRESS REDUCTION!
How much is too much stress and how best to treat it is a separate and long discussion, but what needs to be understood from this presentation is that our bodies have their own intelligence and that needs to recognized and respected.
Our lady’s “not more than people” stress level was clearly too much for her heart.
We all need to take inventory of our stress level everyday. The signs of stress may not always be conscious to our active mind (which is always looking for problems in other people, places, events. It is usually last to know just how stressed we are and quite frankly it is usually too late.
We must constantly “check in” with what our bodies are telling us. Any tightness in areas and muscles you are not using is a sign of stress. Soreness in your jaw, your temple, lower back, mid chest etc…all can be accumulations of stress.
Another great tool I use to detect stress is my Average, Instantaneous Heart rate and my Heart Rate Variability.
Yes, you will need an iWatch or the like, but totally worth knowing more about yourself!
Average Heart Rate:
Think of Average heart rate as your “Overall” mental health: for a given interval. Days to weeks typically, but tracking this over months can give you huge and life altering insights.
40-60 Chill
60-80 Mildly stressed
80-100 Moderate to high and likely out of shape.
100 plus is the Danger zone.
Instantaneous Heart Rate:
This is your “how am I doing right now”!? It can be good stress like meeting someone on a first date, or it could be my boss coming in with a weekly review! Both are ok in short bursts obviously the former seems like more fun, but taken to its limit (ie toxic spouse or tumultuous relationships in general) you can see how they would raise your Average Heart Rate.
This is gross under simplification of our HR responses, but we will discuss this more in later topics.
Heart Rate Variability:
This is a tough one to over simplify, but I will try. This idea goes to HOW we cope with stress? If someone is fit, has managed stress well, and if unfit, very stressed out and or in a medical crises. Here, I am conflating and contrasting fitness and stressfulness on purpose because to the heart, they are antagonists and two sides to the same coin.
To continue, a “Fit” person’s heart rate recovers QUICKER from the stress zone and automatically goes near the Average (Chill or whatever it maybe), but if a person’s HR remains high and is SLOW to return to their normal, then that person is not coping well and is out of shape.
So here the TIME to return to normal is direct reflection of a person’s stress coping mechanisms and ongoing lifestyle. That is a lot to digest but basically you want your heart rate to have good variability that allows you to adapt to what this world throws at you.
The Heart and Wellness Center:
Tips on stress reduction.
1-Be aware of the signals your body is sending you regarding its perception of stress. A heart rate monitor is great and tangible tool that can help with this practice.
2-Checking in with your body at frequent intervals, in it of itself, reduces stress because it forces us out of the mind…ie meditation or the like.
3-Go into the body! The more you place your concentration on the physical activity (I advocate resistance muscle training above all, but any activity that allows you to give your body fixed, prolonged and adequately challenging attention is perfect).
4-Find your flow! Engage in activities that make time seem to fly by and simultaneously bring you great joy and fulfillment. Ie Have Fun! (For me, sometimes this is a cool procedure I do or a new hobby to try or a new foreign place to explore or a new yummy food to make!)
5-Avoid your stressors unless you are doing then specifically for a specific type of growth. This is perhaps the greatest irony of our species;
True growth comes only through adversity.
The key is to use the necessary stress as a tool, like a dumbbell, to be used for a specific purpose then put away.
