Wife Saved Last Minute From Cardiac Arrest - Medpage Today

Join internal medicine and rheumatology specialist Siobhan Deshauer, MD, in unraveling a medical mystery. Can you figure out the diagnosis before it's revealed?

Following is a transcript of the video (note that errors are possible):

Deshauer: Today I'm sharing with you the fascinating story of a middle-aged woman who arrived at the hospital with unusual symptoms. Her medical team was at a loss, unable to pinpoint the underlying cause. That is, until a strange coincidence prompted them to order one simple test that confirmed the diagnosis.

I'm Siobhan, an internal medicine and rheumatology specialist. I want you to learn how to think like a doctor, so let's get right into the video and together we'll unravel this medical mystery.

Andrew and Diane are a married couple in their 40s. They finished lunch and planned to go and take their dog for a walk, but before they could, Diane started feeling unwell. She collapsed into a chair, feeling exhausted, and moments later she got an alert from her smartwatch saying that her pulse was slower than usual and irregular. Diane thought about going to see a doctor, but she was hopeful that her symptoms would go away quickly and she really didn't want to spend hours in a waiting room.

But her symptoms kept getting worse. Her stomach was cramping. She felt nauseated and then she started throwing up, so she wondered what could have caused this. It couldn't be food poisoning because she had eaten the same thing as Andrew and he felt perfectly fine, so she figured it must be a virus that she had picked up at the daycare where she works. She really didn't like going to the doctor unless she absolutely had to. But after 3 days of nausea, vomiting, chest pressure, and palpitations, Andrew was finally able to convince her to go to the emergency department.

Now, when I see someone in the emergency department who is coming in with chest pain, nausea, [and] vomiting, I'm immediately thinking about the deadly things that you absolutely cannot miss and that you have to act on quickly, like a heart attack or inflammation around the heart or a blood clot in the lungs. Right now we have to keep all possibilities on the table.

The first thing I check are the vitals. Now, Diane's blood pressure was normal, which is very reassuring, but her heart rate was 53, which is a little bit slow. Now, without symptoms this could be totally normal. Many athletes have a resting heart rate in the 40s or 50s, but given her symptoms, we can't just write this off. I'd say this is our first clue.

Then we've got to think, is this a heart attack? Well, she is a woman in her 40s, she doesn't have a family history of early heart disease, and she doesn't smoke, so it makes it far less likely. But I have seen it, so we have got to think about it.

There are three main things I look for when I'm diagnosing a heart attack. First, the symptoms. Diane is having chest pressure and nausea. That fits. Next, her troponin level. Now, this is a blood test that measures stress or damage to the heart muscle. Luckily, hers came back normal. Third is the ECG. Now, this is Diane's ECG, which isn't normal and you have to look really closely to spot the abnormality. The distance between these two squiggles is too long, which suggests there is a delay in the electrical conduction of the heart. Now, this can happen with a heart attack, but I'd usually expect to see other abnormalities on the ECG, not just this one.

Putting that all together, it doesn't look like a heart attack, so her doctors went on to do more blood work and imaging to rule out other causes. No signs of a blood clot in her lungs. No pneumonia. No signs of an aortic dissection. Now, that's all good, but she is still having symptoms, her heart rate is slow, and her ECG is abnormal. The emergency doctor didn't feel comfortable sending her home. Instead, he consulted the cardiologist.

When the cardiology team arrived, they repeated blood work and repeated the ECG. Again, they were looking at that troponin level, a measure of stress and damage to the heart muscle. Luckily, it was normal, which is really reassuring, but the ECG had changed -- for the worse.

The cardiologist came into the room with a concerned look on his face and he told Diane that she had a complete heart block. Diane thought he was telling her that she had a blocked artery and that she was having a heart attack, but it was actually a blockage in the electrical conduction. Think of it like a problem with the electrical wiring in the house, not with the plumbing.

What does that actually mean? Well, to explain what a heart block is, let me quickly explain the ingenious way that our heart beats, how your heart is beating right now. There is a cluster of specialized cells at the top of the heart that act as a pacemaker. They fire off electrical impulses that travel through special conducting cells in the heart, allowing it to beat in an organized, orderly fashion. For the perfect beat, we need the timing to be just right. There is a bottleneck called the AV node, which allows for the perfect interval of time between contractions of the upper part of the heart and the main pumping chambers at the bottom of the heart.

So back to Diane. When she first came to the hospital, her AV node was slowing down the conduction in the heart too much, and now the electrical signal is completely blocked and it can't get down to the bottom of the heart at all, which is why we call it a complete heart block. You're probably thinking if there is no electrical signal to the bottom of the heart, how is it pumping? How is she alive? Well, this is where the human body is incredible -- so resilient.

Get this. There is actually a backup pacemaker inside the AV node, so if it doesn't sense a signal from the top of the heart, then it'll just start firing on its own to keep the heart pumping and keep you alive, just like how a backup generator kicks in if the electricity goes out. But now the upper part of the heart and the lower part of the heart are totally out of sync, contracting at different times. Bonus points to any musicians who can recognize this rhythm.

When I see this in the hospital, my first thought is, is this patient stable? Luckily, Diane's pulse and blood pressure are holding out for now, but that could change at any moment. The medical team stuck pacer pads on her chest that can deliver shocks if her blood pressure went too low or her heart rate became too slow.

At this point, she was transferred to the cardiac care unit where her heart rhythm could be monitored 24/7. Now that Diane is safe and relatively stable, it gives us a moment to think about what is causing this AV block and can we reverse it. Surprisingly, there is actually a pretty long list of causes. We know Diane isn't taking any medications or supplements, so we can cross that out. Based on her blood work, we can rule out high potassium and thyroid disease. With a normal troponin level, myocarditis is pretty unlikely.

She was then sent for an echocardiogram, which is an ultrasound that looks at the structure of the heart -- how thick are the walls, how is it pumping, what do the valves look like. Everything was normal. Because she was still having chest pain, she was sent for a coronary angiogram to look inside the arteries of the heart to see if there are any blockages. It's actually a really interesting procedure, so if you want to learn more about it, check out this video. But, again, everything is normal. She has no coronary artery disease. Where does that leave us now?

Well, after ruling out all of these causes -- we've got a previously healthy woman in her 40s who comes in with a heart block -- my money is on a condition called sarcoidosis. It's an inflammatory disease caused by an overactive immune system. And the immune system causes these tiny clumps of immune cells that we call granulomas that can form pretty much anywhere in the body. One of the classic places is inside the heart. These little granulomas can interrupt the electrical conduction in the heart, leading to heart block. But that's just my theory. We still have to prove it.

All of a sudden, Diane's heart rhythm changes again. Alarms start going off in the nursing station and everybody rushes into her room. Diane has gone into a deadly heart rhythm called ventricular tachycardia. The doctor is paged stat and in the meantime the nurses prepare the equipment to shock her heart. But luckily, the dangerous rhythm stopped on its own before they needed to shock her. Diane was OK -- for now. That was a clear warning sign things are going from bad to worse and the medical team knows they need to act quickly.

They went back in to talk with Diane and they explained that they suspect a condition called sarcoidosis, but that they need a cardiac MRI or a PET scan to confirm that diagnosis. Unfortunately, this particular hospital doesn't have either of those, so they need to arrange to transfer her to a different hospital. Plus, if her blood pressure drops or she becomes unstable, then they are actually going to have to put in a temporary pacemaker to get her to the other hospital safely.

Diane agreed with the plan, but she felt so overwhelmed and scared. Normally, her husband Andrew was by her side all day, but for some reason he hadn't come in yet today. She knew she wouldn't remember all the medical details the cardiologist had said, so she asked him to call Andrew with a medical update. They tried multiple times, but Andrew's phone kept going straight to voicemail.

Diane felt a sinking feeling at the pit of her stomach. This was so unlike him. Where could he be at such a critical time?

What they didn't know is that earlier that day Andrew woke up feeling weak and unwell. He had been so worried about Diane, spending each day with her in the hospital and then going home and sleeping poorly at night. He just figured that's why he was feeling run down.

But then he felt an intense pressure in his chest and an alarm went off on his smartwatch telling him his heart rate was irregular and slow. He was in a state of shock. Was he having a heart attack? Wasn't he too young for that? Terrified, he called his friend who drove him to the same hospital where Diane was admitted.

When he arrived in the emergency department, he was quickly brought into a room and hooked up to cardiac monitors. Andrew's heart rate was slow, at times dipping down into the 30s. When the cardiologist came downstairs to the emergency department to assess Andrew, he was surprised to learn that it was Diane's husband with very similar symptoms. Are you thinking what I'm thinking? This cannot be a coincidence. It must be some sort of toxin that they were both exposed to, but where?

We need to know everything that happened leading up to Diane feeling unwell. Details that may not have seemed relevant before are all of a sudden critical. It turns out that Andrew had recently built them a vegetable garden in their backyard and their neighbor had given them some plants and herbs to get started. The day Diane got sick, Andrew had surprised her by preparing a fresh salad for lunch. He proudly picked some kale from the garden and sprinkled it into their salad. Diane recalls the kale was quite bitter, but they had been so excited to be eating their own vegetables from their own garden that she finished the whole bowl.

Hours later, her symptoms started and they couldn't think of anything else that was different in their routine. That leaves us wondering, was that really kale or did they eat some other plant? Well, there is only one way to find out.

The medical team asked one of Diane's family members to go to their garden and take samples of each of the plants in the garden and bring it back to the hospital. In the meantime, they did more blood work, this time looking for toxic ingestions. Shockingly, both Diane and Andrew had high levels of a cardiac medication called digoxin in their blood. You might recall that digoxin was actually on our list of potential medications that can cause heart block, but we dismissed it because she wasn't on any medications or any supplements. How did this happen?

It turns out the "kale" that Andrew picked from their garden was actually a plant called foxglove, and that's the plant that the medication digoxin is made from. It's like they say. The dose makes the poison because a little bit can be an excellent treatment, whereas a lot is extremely toxic.

But I bet those of you who know your plants well are probably wondering how do you confuse foxglove with kale because foxglove has these beautiful purple flowers. Well, as I've since learned, the plant doesn't flower in its first year and there are a bunch of different types of kale, some of which look much more similar to foxglove.

Now it all makes sense. Weakness, nausea, vomiting, abdominal pain, chest pain, heart block -- all of it can be explained by cardiac glycoside toxicity. Plus, on further questioning, both Diane and Andrew had had subtle vision changes that they hadn't mentioned. They were seeing yellow halos around objects and lights, perhaps something like these paintings by Vincent van Gogh. Get this, van Gogh was likely treated with foxglove by his doctor and many people believe that changed the way that he could see colors. It's probably why he became obsessed with painting the color yellow.

OK, back to Diane and Andrew. Now that we have the diagnosis, they can get treatment and they were given the antidote called Digibind [digoxin immune fab]. As the name suggests, it binds digoxin and deactivates it. Within an hour of receiving the antidote, they started feeling better. But it took a few days and a total of 12 vials of the antidote for their symptoms to completely resolve. Their heart rhythm returned to normal, their vision returned to normal, and they were discharged home to rethink their garden and probably have a conversation with their neighbor who gifted them those plants.

The moral of the story is they got lucky, especially Diane. I mean, I just wish she had come into the hospital sooner rather than waiting 3 days at home with chest pain, palpitations, and nausea. Just remember, women in particular can have atypical symptoms when they are having a heart attack and this can delay their diagnosis. Don't ignore chest pain or other symptoms that come on when you exert yourself. It's always better to be safe and come in to get checked out.

Siobhan Deshauer, MD, is an internal medicine specialist in Toronto. Before medicine, she was a violinist, which is why her YouTube channel is called Violin MD.

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